Every finding on record at Marywood Heights

Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members and the use of a mechanical lift as planned to ensure safety and prevent major injuries. As a result, the resident sustained a fracture of the clavicle and a fracture of the first rib, representing actual harm for one resident (Resident 65) out of 20 residents sampled.Findings include: A review of a facility policy titled Investigation of Allegations of any Abuse Type last reviewed by the facility on January 3, 2026, revealed it is the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse and neglect. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses, which included need for assistance with personal care, and generalized muscle weakness (reduced muscle strength which can impair mobility and increase fall risk). A review of Resident 65's Annual MDS Assessment (Minimum Data Set, a federally mandated standardized assessment process completed periodically to plan resident care) dated December 24, 2025, revealed the resident was totally dependent on staff assistance for bathing and required maximum assistance of staff members for personal hygiene, dressing, toileting hygiene, bed mobility (ability to move or reposition in bed), and required assistance lying down in bed. The MDS revealed the resident was dependent on staff for all transfers (moving from one position to another, such as from chair to bed). The MDS revealed the resident was cognitively intact as evidenced by a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). A review of the individualized care plan, initiated December 16, 2025, revealed Resident 65 had an activity of daily living self-care deficit related to limited mobility and weakness. Activities of daily living are routine personal care tasks such as bathing, dressing, toileting, transferring, and mobility. The care plan required the assistance of two staff members with the use of a Hoyer lift (a mechanical lifting device used to safely move residents who cannot stand or bear weight independently) for all transfers. A review of a Task List Report (a document that communicates resident care instructions to staff through the Kardex, a quick reference summary of required care) revealed Resident 65 required assistance of two staff members for all care as of December 16, 2025. Progress notes dated March 5, 2026, at 9:00 PM documented Resident 65 experienced a fall from the bed. Documentation indicated the resident was observed with a hematoma to the left forehead (localized swelling filled with blood caused by injury). The note revealed the resident vomited undigested food. The physician was contacted and an order was obtained to transfer the resident to the hospital for further evaluation. Progress notes dated March 5, 2026, at 10:44 PM written by the Director of Nursing revealed staff reported a witnessed fall at 8:58 PM. The documentation revealed Resident 65 had a 2 centimeter (cm) by 2 cm raised hematoma to the left forehead. The resident was unable to verbally communicate pain due to aphasia (a disorder that affects the ability to speak, understand, read, or write language); however, the resident was observed holding her head and grimacing (facial expression commonly indicating pain). The resident was observed holding her stomach and vomited a large amount of undigested food 10 minutes after the fall. Review of a facility provided investigative document dated March 5, 2026, included a written statement from Employee 22, Nurse Aide (NA). Employee 22 documented he was transferring Resident 65 from a recliner chair to the bed. Employee 22 documented that he stood in front of the resident and lifted the resident from the chair to a standing position. Employee 22 documented that the resident was not wearing nonslip socks (footwear designed to improve traction and reduce slipping risk), but this was not identified until after the resident was already standing. Employee 22 documented the resident slid to the floor. Employee 22 documented he lifted the resident from the floor and placed the resident in bed and then notified the nurse to assess the resident. Employee 22, NA, documented he was aware Resident 65 required assistance of two staff members and the use of a Hoyer lift for transfers, but he indicated that he had transferred the resident independently previously without incident. According to the facility investigative documentation. Employee 22 NA was immediately suspended and subsequently terminated from the facility. A review of hospital records revealed Resident 65 was evaluated for injuries sustained during the incident. Diagnostic imaging including a CT scan (computed tomography, an advanced imaging method that creates detailed pictures of internal structures of the body) of the cervical spine (neck bones), chest, abdomen, and pelvis revealed a mildly displaced fracture of the lateral end of the left clavicle (break of the collarbone, the bone connecting the arm to the body) and an acute fracture of the left posterior first rib (break in the upper rib located near the collarbone). Attempts to contact Employee 22 via telephone to obtain an interview on March 25, 2026, and March 26, 2026, were unsuccessful. A review of Employee 22's personnel file revealed Employee 22 signed an attestation on September 9, 2025, acknowledging completion of orientation training, which included instruction on the facility abuse and neglect policy and safe transfer and lift techniques. During an interview on March 25, 2026, at 12:45 PM the Director of Nursing confirmed the facility investigation determined Employee 22 did not follow the resident's care plan requiring assistance of two staff members and the use of a Hoyer lift for transfers substantiating neglect. The Director of Nursing confirmed Employee 22 was suspended pending investigation and was subsequently terminated. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to ensure residents were free from unnecessary antibiotic medications for two of 20 residents reviewed (Residents 2 and 50). Findings include: A review of the facility policy titled Antibiotic Stewardship, last reviewed January 3, 2026, revealed appropriate indications for antibiotic use include meeting minimum clinical criteria for active infection utilizing McGeer Criteria (standardized clinical criteria used in long-term care to determine whether sufficient signs and symptoms are present to support diagnosis of infection and initiation of antibiotic therapy). A review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including dementia (decline in memory and thinking ability affecting daily functioning), urinary retention (inability to completely empty the bladder), history of cystitis (inflammation of the bladder), and presence of a suprapubic tube (a flexible tube inserted through the lower abdomen to drain urine directly from the bladder). A nursing progress note dated December 10, 2025, at 12:08 PM indicated Resident 2's son requested a UA (urinalysis, a test of urine) and C&S (culture and sensitivity, a laboratory test used to identify bacteria and determine effective antibiotics). Documentation indicated no unusual behaviors were observed or reported for Resident 2 during the shift. A physician order dated December 13, 2025, directed Doxycycline Hyclate (an antibiotic medication used to treat bacterial infections) 100 milligrams twice daily for seven days for urinary tract infection (UTI, infection involving the urinary system) for Resident 2. Following the December 13, 2025, physician order, a nursing progress note dated December 13, 2025, at 9:54 AM documented Resident 2's final urine culture (laboratory test used to identify bacteria) resulted positive for Klebsiella pneumoniae (bacteria capable of causing infection) and Staphylococcus aureus (MRSA, bacteria resistant to some antibiotics). Documentation indicated the primary care provider was notified and an order was received to initiate Doxycycline therapy for Resident 2. Clinical record review revealed a completed Revised McGeer Criteria for Infection Surveillance checklist dated December 11, 2025, completed by Employee 4, Licensed Practical Nurse (LPN), indicated Resident 2 did not meet clinical criteria supporting the presence of infection requiring antibiotic therapy. An infection progress notes dated December 16, 2025, completed by Employee 4, LPN, indicated the physician assistant reviewed the McGeer Criteria findings and documented Resident 2 did not meet clinical criteria for infection; however, antibiotic therapy was continued due to Resident 2's history of prior urinary tract infections, with documentation indicating the perceived benefit of antibiotic therapy outweighed the risk. A review of the December 2025 Medication Administration Record (MAR, the legal record of medications administered) revealed Resident 2 received fourteen doses of Doxycycline without documented clinical evidence supporting the presence of infection meeting McGeer Criteria. A nursing progress note dated January 30, 2026, at 4:31 PM documented gross hematuria (blood present in urine) was observed for Resident 2. Documentation indicated Resident 2 denied urinary complaints, no abdominal distention was present, and no signs or symptoms of infection were documented. Orders were obtained for urinalysis and culture for Resident 2. A physician order dated February 2, 2026, directed Levaquin (an antibiotic medication) 250 milligrams, two tablets daily for seven days for urinary tract infection for Resident 2. Clinical record review revealed a completed McGeer Criteria checklist dated February 2, 2026, indicated Resident 2 did not meet clinical criteria for initiation of antibiotic therapy. An infection progress note completed by Employee 4, LPN, dated February 3, 2026, at 10:33 AM documented Resident 2 was afebrile (without fever), had no change in mental status, and exhibited no signs or symptoms of infection. Documentation indicated Resident 2's suprapubic catheter remained patent with hematuria present. The note indicated Resident 2 did not meet McGeer Criteria for antibiotic therapy and findings were forwarded to the medical provider for review. A review of the February 2026 MAR revealed Resident 2 received seven doses of Levaquin without documented clinical evidence supporting the presence of infection meeting McGeer Criteria. A nursing progress note dated February 14, 2026, indicated Resident 2's responsible party expressed concern regarding possible infection and requested repeat testing. Documentation indicated Resident 2 had no urinary complaints or observable signs or symptoms of infection. Urinalysis and culture were obtained for Resident 2. Clinical record review revealed a completed McGeer Criteria checklist dated February 16, 2026, indicated Resident 2 did not meet criteria supporting the presence of infection requiring antibiotic therapy. A nursing progress note dated February 18, 2026, documented the physician assistant indicated Resident 2's condition was not a true UTI. Documentation further indicated Resident 2's responsible party requested antibiotic treatment despite absence of documented clinical criteria for infection. A physician order dated February 18, 2026, directed Doxycycline 100 milligrams twice daily for seven days for urinary tract infection for Resident 2. A review of the February 2026 MAR revealed Resident 2 received seven doses of Doxycycline without documented clinical evidence supporting the presence of infection meeting McGeer Criteria. The facility failed to ensure Resident 2's medication regimen was free from unnecessary antibiotic therapy when antibiotics were administered without sufficient documented clinical evidence supporting the presence of infection according to McGeer Criteria.A review of Resident 50's clinical record revealed Resident 50 was admitted to the facility on [DATE], with diagnoses including stroke (interruption of blood supply to the brain which can result in loss of neurological function), diabetes (a condition affecting the body's ability to regulate blood sugar), and overactive bladder (a condition characterized by frequent urge to urinate that may result in urinary urgency or incontinence). A nursing progress note dated January 20, 2026, at 9:08 AM documented Resident 50 was observed with odorous urine and urinary incontinence consistent with baseline functioning. Documentation indicated Resident 50 reported increased urinary incontinence. The primary care provider was notified, and an order was obtained for UA and C&S. Clinical record review revealed a completed Revised McGeer Criteria for Infection Surveillance checklist completed by Employee 4, LPN, dated January 21, 2026, indicated Resident 50 did not meet clinical criteria supporting the presence of infection requiring antibiotic therapy. A physician order dated February 23, 2026, directed Macrobid (Nitrofurantoin, an antibiotic medication used to treat urinary tract infections caused by certain bacteria) 100 milligrams twice daily for seven days for urinary tract infection for Resident 50. A review of the February 2026 MAR revealed Resident 50 received seven doses of Macrobid without documented clinical evidence supporting the presence of infection meeting McGeer Criteria. The facility failed to ensure Resident 50's medication regimen was free from unnecessary antibiotic therapy when antibiotics were administered without sufficient documented clinical evidence supporting the presence of infection according to McGeer Criteria. During an interview on March 25, 2026, at 1:32 PM, the Director of Nursing confirmed the above findings were reviewed, including documentation indicating Residents 2 and 50 did not meet McGeer Criteria for initiation of antibiotic therapy. 28 Pa. Code 211.2 (3) Medical Director. 28 Pa. Code 211.9 (k) Pharmacy Services. 28 Pa. Code 211.12 (d)(1)(3) Nursing Services. 28 Pa. Code 211.10 (c)(d) Resident Care Policies. 28 Pa. Code 211.5 (f) Medical records.

Based on a review of facility policy, Resident Council meeting minutes, grievance documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility did not ensure ongoing communication or timely follow-up regarding issues presented by five of five residents attending a Resident Council group meeting (Residents 31, 48, 30, 38, and 35).Findings include: A review of the facility's Grievance Policy last reviewed on January 5, 2026, indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official will follow up on all concerns and grievances registered by any resident or resident representative. A review of the Minutes from a Resident Council meeting dated December 29, 2025, revealed concerns from residents that snacks were not being provided daily. A grievance was filed on December 29, 2025, regarding this concern. Review of this grievance revealed that audits would be completed. The grievance was signed as resolved as of December 31, 2025. A group meeting conducted on March 25, 2026, at 10:00 AM with five residents (Residents 31, 48, 30, 38, and 35) revealed unanimous reports that the facility failed to address their complaints regarding the snacks. All residents in attendance stated they felt the consistency of snacks is a problem, they are delivered for a while and then it stops and they don't receive them. Further stating that they do not feel the facility has resolved this grievance as to all residents in attendance it is an ongoing concern. The facility was unable to provide documented evidence that residents were satisfied with the outcome of the grievance regarding snacks. During an interview on March 26, 2026, at 9:10 AM, the Nursing Home Administrator (NHA) could not provide documented evidence of resident satisfaction in addressing grievances raised during Resident Council meetings and written grievances. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies.

Based on review of clinical records, facility policy, pharmacy recommendations, behavior monitoring documentation, observations, and staff interview, it was determined the facility failed to ensure one of 20 residents reviewed (Resident 36) was free from the use of a chemical restraint Findings include: A review of a facility policy titled Use of Psychotropic Medication(s) last reviewed by the facility on January 3, 2026, revealed it is the policy of the facility to ensure that residents only receive psychotropic medications when other nonpharmacological interventions (approaches that do not involve medication, such as environmental modification, reassurance, or behavioral techniques) are clinically contraindicated. The policy defined a psychotropic medication as a drug that affects brain activity associated with mental processes and behavior. The policy indicated that use of psychotropic medications without documentation demonstrating that other treatments were clinically contraindicated is considered inadequate justification for use. The policy revealed the indications for initiating the medication, as well as the use of non-pharmacological approaches will be determined by evaluating the resident's physician, behavioral, mental, and psychosocial signs and symptoms to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The policy documents residents who use psychotropic drugs shall receive gradual dose reductions (stepwise reduction of medication dosage to determine if symptoms can be managed with less medication), unless clinically contraindicated, in an effort to discontinue these drugs. The policy defines a chemical restraint as any drug used for discipline, or that makes it more convenient (less effort) for staff to care for a resident and not required to treat medical symptoms. This includes when psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety. A review of Resident 36's clinical record revealed admission to the facility on September 12, 2023, with diagnoses to include dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and hypertension (persistently elevated blood pressure). A review of Resident 36's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2026, revealed that Resident 36 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of (0-7 moderate cognitive impairment). Review of Resident 36's clinical record revealed a physician order dated February 22, 2026, at 2:29 PM for Quetiapine Fumarate 25 milligrams (Seroquel, an antipsychotic medication that alters brain chemicals to affect mood, thinking, and behavior) to be administered by mouth once daily at noon related to dementia with behavioral disturbance. A nursing progress note dated January 31, 2026, at 11:25 PM documented Resident 36 periodically yelled out help me. Review of February 2026 behavior monitoring documentation revealed Resident 36 exhibited yelling behaviors on February 3, 2026 (dayshift), February 7, 2026 (dayshift), February 10, 2026 (dayshift), February 14, 2026 (dayshift), February 15, 2026 (dayshift), February 16, 2026 (evening shift), February 17, 2026 (evening shift), February 19, 2026 (evening shift), February 20, 2026 (dayshift and evening shift), February 21, 2026 ( dayshift) and February 22, 2026 (dayshift and evening shift) A progress note dated February 5, 2026, at 9:39 PM documented Resident 36 had occasional verbal outbursts which stopped when the resident's daughter arrived. A progress note dated February 22, 2026, at 2:11 PM documented the responsible party met with the attending physician to discuss Resident 36's medications and behaviors. Following the discussion, the physician issued an order for Quetiapine Fumarate 25 milligrams daily at noon for diagnosis of dementia Observations conducted on March 24, 2026, at 11:30 AM and 1:48 PM revealed Resident 36 seated in a Geri-chair (a wheeled reclining chair designed to support residents with limited mobility) asleep. An additional observation on March 26, 2026, at 1:10 PM revealed Resident 36 seated in a chair in the dining room appearing sleepy while being fed by staff. Review of March 2026 behavior monitoring documentation revealed Resident 36 exhibited yelling behaviors on March 2, 2026 (dayshift), March 13, 2026 (dayshift), March 14, 2026 (dayshift and evening shift), March 15, 2026 (dayshift and evening shift), and March 22, 2026 (dayshift and evening shift). Documentation also revealed blank entries for behavior monitoring on March 10, 2026 (evening shift), March 12, 2026 (evening shift), March 16, 2026 (evening shift), March 19, 2026 (evening shift), March 21, 2026 (night shift), March 22, 2026 (night shift), and March 25, 2026 (evening shift). A review of a pharmacy recommendation dated March 18, 2026, revealed the pharmacist recommended evaluation for a dose reduction within 14 days of initiation of the antipsychotic medication (Seroquel). Documentation revealed the physician disagreed with the recommendation and documented that a new order would follow. At the time of survey exit on March 26, 2026, the clinical record did not contain evidence of a new order or documented clinical rationale supporting continuation of the current dose of Seroquel 25 mg following Resident 36's yelling behaviors.A review of Resident 36's clinical record failed to contain sufficient documentation that less restrictive alternative treatments were attempted prior to initiating the antipsychotic medication. Less restrictive alternatives include nonpharmacological interventions (approaches that do not involve medication), such as reassurance, redirection, reducing environmental stimulation (for example excessive noise or activity), addressing possible pain or discomfort, providing social interaction, or other individualized interventions developed through care planning by the interdisciplinary team (group of staff responsible for evaluating and planning resident care). The clinical record failed to contain sufficient documentation of an assessment identifying a medical symptom requiring the antipsychotic medication or documentation that nonpharmacological interventions were attempted or determined to be clinically contraindicated (not medically appropriate). A review of Resident 36's clinical record also failed to contain sufficient documentation that staff and/or the physician identified and evaluated possible underlying causes of the resident's yelling behaviors. Potential contributing factors may include environmental overstimulation (too much noise or activity), emotional distress, changes in routine, discomfort, pain, or need for social interaction or reassurance. The clinical record did not demonstrate these possible causes were assessed and addressed prior to initiating the antipsychotic medication. During an interview with the Director of Nursing on March 26, 2026, at 2:00 PM, the surveyor reviewed the above findings, including the lack of documented clinical rationale supporting the need for the antipsychotic medication, lack of documentation that nonpharmacological interventions were attempted or clinically contraindicated prior to initiating the medication, and lack of documentation demonstrating evaluation of potential underlying causes of the resident's yelling behaviors. The above findings were reviewed with the Director of Nursing at that time. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.10 (c)(d) Resident care polices. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 28 Pa. Code 211.8 (c.1)(1)(e) Use of Restraints. 28 Pa. Code 211.5 (f) Medical records

Based on review of clinical records, observation, and staff interviews, it was determined the facility failed to develop and implement an individualized, person-centered comprehensive care plan that addressed ongoing behavioral concerns and identified interventions to manage accusatory behaviors for one of 20 residents reviewed (Resident 57).Findings include: A review of the clinical record revealed Resident 57 was admitted to the facility on [DATE], with diagnoses to include generalized anxiety (a common, mental health condition characterized by excessive, persistent worry and fear that disrupts daily life) and depression (common mental illness characterized by persistent sadness, loss of interest in activities, and reduced energy, affecting how a person feels, thinks, and acts). A review of Resident 57's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 9, 2026 revealed that Resident 57 was moderately cognitively impaired with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates no cognitive impairment). The MDS revealed Resident 57 had no behaviors related to rejection of care, wandering, physical behaviors, or verbal behaviors. Review of nursing progress notes identified a pattern of ongoing behavioral concerns following admission. A progress note dated March 3, 2026, at 2:32 PM documented Resident 57 contacted her responsible party stating she had not received her noon medications. Nursing documentation indicated staff spoke with the resident and confirmed that the nurse had observed the resident swallow the medications as prescribed. A progress note dated March 20, 2026, at 11:28 PM documented Resident 57 refused a scheduled shower and reported concerns that other residents were entering her room and touching and taking her belongings, including socks. A progress note dated March 23, 2026, at 5:59 AM documented nursing staff, including the nursing supervisor, administered medications to Resident 57 and reviewed each medication with the resident. Documentation indicated the resident signed an acknowledgement form confirming she received her medications. A progress note dated March 23, 2026, at 11:04 AM documented Resident 57 stated her daughter would assume responsibility for laundry due to concerns that clothing items were missing. Documentation indicated staff communicated with the resident's responsible party and facility staff, who reported no knowledge of missing clothing. The responsible party indicated she did not plan to wash the resident's laundry, and the facility would continue to provide laundry services. During an observation conducted on March 25, 2026, at 8:22 AM, Employee 1 LPN (Licensed Practical Nurse) requested Employee 3 RNS (Registered Nurse Supervisor), to observe medication administration for Resident 57. Interview with Employee 3 RNS at the time of observation revealed staff had recently been accused by the resident of not administering medications and of taking items belonging to the resident. Employee 3 RNS stated staff had begun providing care with two staff members present due to the resident's ongoing accusatory statements. Review of progress notes, staff interviews, and observation of medication administration indicated Resident 57 demonstrated ongoing accusatory behaviors related to medication administration and personal belongings. However, review of the comprehensive care plan revealed no documented revisions to address the resident's ongoing behaviors, identify potential triggers (events or circumstances that may lead to behavioral responses), or include individualized interventions such as the use of two staff members during care interactions to support reassurance and reduce distress. During an interview on March 25, 2026, at 12:30 PM, the findings related to the facility's failure to update Resident 57's comprehensive care plan to reflect ongoing behavioral concerns and individualized interventions were reviewed with the Nursing Home Administrator and Director of Nursing. The facility failed to revise Resident 57's comprehensive care plan to reflect changes in condition, failed to identify person-centered interventions to address ongoing accusatory behaviors, and failed to ensure the care plan accurately reflected the resident's current needs and individualized approaches to care. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, and staff interviews, it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a bowel protocol for one of 20 residents reviewed (Resident 8). Findings include: According to the American Academy of Family Physicians one of the largest medical organizations in the US founded to promote the science and art of family medicine), the primary goal of constipation management (treatment of difficulty passing stool or infrequent bowel movements) is improvement of symptoms, with the passage of soft, formed stool without straining generally occurring at least three times per week. A review of the clinical record revealed Resident 8 had physician orders dated July 19, 2024, for a bowel regimen (a step-by-step treatment plan used to prevent or relieve constipation) which included: Milk of Magnesia (magnesium hydroxide, a medication used to relieve constipation by drawing water into the bowel) suspension 400 mg/5 ml; administer 30 milliliters by mouth as needed for constipation if no bowel movement (BM) by day 3. Dulcolax suppository 10 mg (a rectal medication inserted into the rectum to stimulate bowel movement); insert one suppository rectally as needed for constipation if no bowel movement by day 4. Fleet enema (a rectal liquid medication used to stimulate bowel evacuation); insert one application rectally as needed for constipation if no bowel movement by day 5, and if no result notify the physician (MD, medical doctor) for further direction. A review of Resident 8's bowel tracking documentation for January 2026 revealed Resident 8 did not have a documented bowel movement on January 18, 19, and 21, 2026, across all three shifts. Documentation further indicated Resident 8 did not have a bowel movement on January 20 and January 22, 2026, on first and third shifts. There was no documented evidence on the bowel tracking record for the second shift on those dates to determine whether a bowel movement occurred. Continued review of January 2026 bowel tracking revealed Resident 8 did not have a documented bowel movement on January 28, 29, 30, or 31, 2026. A review of Resident 8's Medication Administration Record (MAR, a clinical record used to document medications administered to a resident) for January 2026 revealed no documented evidence that nursing staff administered the physician-ordered bowel protocol during the periods Resident 8 went multiple consecutive days without a bowel movement. A review of Resident 8's bowel tracking documentation for February 2026 revealed Resident 8 did not have a documented bowel movement on February 2, 3, 4, and 5, 2026. Further review revealed Resident 8 did not have a documented bowel movement on February 16, 17, 18, 21, 22, and 23, 2026. A review of Resident 8's February 2026 MAR revealed Milk of Magnesia was administered on February 6, 2026, which corresponded to day 4 without a documented bowel movement. Review of the MAR revealed no documented evidence that nursing staff administered the remaining physician-ordered bowel protocol interventions during the identified periods when Resident 8 had no bowel movement for multiple consecutive days. During an interview conducted on March 25, 2026, at 1:30 PM, the Director of Nursing (DON) reviewed the above findings and was unable to provide documented evidence that nursing staff consistently followed the physician-ordered bowel protocol for Resident 8 during the identified periods without bowel activity. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Medical records.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate documentation of drug administration for one of 20 residents reviewed (Resident 34).Findings include:A review of the facility policy titled Controlled Substances, (medications regulated by federal law due to their potential for misuse or dependence and require accurate tracking from receipt through administration and disposition) last reviewed March 13, 2025, revealed the facility maintains a Master Controlled Substance Log, which includes individual medication sign-off sheets for each controlled medication and a shift-to-shift count reconciliation sheet located on each medication cart. The policy indicated staff are responsible for accurately documenting each dose removed and administered to ensure accountability and safe medication practices. A review of the clinical record revealed Resident 34 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (a condition involving buildup of fatty deposits inside the arteries that can reduce blood flow) and unspecified dementia (a decline in memory and thinking ability severe enough to interfere with daily functioning). A review of the clinical record revealed a physician's order dated February 12, 2026, for Ativan (Lorazepam) 0.5 milligram (mg) oral tablet to be administered every 6 hours as needed for agitation. Lorazepam is a Schedule IV controlled medication (a drug classified by the federal government as having a potential for misuse and therefore requiring strict inventory tracking and documentation). Further review revealed a physician's order dated March 15, 2026, for Ativan (Lorazepam) 0.5 mg oral tablet to be administered every 4 hours as needed for restlessness and agitation. A review of facility records revealed the facility utilizes a Master Controlled Substance Log to track the removal and administration of controlled medications, including Lorazepam. A review of the Medication Administration Record (MAR) (a clinical record used to document medications administered, including date, time, dosage, and staff responsible for administration) indicated documentation of medications administered to Resident 34. A comparison of Resident 34's Master Controlled Substance Log with the MAR for February 2026 through March 2026 revealed six entries indicating Lorazepam 0.5 mg was removed according to the Master Controlled Substance Log; however, there was no corresponding documentation in the MAR indicating the medication was administered on the following dates: February 11, 2026, at 7:34 PMFebruary 13, 2026, at 12:00 PMFebruary 19, 2026, at 6:00 PMMarch 1, 2026, at 12:00 AMMarch 3, 2026, at 5:30 AMMarch 4, 2026, at 12:00 AM Comparison of the Master Controlled Substance Log with the MAR for February 2026 through March 2026 revealed two entries indicating Lorazepam 0.5 mg was documented as administered on the MAR; however, there was no corresponding documentation in the Master Controlled Substance Log indicating the medication was removed from inventory on the following dates: February 19, 2026, at 4:00 PMFebruary 27, 2026, at 9:00 PM These discrepancies demonstrated that the facility failed to ensure accurate reconciliation between the controlled substance inventory log and the Medication Administration Record, which is necessary to maintain accountability and prevent medication errors or diversion (the unauthorized use or removal of medication). During an interview on March 25, 2026, at 1:30 PM, the Director of Nursing was made aware of the above findings related to the facility's failure to implement effective procedures to reconcile Resident 34's controlled substance medication documentation. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications for 2 of 18 residents reviewed. (Resident 9 and 41). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse (RN) was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care including Medication Records. A review of facility policy entitled: Medication Administration last reviewed by the facility on January 2, 2025, indicated that medications are administered within 60 minutes of their scheduled time. A review of the clinical record of Resident 9 revealed admission to the facility on [DATE], with diagnoses which included unspecified dementia (a progressive loss of cognitive function) and muscle weakness. A review of Resident 9's Medication Administration Record for May 2025 revealed the resident was prescribed and scheduled to receive the following medications: Loratadine 10MG (antihistamine used to treat allergies) 1 tablet by mouth at 8:00 AM Duloxetine HCL 30MG (antidepressant) 1 capsule by mouth at 8:00 AM Lactobacillus Rhamnosus- (probiotic supplement used to treat digestive issues) 1 capsule by mouth at 08:00AM Glucosamine-Chondroitin 750/600 mg-(dietary supplement to treat joint disorders) 1 tablet by mouth at 08:00AM Triamterene-HCTZ 37.5-25MG (a water pill used to commonly treat high blood pressure)- 1 tablet by mouth at 08:00AM Allopurinol 100MG- (used to prevent gout and decrease uric acid levels)1 tablet by mouth at 08:00AM Metoprolol Succinate 50MG (used to treat high blood pressure)- 1 tablet by mouth at 08:00AM Miralax Powder 17 GM- (used to treat constipation)1 scoop by mouth at 08:00AM Review of the resident's medication administration audit report for May 2025 indicated that on May 3, 2025, the medications scheduled for 8:00 AM were administered at 10:19 AM, 2 hours and 19 minutes after the scheduled time. On May 6, 2025, the scheduled 8:00 AM medications were administered at 10:23 AM, 2 hour and 23 minutes after the scheduled time. A review of the clinical record of Resident 41 revealed admission to the facility on [DATE], with diagnoses, of Parkinson's disease (a progressive neurological disorder that affects movement causing tremors and stiffness of the muscles), and generalized muscle weakness. A review of Resident 41's Medication Administration Record for May 2025 revealed that the resident was prescribed and scheduled to receive the following medications: Carafate 1 GM/10ML (anti ulcer medication)- 10ML by mouth at 08:00AM Vitamin D 50mcg- 1 tablet by mouth at 08:00AM Sennosides 8. 6mg (used to treat constipation)- 2 tablets by mouth at 08:00AM Finasteride 5mg (used to treat difficult urination)-1 tablet by mouth at 08:00AM Carbidopa-Levodopa 25/100MG (used to treat Parkinson's disease)- 2 tablets by mouth at 08:00AM Protonix 40MG (used to treat stomach disease/ulcers)- 1 packet by mouth at 08:00AM Multivitamin- 1 tablet by mouth at 08:00AM Calcium Carb/Cholecalciferol 600 MG/10 MCG (calcium supplement)- 1 tablet by mouth at 08:00AM Liquacel Oral Solution (protein supplement)- 30 ml by mouth at 08:00AM Gabapentin 100MG (used to treat nerve pain)- 1 tablet by mouth at 08:00AM Folic Acid 1MG- 1 tablet by mouth at 08:00AM Lasix 20mg (diuretic or water pill)- 1 tablet by mouth at 08:00AM Toprol XL 25MG (used to treat high blood pressure)- 1 tablet by mouth at 08:00AM Klor-Con 20 mEq (potassium supplement)- 1 tablet by mouth at 08:00AM Review of the resident's medication administration audit report for May 2025 indicated that on May 5, 2025, the medications scheduled for 8:00 AM were administered at 09:52 AM, 1 hour and 52 minutes after the scheduled time. On May 6, 2025, the medications scheduled at 08:00AM were administered at 10:54 AM, 2 hours and 54 minutes after the scheduled time. Interview with the Nursing Home Administrator on May 8, 2025, at approximately 2:45 PM confirmed that the late medication administration is not consistent with the professional standards and medications should be received in a timely manner. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of controlled drug shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed. Findings include: A review of facility policy entitled Marywood Heights Count Records last reviewed January 2, 2025, revealed controlled drugs are inventoried and documented under proper conditions in regard to security and state/federal regulations. Further the policy indicated Scheduled II medications are counted by the oncoming nurse and outgoing nurse at the change of each shift and documented on the individual shift count sheet for narcotics. A review of the facility Master Control Substance Log from the 215 to 271 nursing unit medication cart revealed the following: April 13, 2025, the day shift on coming nurse failed to sign that the narcotic count was completed and correct. April 13, 2025, the evening shift off going nurse failed to sign that the narcotic count was completed and correct. April 15, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct. April 16, 2025, the day shift oncoming nurse failed to sign that the narcotic count was completed and correct. April 16, 2025, the evening shift oncoming nurse failed to sign that the narcotic count was completed and correct. April 16, 2025, the day shift off going nurse failed to sign that the narcotic count was completed and correct. April 16, 2025, the night shift oncoming nurse failed to sign that the narcotic count was completed and correct. April 16, 2025 the evening shift off going nurse failed to sign that the narcotic count was completed and correct. April 19, 2025, the night shift on coming nurse failed to sign that the narcotic count was completed and correct, April 20, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct. An interview with Employee 1 LPN (licensed practical nurse) on May 6, 2025, at 9:05 AM confirmed the narcotic sheet was not signed off by the off going and oncoming nurses on the above dates. A review of the facility Master Control Substance Log from the 202 to 262-unit medication cart revealed the following: May 2, 2025, the day shift off going nurse failed to sign the narcotic count was completed and correct. May 2, 2025, the night shift on coming nurse failed to sign the narcotic count was completed and correct. May 2, 2025, the night shift off going nurse failed to sign the narcotic count was completed and correct. An interview with Employee 2 RN (registered nurse) on May 6,2025, at 9:25 AM, confirmed the narcotic sheet was not signed by the off by the off going and oncoming nurses on the above dates. An interview on May, 6 2025, at approximately 1:45 PM, the Nursing Home Administrator confirmed the facility failed to demonstrate consistent implementation of procedures for promoting accurate controlled drug records. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service 28 Pa Code 211.9 (c)(k) Pharmacy services 28 Pa Code 211.5(f)(x) Clinical records

Based on observation, select facility policy review and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. Findings include: A review of facility policy titled Disposal of Medications and Medication Related Supplies, last reviewed by the facility in January 2, 2025, revealed that discontinued medications and mediations left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. Observation of the medication storage room on May 6,2025, at 8:44 AM revealed an unsecured, opened white paper bag located on the counter of the medication room. The bag contained the following: Two separate rolls of medication packets, one roll containing 46 packets of medications, the second roll contained 29 packets of medications. One box containing two tabletss of Cefdinir (antibiotic). A clear plastic envelope containing two capsules of tizanidine (a muscle relaxant). One clear plastic envelope containing two tablets of Furosemide (a diuretic). A clear plastic envelope contained seven tablets of Potassium Chloride (a mineral supplement). 11 tabs of Torsemide (a diuretic). 14 tablets of Cefuroxime Axetil (an antibiotic). One box of Enalapril- HCTZ (blood pressure medication). One box containing four capsules of Doxycycline(antibiotic). One box containing 14 tabs of Olanzapine (an antipsychotic medication). One clear plastic envelope containing 20 tablets of Escitalopram(an antidepressant). A clear plastic envelope containing four tablets of Metoprolol Tartrate (blood pressure medication). A clear plastic envelope containing Metoprolol Succinate (blood pressure medication). One clear plastic envelope containing 12 tablets of Vitamin D3. A clear plastic envelope containing three tablets of Vitamin C. Interview with Employee 1 a licensed practical nurse (LPN) during the time of the observation, confirmed the medications were all discontinued resident medications that were removed from the medication carts and brought into the medication storage room to be destroyed or returned to the pharmacy. Employee 1 indicated the medications are destroyed when the nurses have time. Employee 1 further stated she was a new employee to the facility and was unsure if she was allowed to destroy the medications without another nurse present. Employee 1 was uncertain of the timeframe which the pharmacy picks up discontinued medication. Interview the Director of Nursing (DON) and the Nursing Home Administrator on May 6,2025 at 1:45 PM confirmed the expectation was that discontinued resident medications would be removed from the medication cart by a licensed nurse and destroyed or returned to pharmacy per facility policy. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by six of six residents attending a resident group meeting (Residents 16, 43, 62, 129, 32, and 71) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the facility's Grievance Policy last revised in December 2019 indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official or designee will meet with the resident to formally review the resolution to the grievance. A review of the Minutes from Resident Council meetings dated March 5, 2025, revealed concerns from residents that call bells were not answered timely. A grievance was filed on March 5, 2025, regarding this concern. Review of this grievance revealed no follow up was completed with the residents who raised this concern during resident council. There was no documented evidence of corrective actions taken to address this issue. A group meeting conducted on May 7, 2025, at 10:00 a.m. with six residents (Residents 16, 43, 62, 129, 32, and 71) revealed unanimous reports the facility failed to address their complaints regarding the timeliness of call bell response. The facility was unable to provide documented evidence that efforts had been made to resolve resident complaints concerning call bell timeliness as of the survey ending May 8, 2025, that had been brought up during resident council meeting. During an interview on May 8, 2025, at 9:10 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the absence of documented actions addressing grievances raised during Resident Council meetings or verbal complaints. 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident Rights

Based on clinical record and select facility policy review and staff interview, it was determined the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of 18 sampled residents (Resident 69). Findings include: A review of the facility's policy entitled Pain Management with a policy review date of January 2, 2025, indicated that all residents are assessed for pain every shift by a nurse utilizing a 0 (zero) to 10 pain intensity scale (0 = no pain, 1,2, and 3 are classified as mild pain, 4, 5, 6, and 7 are classified as moderate pain, 8, 9, and 10 are classified severe pain). Non-pharmacological interventions may be effective for pain relief and might include ice packs, heat, (these require a physician's order) toileting, position changes, therapeutic touch, music, breathing exercise, distraction, and equipment such as a TENS (transcutaneous electrical nerve stimulation uses low voltage electrical current to relieve pain) unit (also requires a physician order). The nurse must assess for pain after utilizing these measures, which may be appropriate, and must note this in a progress note. A clinical record review revealed that Resident 69 was initially admitted to the facility on [DATE], and a more recent readmission to the facility on [DATE], with diagnoses that included major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest that affects how one feels, thinks, and behaves and can lead to a variety of emotional and physical problems) with severe psychotic symptoms (is the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), lack of coordination, abnormal gait (walking patterns) and mobility, and history of fracture to the left pubis (left pelvis is the sturdy ring of bones located at the base of the spine). A review of the resident's physician's orders revealed an order dated September 28, 2024, at 6:18 PM, Acetaminophen Tablet 325 mg (milligrams), give 2 tablets by mouth every 4 hours PRN (as needed) for mild pain and Oxycodone HCl (an opioid analgesic used to treat moderate to severe pain) oral tablet 5 mg, give 5 mg by mouth every 5 hours PRN for pelvic pain. Additionally, the orders for Oxycodone HCl failed to specify a corresponding administration intensity scale. A review the resident's electronic Medication Administration Record (eMAR - is used to document medications taken by each resident) dated January 2025, revealed that the PRN Acetaminophen (non-opioid pain medication) ordered to manage mild pain and PRN Oxycodone HCl (opioid pain medication) were administered without any documented attempts of nonpharmacological interventions and administered outside of the prescribed physician orders/pain intensity scale on the following dates as follows. January 5, 2025, at 10:57 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 7, 2025, at 9:24 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 14, 2025, at 2:22 AM, administered PRN Acetaminophen for a reported pain level at 9 and without attempted nonpharmacological interventions with pain level exceeding the mild pain intensity scale. January 14, 2025, at 2:36 AM, administered PRN opioid pain medication for a reported pain level at 9 and without attempted nonpharmacological interventions. January 14, 2025, at 9:45 AM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 15, 2025, at 3:04 AM, administered PRN Acetaminophen for a reported pain level at 3 and without attempted nonpharmacological interventions. January 15, 2025, at 5:22 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 15, 2025, at 10:00 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 16, 2025, at 7:26 PM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 17, 2025, at 7:25 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 18, 2025, at 2:48 AM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 18, 2025, at 5:23 AM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 18, 2025, at 11:26 PM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 20, 2025, at 3:29 PM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 21, 2025, at 10:00 PM, administered PRN opioid pain medication for a reported pain level at 6 and without attempted nonpharmacological interventions. January 22, 2025, at 9:01 AM, administered PRN opioid pain medication for a reported pain level at 5 and without attempted nonpharmacological interventions. January 23, 2025, at 3:18 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 24, 2025, at 5:17 AM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 24, 2025, at 4:14 PM, administered PRN opioid pain medication for a reported pain level at 7 and without attempted nonpharmacological interventions. January 24, 2025, at 8:58 PM, administered PRN Acetaminophen for a reported pain level at 3 and without attempted nonpharmacological interventions. January 26, 2025, at 3:00 AM, administered PRN opioid pain medication for a reported pain level at 10 and without attempted nonpharmacological interventions. January 26, 2025, at 3:12 AM, administered PRN Acetaminophen for a reported pain level at 10 and without attempted nonpharmacological interventions with pain level exceeding the mild pain intensity scale. January 26, 2025, at 8:58 PM, administered PRN Acetaminophen for a reported pain level at 3 and without attempted nonpharmacological interventions. January 29, 2025, at 3:32 PM, administered PRN opioid pain medication for a reported pain level at 8 and without attempted nonpharmacological interventions. January 30, 2025, at 9:31 AM, administered PRN Acetaminophen for a reported pain level at 3 and without attempted nonpharmacological interventions. Further review of Resident 69's clinical record failed to consistently reveal that licensed nursing staff attempted to notify the resident's attending physician of increased complaints and effectively alleviate her increased pain intensity levels. Additionally, the facility failed to assure that licensed nursing staff attempted non-pharmacological interventions prior to administering analgesic pain medication that included opioids. An interview with the Director of Nursing (DON) on May 8, 2025, at 2:30 PM, confirmed that licensed nursing staff failed to timely notify the resident's attending physician of increased complaints to develop an effective pain management regime to manage Resident 69's increased pain intensity levels. The DON also confirmed that the facility could not provide documented evidence that licensed nursing staff attempted non-pharmacological interventions prior to the administration of opioid pain medication. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 18 residents sampled (Resident 56). Findings included: A review of Resident 56's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include senile degeneration of the brain (a decline in cognitive function associated with aging) and chronic lymphocytic leukemia (a slow growing cancer of the white blood cells). A nursing progress note dated April 23, 2025, indicated the resident was noted to have yellow discharge from his penis. The physician was notified, and an order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for possible infection. A nursing progress note dated April 24, 2025, at 10:22 AM documented that a urine sample was obtained from the resident, the progress note further revealed the resident's urine appeared concentrated (dark in color, indicating potential infection or dehydration) A review of a nursing progress notes dated April 25, 2025, at 10:40 AM revealed the resident's urinalysis results were received, and faxed to the physician with no new orders at the time. A review of a nursing progress notes dated April 25, 2025, at 1:37PM revealed a new order for Ciprofloxacin 500mg by mouth twice daily for 7 days for a diagnosis of a urinary tract infection. A review of the resident's laboratory report dated April 25, 2025, 10:10AM revealed the urine culture identified Morganella morganii (a rare infection of urinary tract, commonly associated with antibiotic resistance. These enzymes break down certain antibiotics making the bacteria resistant to these medications) with bacterial growth of 50,000- 100,000 CFU/ml. The report further indicated the prescribed antibiotic (Ciprofloxacin) was resistant to the bacteria found in the resident's urine, rendering the treatment ineffective. A review of Resident 56's Medication Administration Record (MAR) for April 2025 revealed the resident received eight (8) doses of Ciprofloxacin, an unnecessary antibiotic, even though the culture and sensitivity results confirmed the prescribed medication was ineffective. During an interview with the Director of Nursing (DON) on May 8, 2025, at approximately 1:15 PM, the DON confirmed the administration of Ciprofloxacin was not clinically justified, as the prescribed antibiotic was ineffective against the identified organism. The DON acknowledged the resident received an unnecessary medication, which did not align with evidence-based infection control and antimicrobial stewardship practices. 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of clinical records and select investigation reports and staff interviews, it was determined that the facility failed to provide necessary supervision, and implement effective individualized safety measures for a resident with known unsafe behaviors to prevent multiple falls for one resident (Resident 13) and a serious burn, to one resident (Resident 27) out of 19 residents sampled. Findings include: A review of Resident 27's clinical record revealed that the resident was admitted to the facility April 14, 2023, with diagnoses to include hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side. (Hemiparesis, also called unilateral paresis, is the weakness of one entire side of the body. Hemiplegia, in its most severe form, is the complete paralysis of one entire side of the body). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 15, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The resident required supervision and the assistance of one staff person when eating according to the MDS assessment. The resident had a current physician order, initially dated January 23, 2024, for the use of a Kennedy cup (a lightweight spill proof drinking cup that is used with a straw) at all meals and for the use of Divided scoop dish and built up utensils to max his ability to engage in self-feeding tasks dated November 27, 2023. An Occupational Therapy treatment encounter note dated December 14, 2023, the last encounter the resident had with Occupational Therapy, prior to an incident that occurred while the resident was eating on July 14, 2024, indicated that the resident required precautions due to the resident's left sided hemiplegia (paralysis on one side of the body). The resident was able to drink from a Kennedy cup and utilize built-up utensils and scoop dish with moderate staff assistance to manage eating with these assistive devices. Review of documentation in Resident 27's clinical record revealed the resident had multiple falls since the resident's admission to the facility on [DATE], through the time of the survey ending July 25, 2025, with progress note documentation revealing that the resident displayed frequent behaviors of restlessness and impulsivity. A nurses note dated July 14, 2024, indicated that at approximately 4:00 PM Resident 27 accidentally spilled soup on his LLQ (left lower quadrant) and left groin during evening meal. Area from lower abdomen to groin erythematous with bright coloration and shiny appearance. One (1 cm) blister noted on center of LLQ area. Resident c/o pain and was medicated per order. At time of event, resident was sitting in chair at dining table, soup was placed in center of table out of exact reach, staff were present in dining room serving other residents, clothing protector was in place for protection. Resident over estimated ability to handle soup bowl independently. Resident diagnosed with left hemiplegia/hemiparesis post cerebral infarct as well as lack of coordination. Following event, nurse immediately removed source of heat and rushed [Resident 27] to wash area where clothing was removed, area soaked in cool running tap water. SSD applied. Call out to on-call provider. A review of the incident report completed by the facility Director of Nursing, dated July 15, 2024, revealed that Resident 27 sustained a burn while reaching for his soup, which staff placed on the table in a reachable distance from the resident, when staff turned to get an ice cube to cool the resident's soup per his preference. The incident report revealed that the dietary staff had taken the temperature of the soup in the kitchen, prior to point of service to the resident, and noted the temperature 179 degrees fahrenheit at that time. The facility staff did not obtain the temperature of the soup after it was brought to the dining room steam table, the point of service to residents, as per facility policy. Review of a witness statement from Employee 3, LPN, dated July 14, 2024, revealed that at dinner time, she delivered Resident 27's soup from the steam table in the dining room and set him up at the dining table to eat, thinking the soup was out of the resident's reach. Employee 3 stated she turned around to get the resident an ice cube per his preference and the resident was able to reach his soup and it spilled in his lap. Resident 27's clinical record revealed resident sustained a 12 cm x 15-centimeter reddened area on his left lower stomach with a 1-centimeter blister noted. A physician order dated July 15, 2024, was noted to cleanse the blister on the resident's left lower abdomen with NSS, apply Silvadene cream, non-stick dressing and optifoam daily and prn soilage/displacement. An Occupational Therapy consult dated July 16, 2024, after the resident sustained the burn on July 14, 2024, revealed that the resident had a decline in ability to feed himself even with the use of built up utensils, and now required moderate staff assistance during eating. The consult noted that the resident's poor safety awareness contributed to his spillage of soup and subsequent burn. The facility failed to consistently provide the resident with the necessary staff supervision at meals, based on the resident's known restlessness and impulsivity, to prevent a serious injury to the resident. Interview with the NHA and DON on July 25, 2024, at approximately 12:00 PM revealed that the facility was unable to provide evidence that staff supervised Resident 27 while eating to prevent the resident from spilling hot soup on himself sustaining painful burns. Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety. Review of Resident 13's transfer paperwork the facility received from a prior skilled nursing facility revealed that the resident was at high risk for falls. The sending [NAME] nursing facility provided this current facility with the resident's plan of care, which included all interventions implemented for safety. These interventions included to encourage the resident to be out of bed for all meals, placement of a fall mat to left side of bed while resident in bed, low bed- keep in lowest position (bed controls out of resident's reach), offer to adjust temperature when placed in bed, offer toileting between 1:30 PM and 2:30 PM and change (incontinence care) if needed, pad alarm to bed hung behind headboard [control box] to alert staff of self-transfers and check functioning and placement every shift, resident request is to be in bed between 7:30 PM and 8 PM, resident to be out of bed in wheelchair with rearward tilt of wheelchair seat, thicker fall mat to window side (left) side of bed when resident in bed and check every shift, keep frequently used items in reach, and high risk for falls. Resident 13's transfer documentation also revealed that she had a self-releasing seat belt with alarm to alert staff of attempts to self transfer initiated October 19, 2023, and had experienced a recent fall on May 24, 2024. An Admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 12, 2024, revealed that the resident was cognitively intact with a BIMS score of 15 (a score of 13 to 15 indicates no cognitive impairment). A Fall Morse Scale evaluation dated June 5, 2024, revealed that the resident was identified as a Moderate Fall Risk. Interventions implemented upon admission included to have call bell in reach, pain evaluation, non-skid socks, and a therapy screen. A review of Resident 13's baseline care plan dated June 5, 2024, revealed that interventions implemented upon admission on June 5, 2024, were to anticipate and meet resident's needs, encourage resident to use call bell for assistance as needed, and for room to be free from spills and/or clutter with adequate light. An incident report investigation dated June 18, 2024, revealed that at 1:45 PM, Resident 13 fell to the floor in her room while attempting to self-transfer to wheelchair from standard chair. The resident was found on the floor, lying on her left side, after the resident's roommate rang the call bell for staff assistance. According to investigation, Resident 13's roommate witnessed the fall, and Resident 13 did not sustain any injuries. Safety interventions implemented after fall included to apply dycem (non-skid material) beneath cushion. Review of care plan revealed that interventions added June 20, 2024, included a sensor pad to both the resident's bed and chair. An incident report investigation dated June 25, 2024, revealed that at 11:35 AM, staff again found the resident on the left side of her bed on the floor. She sustained a bump on the back of her head. According to the investigation, the resident stated that she was attempting to get out of bed to go out the door. The physical therapy assistant found the resident on the floor when she had returned Resident 13's roommate to their room. There was no evidence according to incident report and witness statement, that bed or chair alarms were sounding/functioning to alert staff that Resident 13 had self-transferred and on the floor. The incident report indicated that a low-bed and a medication review were to be implemented, and orders received for ice to be applied to bump on the back of resident's head, and neuro checks were initiated. Review of documentation dated June 25, 2024, at 2:27 PM revealed that the resident complained of dizziness and nausea. Neuro check within normal limits with the exception of the new nausea and dizziness. Orders were received from the physician to send the resident to the emergency room for an evaluation. Review of emergency room evaluation dated June 25, 2024, the resident was seen after falling backwards in her bathroom, hitting the back of her head on the tile. En route to the ED [emergency department], patient offered complaints of HA [headache] accompanied by blurry vision, nausea, and dizziness. No injuries were identified and based on urinalysis, the resident returned to the facility on antibiotic for possible urinary tract infection. An incident report investigation dated June 29, 2024, revealed that at 6:45 AM, staff again found the resident on the floor to the left side of the resident's bed. The bed alarm was sounding and the resident's call bell within reach. According to the investigation, the resident rolled out of bed. Resident 13 then complained of left knee and left hip pain and x-rays were ordered by the physician. No fractures/injuries were identified and floor mats were to added to both sides of the resident's bed when the resident in bed (an intervention that had been in place when the resident resided at the prior skilled nursing facility and noted on the transfer form, with a thicker fall matt on the left side). Review of an incident report investigation dated July 7, 2024, revealed that at 10:45 AM, Resident 13's roommate rang the call bell to alert staff that Resident 13 was ambulating unassisted. Staff found Resident 13 sitting on the floor, on the left side, in front of wheelchair. According to the investigation, Resident 13 stated that she went to get my sneakers, I didn't ring because I'm stupid. The investigation's conclusion indicated that the resident self-removed chair alarm and attempted to ambulate across the room to retrieve item, and overestimates functional abilities and has poor safety recall. The alarm was replaced, and a therapy screen was submitted for further recommendations. An incident report investigation dated July 11, 2024, revealed that at 6 AM, the resident had an unwitnessed fall while attempting to self-transfer out of bed. The resident was found on window side of the bed with alarm sounding, fall mats were noted to be in place, call bell within reach, and non-skid socks in place. The resident stated she wanted to get up. According to the report, the resident had been tended to approximately 30 minutes prior to fall. Additional intervention included application of a perimeter/raised edge mattress to the resident's bed to enhance safety awareness of bed perimeter. A incident report investigation dated July 16, 2024, revealed that at 10:45 AM, staff found Resident 13 on the floor in the bathroom of the resident's room, sitting next to the toilet. According to the investigation, the resident stated that she transferred herself from the toilet to the wheelchair and slid to the floor. The investigation's conclusion, revealed that resident did not ask for assistance, requires assist of 2 staff members with rollator walker for transfers, is non-ambulatory, forgets to ask for assistance, and self-removed alarm. The resident did not sustain any injuries. The resident's risk for falls and need for multiple safety and fall prevention measures was included in the resident's transfer documentation upon the resident's admission to the facility. The facility failed to timely address the resident's high risk for falls and promptly implement sufficient safety and fall prevention interventions, individualized to the resident's habits and behaviors identified in the resident's transfer documentation, to prevent repeated falls, which increased the resident's risk for serious injury. Interview with the NHA and DON on July 25, 2024, at 11:30 AM confirmed that the facility was unable to demonstrate the implementation of necessary individualized fall prevention measures, and sufficient staff supervision at the level and frequency required, to prevent Resident 13's repeated falls. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on review clinical records and medication administration record, and staff interview, it was determined that the facility failed to ensure that the attending physician acted upon on the pharmacist's reports of irregularities in the drug regimen of one resident of 19 residents reviewed (Resident 41). Findings include: Review of Resident 41's clinical record revealed admission to the facility on [DATE], with diagnoses that included major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, obsessive-compulsive disorder and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated January 24, 2024, addressed the physician's order for Ativan (an antianxiety medication) 0.5 mg three times a day for anxiety. The pharmacist recommended a Gradual Dose Reduction (GDR), noting that per CMS guidelines for psychotropic drugs, a GDR must me attempted annually, unless clinically contraindicated. The pharmacist further noted that if the drug therapy is to continue, the physician must document why the risk of the adverse consequences presented by an attempted GDR exceed the benefit of the GDR due to potential negative impact on the resident's psychiatric instability, functional capacity and quality of life. The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's recommendation and there was no documentation that the resident's physician acknowledged this identified pharmacy report. Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated April 24, 2024, noted that Resident 41 was prescribed three medications for anxiety: Remeron, Ativan, and Buspar with recommendation to evaluate if any of the medications could be reduced or discharged to avoid duplication of effect. The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's recommendation and there was no documentation that the resident's physician acknowledged this identified pharmacy report. Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated June 26, 2024, indicated that this is the 2nd request regarding three medications for anxiety: Remeron, Ativan, and Buspar with recommendation to evaluate if any of the medications could be reduced or discharged to avoid duplication of effect. The facility failed to provide written documentation of the attending physician's response to the consultant pharmacist's 2nd request for recommendation and there was no documentation that the resident's physician acknowledged this identified pharmacy report. An interview with Director of Nursing on July 24, 2024, at approximately 2:00 PM confirmed that the facility was unable to provide documented evidence that the attending physician acted upon the pharmacy recommendations. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa Code 211.5 (f) Medical records 28 Pa. Code 211.2 (d)(7) Medical director

Based on review of clinical records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, reflecting the medial care for three residents out of 19 sampled (Residents 13, 37 and 60). Findings included: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient ' s designated support person and other third parties. Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety. Review of documentation dated June 25, 2024, at 2:27 PM revealed that Resident 13 was sent to the emergency room for an evaluation due to complaints of dizziness and nausea after sustaining a fall. Documentation dated June 25, 2024, at 9:53 PM indicated that Resident 13 returned to the facility at 8 PM. Verbal report was received from the hospital with instruction for the facility to administer Keflex 500mg twice a day for 10 days for a possible urinary tract infection. A review of the resident's clinical record conducted during the survey ending July 25, 2024, revealed no documented evidence from Resident 13's evaluation in the emergency roiagnom on [DATE], which resulted in treatment for a possible UTI. During an interview with the Infection Preventionist on July 25, 2024, at 11:00 AM confirmed there was no evidence of any documentation from the emergency room evaluation of Resident 13. The Infection Preventionist produced the information at approximately 1 PM on July 25, 2024. Review of Resident 37's clinical record revealed admission to the facility on [DATE], with diagnoses which included Alzheimer's disease, venous insufficiency, and hypertension. Review of resident's immunization record failed to provide evidence that Resident 37 was screened for Tuberculosis prior to admission to the facility or annually per facility policy. Interview with the facility's Infection Preventionist (IP) on July 24, 2024, at approximately 10:30 AM, confirmed that the resident's clinical record did not include evidence of screening for Tuberculosis since admission to the facility. Review of resident screenings for Tuberculosis provided by the IP on July 24, 2024, revealed that Resident 37 had been screened according to policy, and last screening was performed in October 2023, yet the screenings were not provided in the resident's clinical record. Interview with the DON and Nursing Home Administrator (NHA) on July 25, 2024, at approximately 1:45 PM confirmed that the resident clinical records were not completed and or maintained accordingly. A review of the clinical record revealed Resident 60 was admitted to the facility on [DATE], with diagnoses to include polyneuropathies (damage/disease affecting the peripheral nerves featuring weakness, numbness and burning pain), autonomic neuropathy (damage to the nerves that control the automatic body functions such as blood pressure, temperature control, digestion, and bladder function), and anxiety. An Admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 29, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 14 (13-15 represents cognitively intact responses). Review of a nurses note dated May 31, 2024, at 11:29 AM revealed the facility received a call from the resident's wife stating that she received a call regarding a referral that was made while the resident was in the hospital. The resident had a scheduled appointment with Psychology at [NAME] in Danville on July 1, 2024, at 12:25 PM. MD aware. A nurses note dated June 12, 2024, at 7:54 AM revealed a call was placed to the resident's wife to communicate that the facility was unable to accommodate transporting the resident to the [NAME] Psychology appointment on July 1, 2024, due to distance as per Administrator and DON (Director of Nursing). Message left. A nurses note dated June 12, 2024, at 12:00 PM revealed a call was received from the resident's wife acknowledging that the facility was unable to transport the resident. Wife stated she will call [NAME] Psychology to see if they will do a telehealth appointment. A nurses note dated July 12, 2024, at 1:18 PM revealed the facility spoke with the Psychology department at [NAME] and the receptionist stated the resident will login (for his appointment) through his MyChart login. During an interview with Resident 60 on July 23, 2024, at 11:50 AM, the resident stated that the facility was unable to transport him to the July 1, 2024, appointment so his wife and daughter drove him to his [NAME] Psychology appointment in Danville. A review of the resident's clinical record revealed no documented evidence that the resident had left the facility to attend the appointment on July 1, 2024, or the results of that appointment upon the resident's return to the facility. Continued interview with Resident 60 revealed that the resident had a telehealth visit on July 12, 2024. The resident expressed frustration that the facility did not provide an electronic device to conduct the visit and his daughter had to scramble to get my son to bring in a device. Further review of the resident's clinical record revealed no documented evidence that the resident had a scheduled telehealth visit and no documented evidence of the results of that visit. Interview with the Director of Nursing on July 25, 2024, at approximately 12:15 PM, confirmed there was no documented evidence the resident left and returned to the facility for an appointment on July 1, 2024, no documented evidence that the resident attended a telehealth visit on July 12, 2024, and no documented evidence of the outcome of those visits. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records

Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 19 sampled (Resident 13). Findings included: Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety. Review of Resident 13's transfer paperwork revealed that the resident was at high risk for falls and had last experienced a fall on May 24, 2024. A review of Resident 13's Admission MDS assessment dated [DATE], Section J - Health Conditions, question J1700 Fall History on Admission/Entry or Reentry, did the resident have a fall any time in the last month prior to admission/entry or reentry, revealed that the coded answer was 0 which indicated no. There was no evidence that Resident 13's Admission assessment accurately identified the resident's fall history.

Based on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of bipolar disorder for one resident (Resident 41) out of 19 residents sampled. Findings include: A review of the Resident 41's clinical record revealed that the resident was admitted to the facility on [DATE], with three psychiatric/mood disorders: major depressive disorder, anxiety disorder, and obsessive-compulsive disorder. A review of Resident 41's resident's medical diagnosis list revealed a diagnosis of bipolar disorder, was added on April 4, 2023. A review of a physician progress note dated April 30, 2023, at 4:32 PM revealed that the physician examined the resident who presented with severe anxiety. Since the previous dose reduction and reintroduction (of medications), the resident has not responded to medical management. The physician indicated that her impression was the resident had bipolar depression. The plan of treatment was to change Seroquel (antipsychotic medication) to Zyprexa (antipsychotic medication) and discharge Atarax (medication used to treat anxiety). Review of Resident 41's Documentation Survey Report v2, Monitor-Behavior Symptoms dated April 2023, revealed staff documented on the resident's behavior daily. The report indicated that there were no days in April where Resident 41 exhibited adverse behaviors such as frequent crying, repeated movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, and rejection of care. All entries made by staff indicated that none of the above observed. A review of Resident 41's comprehensive plan of care initially dated July 12, 2023, and revised April 17, 2024, revealed a significant change in mental condition with a diagnosis of bipolar disorder. The interventions included monitoring behavior and mood and administer medications as prescribed. Review of a psychiatry consult dated October 11, 2023, revealed that the resident was diagnosed with generalized anxiety disorder. There was no documented evidence in the resident's clinical record to demonstrate that a clinical practitioner had diagnosed the resident with bipolar disorder with documented supporting clinical findings in the resident's clinical record from the time of the resident's admission to the facility on [DATE], through the current survey which ended on July 25, 2024. Interview with the Director of Nursing on July 24, 2024, at 1:40 PM, confirmed that the facility did not have documented evidence of a practitioner diagnosing the resident with bipolar disorder according to professional standards. 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa. Code 211.5 (f) Medical records

Based on observation, review of clinical records, and resident and staff interviews it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 24) to promote normal bowel activity to the extent practicable and failed to follow physician orders for the consistent application of a prescribed therapeutic measure, Darco shoes, for one resident of 19 sampled (Resident 55). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 24 had physician orders, dated February 27, 2024, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 7.75% (Magnesium Hydroxide), give 30 ml by mouth as needed for constipation. Give 30 ml on evening shift if no BM (bowel movement) by day 3. -Biscolax Suppository 10 mg (Bisacodyl), inset 1 suppository rectally as needed for constipation. Give on evening shift if no BM by day 4 if MOM is not effective. -Fleet Bisacodyl Enema 10 mg/30 ml (Bisacodyl), insert 1 applicatorful rectally as needed for constipation. Give on evening shift on day 5 if suppository is not effective. If not effective notify MD (physician). Review of Resident 24's Documentation Survey Report v2 for July 2024, revealed that Resident 24 did not have a bowel movement on July 4, 5, 6, 7, 8, 9, 2024. Review of Resident's Medication Administration Record (MAR) for July 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. There was no documented evidence that the staff had notified the physician that the resident went six consecutive days, July 4, 5, 6, 7, 8, 9, 2024, without a bowel movement. During an interview with the Director of Nursing (DON) on July 24, 2024, at 1:10 PM, the DON was unable to provide evidence that physician ordered bowel protocol was followed for Resident 24 during the period without bowel activity stated above, nor evidence of timely physician notification. A review of Resident 55's clinical record revealed a physician's order dated March 20, 2024, for the application of a heel off DARCO shoe (specialty shoe designed to off-load pressure from the heel by shifting weight to the mid and forefront of the foot to promote faster healing of a wound), to the RLE (right lower extremity), and a DARCO shoe to the LLE (left lower extremity). Observation of Resident 55 sitting in his wheelchair in the common area on July 23, 2024, at 12:45 PM, July 24, 2024, at 11:10 AM, and July 25, 2024, at 11:20 AM, revealed that the resident was not wearing a heel off DARCO shoe to his RLE or a DARCO shoe to his LLE as ordered at the time of each observation. Instead, the resident was wearing a pair of socks with sandals. During an interview with Resident 55 on July 23, 2024, at 12:45 PM, he reported that he does not wear DARCO shoes and only wears the socks and sandals that he was currently wearing. Interview with Employee 2 (licensed practical nurse) on July 25, 2024, at 11:20 AM, verified that Resident 55 had a physician's order for a heel off DARCO shoe to the RLE and a DARCO shoe to the LLE. Employee 2 confirmed that the resident was not wearing the DARCO shoes on his bilateral lower extremities at the time observed. During an interview on July 25, 2024, at approximately 12:30 PM, the Nursing Home Administrator and Director of Nursing confirmed that the staff had not followed the physician order for the application of the physician prescribed DARCO shoes. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records

Based on a review of clinical records and staff interview, it was determined that the facility failed provided necessary care to prevent urinary tract infections to the extent possible for one resident with an indwelling urinary catheter out of 19 sampled residents (Resident 1). Findings included: Clinical record review revealed Resident 1 was admitted on [DATE], with diagnoses, which included retention of urine, acute cystitis without hematuria, urinary tract infection, and required the use of an indwelling catheter for urination. Review of physician orders revealed an order dated March 15, 2024, to change catheter monthly/every 30 days and as needed for blockage, leakage, or dislodgement with 16 French and a 10 cc balloon (size of catheter) on the night shift. Review of Treatment Administration Record dated April 2024, failed to provide evidence that the resident's catheter was changed as ordered by the physician during the month of April 2024. Review of clinical record revealed that on May 17, 2024, the resident had an appointment with Urology. Orders received from urology included to irrigate foley daily to prevent sediment buildup, irrigate as needed for decreased urinary output, maintain foley with changes every 4 weeks, treat only symptomatic UTI (urinary tract infection) i.e.: fevers, chills, altered mental status. According to the Urology consult, the resident's urine will always come back with growth i.e.: colonization. Maintain adequate output from foley, avoid obstruction of foley. Physician orders revealed an order dated May 17, 2024, to change the foley catheter monthly on the 17th during the evening shift, to irrigate the foley daily to prevent sediment build-up, and irrigate foley as needed every 8 hours for decreased urinary output. Review of the physician orders revealed that the order dated March 15, 2024, to change the catheter every 30 days continued to be active. There was no evidence that the nursing staff verified what was to be used to flush the foley catheter, or how much solution was to be used for flushing the catheter. Additional review of the TAR dated May 2024 revealed that urinary output from the foley was to be documented each shift. There was no evidence that the solution used to flush the catheter was taken into consideration when calculating total urinary output for each shift, therefore potentially providing inaccurate amount of the resident's true output of urine. Review of TAR dated May 2024, revealed that the resident's catheter was changed on May 17, 2024, as ordered. Documentation dated June 29, 2024, indicated that the resident was prescribed antibiotic therapy due to a urinary tract infection. Review of documentation dated July 2, 2024, at 1023 PM indicated that Resident 1 pulled out the foley catheter and a new one was inserted. Review of the TAR dated July 2024, failed to provide documented evidence that the resident's catheter was changed on July 2, 2024. Further review of the TAR revealed that the resident's catheter was documented as being changed on July 16, 2024, and again July 17, 2024, due to the duplicate orders remaining in the resident's record. There was no evidence that the nursing staff referred to the orders from Urology to change the catheter every 4 weeks. Observation on July 23, 2024, at 11:30 AM, revealed an undated bulb piston syringe, and an undated, unlabeled, opened 1000 mL bottle of sterile water with approximately 600 mL remaining in the bottle setting on top of a 3-drawer cart in Resident 1's bathroom. Interview with Employee 1, licensed practical nurse (LPN), confirmed the observation. Employee 1 further confirmed that there was no evidence of how old the items were, and that the items were not stored in a sanitary manner. At time of survey ending July 25, 2024, there was no evidence that the nursing staff had verified the orders received from Urology on May 15, 2024, regarding flushing of the resident's catheter. Interview with the Director of Nursing on July 25, 2024, at approximately 2 PM, confirmed that the facility failed to provide appropriate care and services for a resident with and indwelling catheter and recurring urinary tract infections. Refer F880 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of five residents sampled (Resident 2). Findings include: A review of the facility's Resident Abuse policy, last revised January 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. This includes the protection of Resident's Rights. Each resident has the right to privacy, dignity and confidentiality for all aspects of care and services. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], 2022, with diagnoses, which included dementia, muscle weakness and the need for assistance with personal care A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 20, 2023, indicated that the resident required the assistance of staff for activities of daily living and and utilized a sit to stand lift for transfers. A review of the resident's current plan of care, initially dated July 8, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit. Planned interventions were that upon admission the resident needed to utilize a sit to stand lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). A review of a facility investigation report dated December 19, 2023, at 9:55 PM revealed that Employee 3, an agency nurse aide, and Employee 4, an agency nurse aide, were transferring Resident 2 from the wheelchair to the bed via a sit to stand lift. The nurse aides placed the resident into the lift and had her hovering {in the lift sling} over her bed. Employee 3, an agency nurse aide, left the room to get a clean brief. At the same time, Employee 4, an agency nurse aide, left the resident in the lift to get a washcloth from the bathroom sink. When Employee 4 looked back from the bathroom, she observed Resident 2 opening the velcro ties to the sling (on the lift), falling onto the bed, and then onto the floor, hitting her buttocks and back. The RN supervisor assessed the resident. The Physician was contacted. No injuries were noted. An interview with the Nursing Home Administrator and Director of Nursing on January 31, 2024, at approximately 2 PM confirmed that Employees 3 and 4 were aware that the resident's transfer was to performed with two people, utilizing a sit to stand lift, but both employees left the resident unattended in the lift sling resulting in the resident's fall. 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on a review of select facility policy, clinical records and select incident reports, and staff interview it was determined that the facility failed to provide necessary staff supervision and consistently implement individualized effective safety interventions to prevent a fall resulting in serious injuries, multiple fractured ribs, fractured thoracic spine, and laceration to left forehead, for one of five residents reviewed (Resident 4) Findings include: A review of facility policy entitled: Fall Management Policy and Procedure indicates the Fall's Management Program's goal is to prevent/reduce falls, reduce injury and ultimately improve the quality of life for our residents and enhance the resident's sense of security and safe environment. Key elements to the Fall Management Program include: Treatment Plan/Interventions will be individualized, the care plan will reflect the interventions on admit and post fall, post fall investigations will be completed by the RN supervisor utilizing the incident/accident form. The interdisciplinary team (IDT) will review resident incident's at morning meeting, data and interventions will bee reviewed and evaluated and patterns and trends will be identified and recommendations will be made and the resident's care plan will reflect needs and interventions. A review of clinical record revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses, which included Alzheimer's Disease ( a progressive disease that destroys memory and other important mental functions), muscle weakness, and abnormalities of gait and mobility. An Annual Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 25, 2021, indicated that the resident was moderately cognitively impaired and required extensive assistance of two persons with bed mobility, transfers, walking, dressing, and toileting. A review of a fall risk assessment dated [DATE], at 4:18 PM revealed that the resident had a history of falls and was identified at high risk for falls. The resident's care plan, last revised December 30, 2021, revealed that the resident was at risk for falls related to limited mobility. Interventions in place at the time of an unwitnessed fall on December 11, 2021, was to have bed and chair alarms in place at all times and to check function every shift and (PRN) as needed to have a bed alarm in place, nonskid footwear at all times except for care, anticipate and meet the resident's needs and a safe environment with even floors free from spills and/or clutter; adequate, glare-free lighting; a working and reachable call light, personal items within reach to prevent falls. Nursing documentation dated December 11, 2021, at 7:41 PM indicated that the resident was found in her room at 4:15 PM sitting on the floor in front of a broda chair (tilt-in-space wheelchair). A review of a resident incident report dated December 11, 2021, at 4:15 PM, revealed that the resident was attempting to go to the bathroom. According to the incident report a chair pad alarm was not in place at the time of the fall as care planned. A review of nurse aide documentation for December 11, 2021, revealed no documented evidence that the resident's chair pad alarm was checked during the 3:00 pm- 11:00 pm shift. A review of licensed nurse documentation revealed that the resident's bed and chair alarm were checked by Employee 1, a Registered Nurse on December 11, 2021 at 4:05 PM and the bed and chair alarms were in place and functioning, 10 minutes prior to the finding of the resident on the floor without a chair alarm in place. Further review of the incident report dated December 11, 2021 at 4:15 PM revealed that post fall interventions put into place were to ensure that the alarm pads and chair alarms were in place and functioning, although licensed nursing staff had documented that the chair alarm was in place 10 minutes prior to this fall. No new interventions were identified on the resident's plan or care. There was no documented evidence the IDT reviewed the data and interventions put in place at the time of the fall was reviewed as noted in the facility's fall management policy. Nursing documentation dated December 25, 2021 at 11:14 PM indicated that resident fell out of bed and landed to the floor-found on floor with laceration to forehead approximately 2 inches long and laceration to left forearm approximately 6 inches long-skin tear. The physician was notified and the resident was transferred to the hospital on December 25, 2021. A review of a resident incident report dated December 25, 2021, at 10:50 PM revealed that the investigation was written by Employee 3, a Registered Nurse noting that Resident placed in bed due to incontinence of bowel on recliner. Found on floor at 10:50 PM. Bleeding from laceration to forehead and left arm. Large 6 inch x 3 inch skin tear, Resident awake, yelling and crying. Difficult to assess secondary to dementia. Complaining of soreness to all areas palpated. The incident report indicated that a nurse aide, Employee 2, had toileted the resident at 9:00 PM. A review of an employee witness statement dated December 25, 2021, written by Employee 2, nurse aide, noted that when finishing collecting linen, I found the resident's (Resident 4) door closed, I opened the door and found the resident on the floor facing up with a huge laceration on her forehead and with a huge skin tear on her forearm. Resident was incontinent and with nothing on. There was no documented evidence in the resident's clinical record or staff witness statements to indicate that staff were alerted to the resident on the floor by the alarm sounding. Review of nurse aide documentation revealed that prior to the fall, the resident was checked and changed and turned and repositioned at 10:36 PM, 14 minutes prior to Employee 2, finding the door to the Resident 4's room closed and Resident 4 naked, on her back, on the floor of the resident's room. Interview with the Director of Nursing on January 12, 2022 at approximately 2:00 PM revealed that the facility was unsure how close the resident was to her bed when found on the floor or how the resident, who was dependent on staff for assistance with dressing, was found naked. The DON stated that the resident generally slept in her recliner rather than her bed, but had been returned to bed because of an episode of bowel incontinence in the recliner. The DON stated that the only statement obtained was from Employee 2, who worked the 11:00 PM- 7:00 AM shift. There were no statements from the staff who rendered care to the resident on the previous shift. The facility failed to identify and interview the staff who had placed Resident 4 in the bed (the resident required the assist of two staff) nor had the facility identified and interviewed the staff who had toileted the resident at 9:00 PM as indicated on the facility investigation. The DON stated that the resident preferred to have her door closed, although the resident had a known history of falls and was cognitively impaired. Review of the resident's current plan of care, in effect at the time of the resident's falls on December 11, 2021, and December 25, 2021, failed to identify the resident's preference for having the door to her room closed as verbalized by the DON during interview on January 12, 2022. The facility's investigation into the resident's fall included no witness statements from staff on the prior shift in an attempt to determine, who placed the resident in the bed, what time the resident was placed in bed, and where the resident's clothing had been placed, where the resident was found with respect to the location on the floor of her room (i.e. near the bed, bathroom, etc). The facility failed to conduct a thorough investigation into the resident's fall which resulted injuries. A review of hospital documentation dated December 26, 2021 at 2:26 AM, revealed that resident had a CT scan (computed tomography scan is a medical imaging technique used in radiology to get detailed images of the body noninvasively for diagnostic purposes) of her head, cervical spine, chest, and abdomen which indicated the resident had large left forehead contusion, closed fracture of multiple ribs on left side ( 3-6), and closed fracture of ninth (9th) vertebrae. Additionally, it was noted the resident had a skin tear on her left forearm. She was admitted to the trauma unit at the hospital. A review of a progress note in the resident's clinical record dated December 29, 2021, at 3:33 AM revealed that the hospital was called for an update on the resident's condition. Nursing noted that as the result of the resident's fall on December 25, 2021, the resident had sustained left rib fractures 3 through 6, a thoracic vertebrae fracture (spine located in the upper and middle part of the back) and Xeroform (wound dressing) and Vaseline gauze with [MEDICATION(S)] pad being applied to the skin tear of the left arm. The surveyor attempted to interview the resident at the time of the survey ending January 12, 2022, but the resident was unable to participate in an interview due to cognitive impairment. At the time of the survey ending January 12, 2022, no new safety or fall prevention interventions had been added to the resident's plan of care as the result of the resident's falls on December 11, 2021 and December 25, 2021. There was no documented evidence the IDT reviewed the data and interventions related to those falls as noted in the facility's fall management policy. An interview with the NHA (nursing home administrator) on January 12, 2022, at approximately 2:30 PM confirmed that the facility failed to consistently implement planned interventions to reduce falls, failed to adequately supervise a resident at risk for falls and failed to thoroughly investigate an unwitnessed fall to identify potential contributing factors and revise the resident's plan of care to prevent recurrence of falls. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 9/2/21 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 9/2/21, 7/27/21, 11/25/20

Based on a review of clinical records, resident incident reports and select facility policy and staff interview, it was determined that the facility failed to provide sufficient supervision as planned to prevent a fall with serious injury for one resident out of 14 sampled (Resident 46). Findings included: The facility's policy entitled, Accident/Incident Reports Residents, dated as reviewed February 2015, included the procedure that staff and the resident will be questioned as to how the incident occurred. The statements from staff are obtained. The statements from all unlicensed staff must be written if the incident involves a fall or anything of unknown origin. A review of the clinical record revealed that Resident 46 had diagnoses, which included Alzheimer's Disease and anxiety. A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment completed at specific intervals to identify resident care needs) dated March 18, 2015, revealed that the resident was severely cognitively impaired. The resident required staff assistance for transfers, ambulation and toileting. A review of the resident's current care plan initially dated November 4, 2014, and revised March 25, 2015, indicated that the resident was at risk for falls, has incurred actual falls, uses psychoactive medications (psychoactive medications can contribute to an increase in falls by increasing drowsiness and dizziness), has had gait/balance problems and needs prompt response to all requests for assistance as she was used to being very independent and does not recall physical/cognitive limitations. The goal was for the resident to be at a reduced risk of injury from falls. The interventions in place to prevent falls included to anticipate and meet the resident's needs as they arise, toilet the resident with routine rounds on the overnight shift and as often as indicated by the resident, be sure the call light is within reach and encourage the resident to use it for assistance as needed, ensure the bed and chair alarms are in place and functioning every shift, low bed, floor mats adjacent to the bed and every 15 minute safety checks. A review of a resident incident report dated April 22, 2015, at 3:15 a.m., revealed that the resident was found on the floor on the left side of the bed. The resident was lying on the left side of the floor mat with her head and arm on the floor. The resident sustained [REDACTED]. The resident's confusion and altered gait/balance were noted as factors contributing to the fall. The resident was noted to be last toileted at 2:15 a.m. At the time of the fall the resident stated that she was trying to go to the bathroom. The corrective/preventive measure to be taken to reduce risk of reoccurrence was to remind the resident, despite being severely cognitively impaired, to call for assistance frequently through the shift. A review of statements from persons involved/witnesses revealed that the only statement completed was from Employee 1 (nurse aide), which noted that this employee responded to the alarm and found the resident on the floor. The facility had planned the intervention of every 15 minute safety checks, but there were no statements from staff who had observed the resident between 2:15 a.m. when the resident was reportedly last toileted and 3:15 a.m. when the resident was found on the floor. A review of the safety checks conducted on April 22, 2015, failed to provide documented evidence that the resident was checked every 15 minutes as care planned to maintain the resident's safety. A review of a resident incident report dated, May 17, 2015, at 3:45 a.m., noted that the resident self-rose, stood behind the door (entry door to resident's room) and fell back trying to open it. A review of statements from persons involved/witnesses revealed a statement from Employee 3 (nurse aide), which noted that the resident's bed alarm was sounding. The resident was found behind the door to the resident's room with the door shut. Upon opening the door the resident was found lying on the floor behind the door. A statement from Employee 4 (nurse aide) noted that the resident was taken to the bathroom around 2:30 a.m., voided, and went back to bed. The facility planned to conduct every 15 minute safety checks as a fall prevention measure, but there were no statements from staff who had observed the resident between 2:30 a.m. when the resident was last toileted and 3:45 a.m. when the resident was found on the floor. A review of the safety checks conducted for this resident on May 17, 2015, failed to provide documented evidence that the resident was checked every 15 minutes as care planned to maintain the resident's safety. Review of a Mobile X-ray Report dated, May 17, 2015, of the right hip with two views, noted that the resident had sustained a mid-inferior right pubic ramus fracture (pelvic fracture) as the result of this fall. Interview with the Director of Nursing (DON) on June 23, 2015, at 2:30 p.m., confirmed that the resident had poor safety awareness and was at risk for falls. The DON also confirmed that there was no documented evidence that safety checks had been conducted as planned to help ensure resident safety. 28 Pa Code 211.11 (d) Resident care plan 28 Pa Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 5/20/2014

Based on a review of clinical records and select facility policy, observation and staff interview, it was determined that the facility failed to consistently conduct accurate wound assessments for two residents (Resident 29 and Resident 36) and failed to timely identify declines in skin integrity and provide prompt treatment and services to prevent pressure sore development, or worsening of a pressure sore, for one resident (Resident 29) out of 13 resident's sampled. Findings include: A review of the facility policy, entitled Prevention of Skin Issues, last reviewed by the facility May 2014, indicated that it is the facility's policy to assess all residents for possible skin issues on a regular basis to help decrease the incidence of pressure related sores. The facility will identify residents who are particularly prone to the development of decubitus ulcers, which include residents with an alteration in the resident's mobility. The facility will check areas that resident's are prone to decubitus, such as the resident's heels. The policy indicates that the facility will institute use of foam or sheepskin boots to support the resident's heels and decrease shearing pressure. A Norton Skin Assessment is completed on every resident. A resident who is at high risk will have skin checks completed every two hours. A review of a Norton Plus pressure ulcer risk review (an assessment tool that identifies risk for pressure sore development) dated January 29, 2014, revealed that Resident 29 scored a nine and was considered to be high risk for development of pressure areas. A review of a Podiatrist consultation, dated February 11, 2014, revealed that the resident had no open wounds at that time and that the resident presented with bilateral pedal/ankle [MEDICAL CONDITION]. A quarterly Minimum Data Set assessment (MDS - standardized assessment facilitating care management in nursing homes) dated January 29, 2014, revealed that the resident's cognition was moderately impaired. The resident required extensive assistance of two staff for bed mobility and required extensive assistance of one staff member for dressing. Although the resident required assistance for dressing, there was no evidence that staff timely identified the resident's skin decline in skin integrity to prevent worsening of an acquired pressure sore. A review of the resident's care plan, entitled potential for ulceration, history of and/or interference with structural integrity of layers of skin, initiated August 9, 2012, identified planned interventions to keep Resident 29's skin intact that included providing the opportunity for offloading and rest periods back to bed or in recliner with legs elevated between meals and as tolerated and to monitor the resident's skin condition every two hours and to report any redness, bruising, or pressure areas. The resident's care plan also indicated that the resident was wearing an open toe shoe, to her right foot. According to interview with the Director of Nursing on May 20, 2014, the open toe shoe was being used due to a bunion. There was no evidence that the facility revised the resident's plan of care with specific preventative measures to include use of foam or sheep skin boots to support the resident's heels of the resident and decrease shearing pressure according to facility policy due to the resident's assessed high risk for pressure sore development. A review of a nursing note, dated February 14, 2014 at 1:00 PM indicated "right outer heel 1 cm x 1/2 cm brown, no depth, skin intact, skin prep to heel, booties on to offload pressure." There was no documented evidence that the heel booties had been use by the resident prior to discovering of the pressure area. There was no documented evidence on the previous month's treatment administration records that heel booties were utilized to prevent skin breakdown. Additionally, there was no documented evidence on the treatment administration records that heel booties were being utilized in February 2014 or March, 2014, to promote healing of the pressure sore. A treatment record/weekly report, dated February 14, 2014, noted the above pressure sore. The report format included date, site, size, depth, presence or absence of exudate/type, odor if present, color, stage, description of wound, when the physician was notified and the name of the nurse assessing the wound. However, the report was incomplete. A review of the resident's Treatment Administration Record, dated April 2014, revealed an order for [REDACTED]. There was no evidence in the resident's clinical record to indicate that this preventative measure was being utilized for Resident 29, who was high risk for pressure sores. A review of a wound clinic consultation, dated May 2, 2014, revealed that the resident was seen for a 1.5 cm x 1.3 cm pressure ulcer on her right lateral heal, which was identified as necrotic (unstageable due to dead tissue), which was debrided on May 9, 2014. An observation on May 20, 2014 at 1:30 PM of the resident's right heal revealed a pressure sore wound approximately the size of a quarter. There was a scant amount of grayish drainage on the dressing when removed. The wound presented yellowish slough and the center of the wound was white in color. During an interview with the Nursing Home Administrator, Director of Nursing and the Assistant Director of Nursing on May 20, 2014, at approximately 1:30 PM, these staff members were unable to explain why the resident's area of skin impairment was not identified by the facility prior to it becoming unstageable. A clinical record review for Resident 36 revealed current [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment dated [DATE], revealed that the resident required assistance with her ADLs (Activities of Daily Living). Review of a Nursing Department Skin Injury/Pressure Ulcer Assessment/Tracking form dated January 9, 2014, revealed that a circular 2 cm. (centimeter) blood blister was found on the resident's right heel. The area was assessed as a Stage II (ulcer involving loss of the top layers of the skin) Pressure Ulcer. There was no indication that the facility had explored potential causative factors for the development of the blood blister. The staff member conducting the assessment did not sign the form. A review of Resident 36's January 2014 Treatment Record revealed that the resident was identified with a 2 cm. blood blister. The documentation noted that the area was a Stage IV, then a Stage II or IV (Stage IV pressure ulcer is an ulcer involving loss of layers of skin, exposing muscle and bone). There were strike marks written over the IV crossing it out, failing to provide an accurate assessment of the wound. A review of the policy titled "Identification of a Skin Issue" reviewed May 2014 indicated that the wound nurse assesses and documents on skin issues weekly. Review of the Weekly (wound) Report revealed inconsistent or no documentation regarding the size, depth, presence or absence of exudate, odor if present, color, stage, description of wound, if and when the physician was notified, and who conducted the assessment and completed the documentation. Further review of the Weekly (wound) Report revealed no documentation of an assessment of the wound from March 26, 2014 to April 16, 2014, from April 16, 2014 to May 7, 2014, and from May 7, 2014 to May 20, 2014. Interview with the ADON (assistant director of nursing) on May 20, 2014, at approximately 11:30 AM confirmed that the weekly wound report was not completed according to the "Identification of a Skin Issue" policy. The ADON was unable to explain how, based on inconsistent assessment and documentation, it could be determined whether the wound was improving or deteriorating or if treatment changes were necessary. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 6/12/13 28 Pa. Code 211.10 (a)(c)(d) Resident care policies