Every finding on record at Meadow View Rehabilitation & Healthcare Center

Based on review of facility policy, resident interviews and staff interviews, it was determined the facility failed to make prompt efforts to resolve resident verbal grievances regarding delayed call light response times for six of twelve residents reviewed (Residents 1, 2, 3, 4, 5, and 6).Findings include: A review of the facility's Grievance Policy last reviewed on July 29, 2025, 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 follow up on all concerns and grievances registered by any resident or resident representative. A review of the facility policy titled Answering the Call Light, last reviewed September 2025, indicated staff are responsible for responding to resident call lights in a timely manner. If immediate assistance cannot be provided, staff are to inform the residents of the approximate response time. The policy indicated staff should complete requests promptly whenever possible, seek assistance from the nurse supervisor if unable to fulfill a request, and document any significant resident requests or complaints, including how the concern was addressed. During resident interviews conducted on July 14, 2026, six residents reported they had verbally complained to nursing staff regarding prolonged call light response times; however, the delays continued without resolution. During an interview on July 14, 2026, at 9:00 AM, Resident 1, who had a BIMS (Brief Interview for Mental Status, a standardized assessment of cognition, memory, attention, and orientation, a score of 13 to 15 indicates intact cognition) score of 15, indicating she was cognitively intact, stated she routinely waited more than 30 minutes after activating her call light. She stated staff frequently responded by saying the facility was short staffed, turned off the call light, advised they would return, and often did not return for an additional 30 to 45 minutes, particularly when she needed assistance to the bathroom. Resident 1 stated she continued to experience the same delays despite reporting her concerns. During an interview on July 14, 2026, at 9:05 AM, Resident 2, who had a BIMS score of 15, stated she frequently waited approximately 45 minutes for assistance after using her call light. She stated staff commonly attributed the delay to being short staffed, turned off her call light after acknowledging it, advised they would return, and did not provide assistance for more than 30 minutes. She stated these delays were especially difficult when she needed assistance toileting. She stated the problem continued despite bringing concerns to staff. During an interview on July 14, 2026, at 9:10 AM, Resident 3, a cognitively intact resident with a BIMS score of 14, was lying in bed. She stated that she had not received her breakfast yet because she had to wait for nursing staff to get to her. She stated that she had been waiting after ringing the call bell for more than 30 minutes. She also stated that she often waits more than 30 minutes for assistance when she rings the call bell. Resident 3 stated prolonged delays continued despite reporting her concerns. During an interview July 14, 2026, at 9:15 A.M., Resident 4, a moderately, cognitively impaired resident with a BIMS score of 10 (score of8 to 12 indicates moderate cognitive impairment), stated that she waits more than 30 minutes for staff assistance when she rings the call bell. She stated that staff tell her that the facility is short staffed. She stated that staff will answer her call bell, turn it off and state that they will return to help her, the wait is greater than 30 minutes. Resident 4 stated the delays continued after she reported her concerns. During an interview on July 14, 2026, at 9:20 A:AM, Resident 5, a cognitively intact resident with a BIMS score of 15, stated that she waits more than 30 minutes for assistance when she rings the call bell. She stated that staff tells her that they are short staffed. She stated that staff will often answer the call bell, immediately turn the bell off and state to the resident that they will be back to assist her. The resident stated that staff do not return timely, it is sometimes greater than 30 minutes. Resident 5 stated no improvement occurred after she voiced her concerns. During an interview July 14, 2026, at 9:45 AM, Resident 6, a moderately, cognitively resident with a BIMS score of 11, stated she had waited as long as one and one-half hours for assistance with toileting. She stated that she recently fractured her knee, is currently receiving physical therapy services and cannot ambulate independently to the bathroom for toileting. She stated that nursing staff often tells her that the facility is short staffed and she must wait for assistance. She stated that it is very hard to wait for long periods for assistance for toileting. She stated she continued to experience prolonged delays despite reporting her concerns to staff. The facility was unable to provide documentation or other evidence demonstrating it investigated, followed up on, or made efforts to resolve the residents' verbal grievances regarding delayed call light response times in accordance with its grievance policy through the conclusion of the survey on July 14, 2026. During an interview on July 14, 2026, at 9:10 p.m., the Nursing Home Administrator confirmed the residents' verbal grievances regarding delayed call light response times had not been resolved. 28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (d) Resident care policies.

Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 15 sampled (Resident 20).Findings include: A review of the facility policy titled Oxygen Administration, last reviewed by the facility on April 30, 2026, revealed it is the facility's policy to provide oxygen therapy to residents upon the order of a physician. The policy further indicated it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen in accordance with physician orders. A review of the clinical record revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis (a chronic autoimmune disease that affects the brain, spinal cord, and nerves) and dementia (a decline in memory, reasoning, judgment, and other cognitive abilities severe enough to interfere with daily functioning). Further review of the clinical record revealed a physician's order dated May 20, 2026, directing staff to administer supplemental oxygen via nasal cannula (a lightweight device consisting of two small prongs placed into the nostrils that delivers oxygen from an oxygen source to the resident) at 2 liters per minute. During an observation on June 3, 2026, at 8:15 AM Resident 20 was awake and sitting in bed receiving supplemental oxygen via nasal cannula. The oxygen concentrator was set at 4 liters per minute despite a physician's order directing oxygen at 2 liters per minute. A second observation conducted on June 3, 2026, at 11:10 AM revealed Resident 20 was sleeping in bed receiving supplemental oxygen via nasal cannula. The oxygen concentrator remained set at 4 liters per minute. During an interview on June 3, 2026, at 11:30 AM, the Nursing Home Administrator confirmed the oxygen concentrator was set at an incorrect flow rate and stated the oxygen setting was subsequently corrected by nursing staff. A review of the June 2026 Medication Administration Record revealed Employee 1 documented that Resident 20's oxygen was being administered at the prescribed liters per minute. However, survey observations conducted over a three-hour period confirmed the oxygen concentrator remained set at 4 liters per minute rather than the physician-ordered 2 liters per minute. The facility failed to ensure Resident 20 received oxygen therapy as ordered by the physician and failed to accurately monitor and verify the oxygen flow rate in accordance with facility policy. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, resident and staff interviews, and facility provided documentation, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for one resident out of 15 residents reviewed (Residents 38). Findings include: A review of Resident 38's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic health condition in which the body cannot properly produce or use insulin, leading to elevated blood sugar levels). Review of Resident 38's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 15, 2026, revealed Resident 38 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview with Resident 38 on June 3, 2026, at 10:30 AM the resident stated she hardly ever gets a shower, that it has gotten worse lately. Stating that yesterday, which was Tuesday, she wanted her shower and no one came and asked her to get her shower. She stated that this happens a lot. When asked if she gets a bed bath if a shower is not provided she stated no she does not. A review of Resident 38's Kardex (a quick-reference summary for staff to guide delivery of care) documented that Resident 38 was scheduled to receive showers on Tuesdays and Fridays during the day shift. A review of the Documentation Survey Report v2 for May 2026 and June 2026 revealed that on multiple scheduled shower dates (May 1, May 12, May 22, and June 3), showers were documented as not applicable with no documented reason that a shower was not provided. During an interview with the Director of Nursing (DON) on June 4, 2026, at 9:00 AM, the DON acknowledged that Resident 38 was scheduled to receive showers on Tuesdays and Fridays and confirmed that showers should have been provided as scheduled. The DON could not explain why showers were not consistently provided or documented. The facility could not provide documented evidence that Resident 38's showers were provided as ordered and preferred by the resident. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on observation, 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 bowel protocol to promote normal bowel activity to the extent practicable for one resident (Resident 24) out of 15 residents reviewed. 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 June 20, 2025, for the following bowel regimen: Milk of Magnesia (magnesium hydroxide), a laxative used to stimulate bowel activity and relieve constipation, 30 milliliters by mouth as needed if no bowel movement, or only a small bowel movement, occurred by the third day.Dulcolax (bisacodyl) suppository, a rectal stimulant laxative used to promote bowel evacuation, one 10-milligram suppository rectally as needed if no bowel movement occurred within 24 hours after administration of Milk of Magnesia.Fleet enema (a rectal solution containing sodium phosphate used to stimulate evacuation of stool from the lower bowel), one rectal application as needed if no bowel movement occurred by the end of the following shift after administration of the Dulcolax suppository. The order directed staff to notify the physician if the intervention was ineffective.A review of Resident 24's bowel monitoring documentation for May 2026 revealed no documented bowel movements on May 1, 2, 3, 4, 16, 17, 18, 27, 28, and 29, 2026, during all three shifts. A review of Resident 24's Medication Administration Records for May 2026 revealed no documented evidence that nursing staff administered the physician-ordered bowel protocol during the periods when the resident had no documented bowel activity. Specifically, there was no documented administration of Milk of Magnesia, Dulcolax suppository, or Fleet enema in accordance with the physician's ordered bowel regimen. An interview with the Director of Nursing (DON) conducted on June 4, 2026, at 9:30 AM, to review the above findings. The DON was unable to provide evidence that staff implemented the physician-ordered bowel protocol for Resident 24 during the periods in which the resident had no documented bowel movement. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records.

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 four of four residents attending a resident group meeting (Residents 22, 29, 43, and 8) 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 reviewed on July 29, 2025, 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 follow up on all concerns and grievances registered by any resident or resident representative. A review of the Minutes from a Resident Council meeting, which included a food committee review, dated June 4, 2025, revealed concerns from residents that snacks were not being provided in the evening. Review of grievances revealed no documented evidence of a grievance regarding this concern and no evidence of any corrective actions taken to address this issue. A review of the Minutes from Resident Council meetings dated July 2, 2025, revealed concerns from residents that call bells were not answered timely. A grievance was filed on July 2, 2025, regarding this concern. Review of this grievance revealed no follow up was completed with the residents who raised this concern during resident council. Review of the food committee minutes reviewed during this resident council meeting revealed continued concerns with snacks not being provided in the evening. A review of the Minutes from a Resident Council meeting, which included a food committee review, dated August 7, 2025, revealed continued concerns from residents that snacks were not being provided in the evening. Review of grievances revealed no documented evidence of a grievance regarding this concern and no evidence of any corrective actions taken to address this issue. A group meeting conducted on September 3, 2025, at 10:30 a.m. with four residents (Residents 22, 29, 43, and 8) revealed unanimous reports that the facility failed to address their complaints regarding the timeliness of call bell response. Snacks continue to be a concern as well. Resident 43 stated that snacks are not brought to residents in the evening, that snacks are left at the nurse's station and stated that residents can come get them. However, the other Residents in attendance (Residents 22, 29, and 8) were unaware that snacks were left at the nurses' station and further stated that if they were in bed already, they would not be able to go to the nurses' station without assistance and were unaware they could ask staff for a snack in the evening. 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 September 4, 2025, that had been brought up during resident council meeting. During an interview on September 4, 2025, at 9:10 a.m., the Nursing Home Administrator (NHA) 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. 28 Pa. Code 211.10 (d) Resident care policies.

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen five employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, 2, 3, 4, and 5).Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility July 29, 2025, revealed the requirement for screening potential employees included obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 1 (Nurse Aide): Hired on June 3, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Registered Nurse): Hired on August 11, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Activities Aide): Hired on May 5, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 4 (Licensed Practical Nurse): Hired on July 31, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the employees' most recent former employer. Employee 5 (Housekeeping): Hired on May 15, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Interview with the Nursing Home Administrator (NHA) on September 4, 2025, at 10:15 a.m. the NHA verified there was no evidence that previous employers were contacted for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.19 (1) Personnel records.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings included:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the dietary department conducted and confirmed with the facility's Certified Dietary Manager (CDM) on September 2, 2025, at 10:15 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: Upon entering the facility's refrigerated and freezer storage room, it was observed that the steel exterior door had an eroded and worn area,1.5 inches in size, at the lower right corner, creating an opening to the outdoors. Inside the storage room, along the shelving that held cases of bread products and 50-pound bags of potatoes and onions, debris was present around the perimeter and corners of the room, including crumbled leaves and small deceased insects. Upon exiting the storage room, observed the exterior door failed to properly latch to securely close the door. An interview with the CDM confirmed the above observations and reported the exterior door had been not functioning properly for a while and reported it to the maintenance department verbally and through TELs (is a computerized maintenance management platform that helps organizations manage preventative maintenance, work orders, and asset tracking).An interview with Employee 6, the facility's maintenance manager, on August 4, 2025, at 10:47 AM, confirmed that he had been made aware of the dietary storage room's broken exterior door of the storage room, but didn't repair it. Interview with the Nursing Home Administrator (NHA) on August 4, 2025, at 10:30 AM, confirmed all areas of food storage in the dietary department was to be maintained to ensure food safety.28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 16 residents reviewed (Resident 9).Findings include: A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). The resident's current care plan, in effect at the time of review on September 4, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator on September 4, 2025, at 10:00 a.m., confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (East Hall).Findings include: Review of the facility policy titled Administering Medication last reviewed by the facility July 29,2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are to be dated at the time of first use, and the expiration or beyond-use date is to be indicated on the medication label to ensure the product remains safe and effective. Dating a multi-use medication at the time of first use is essential because staff must be able to determine when the medication has reached its beyond-use date (the last date it can safely be used once opened). An observation of the medication cart located on East Hall unit on September 3, 2025, at 8:45 AM, in the presence of Employee 4 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened. An interview with Employee 4 (LPN) on September 3,2025, at 8:45 AM confirmed the multi dose insulin pen of Insulin Glargine was opened, and available for resident use, but not dated when initially opened. An interview was conducted with the Nursing Home Administrator (NHA) on September 3, 2025, at 1:30 PM to review the above findings related to the facility's failure to adhere to acceptable storage and labeling practice for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined the facility failed to develop a person-centered care plan that included individual behavioral management for one resident out of 9 sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include alcohol abuse, adjustment disorder, depression and anxiety and a below the knee amputation (surgical removal of leg below the knee). A review of an admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 20, 2025 revealed him to be moderately, cognitively impaired with a BIMS assessment score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 8-12 indicates moderate cognitive impairment) had verbal behaviors towards others, required staff assistance with activities of daily living and utilized a wheelchair for ambulation. Nursing progress notes from the date of admission reflected an ongoing pattern of behavioral concerns. Documentation dated April 15, 2025, at 2:58 PM indicated that Resident 1 was sent to the emergency room after verbally threatening his roommate over control of the television. Additional progress notes documented that Resident 1 continued to exhibit escalating verbal and physical behaviors. On April 20, 2025, at 9:02 PM, Resident 1 reportedly told a nurse aide that he was going to smash the glasses off her face and wished he had a gun to shoot her. On April 28, 2025, at 1:15 PM, nursing and therapy staff observed Resident 1 and Resident 2, both seated in wheelchairs in Resident 1's room. Resident 1 was witnessed holding Resident 2's penis and moving it in an up-and-down motion. Resident 2 was immediately removed from the room. Further documentation dated May 1, 2025, at 7:25 PM noted that Resident 1 continued to be monitored for behaviors. The entry stated that staff had to repeatedly remove Resident 1 from the lobby area due to his close proximity to Resident 2 and attempts by Resident 2 to inappropriately touch Resident 1. A review of Resident 2's clinical record revealed he was admitted on [DATE], with diagnoses including cerebral infarction (stroke), anxiety, and mild cognitive impairment. A Quarterly MDS assessment dated [DATE], revealed Resident 2 had a BIMS score of 9 (indicating mild cognitive impairment), exhibited no behavioral symptoms, and used a wheelchair for ambulation. A review of Resident 1's care plan revealed an entry dated April 16, 2025, addressing verbal aggression toward others. Another care plan problem initiated on April 29, 2025, stated the resident exhibits desire to be sexually expressive but verbally denies same. However, there was no evidence at the time of survey that the care plan had been revised to reflect the ongoing behavioral incidents involving Resident 2 or to implement individualized interventions to mitigate risk and protect resident safety. During an interview on May 13, 2025, at approximately 1:30 PM, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure Resident 1's care plan was updated to address ongoing behavioral incidents and that the care plan did not adequately reflect person-centered approaches or risk management strategies related to his interactions with Resident 2. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of clinical records, resident council meeting minutes, grievances, resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of 8 residents sampled (Residents 2 and 6). Findings include: A review of Resident Council meeting minutes dated March 5, 2025, revealed residents in attendance raised concerns regarding call bell response times. The residents indicated there was an issue with receiving staff assistance for toileting. Residents in attendance raised concerns indicating call bells are not answered when residents ring for assistance. A review of the facility grievances for the month of March 2025 revealed a grievance filed March 9, 2025 noting that residents are complaining of call bell response times. The grievance revealed the facility's plan to resolve this was to conduct call bell audits on all shifts. The results of the action taken was as follows: Day Shift: Average call bell times: 2-45 minutes Evening shift: 2-45 mins Night shift: 2-10 minutes. Per the grievance form, management reports the staff members were re-educated on the need to respond to call bells more timely. An interview with Resident 2 on March 19, 2025, at approximately 12:00 PM, revealed concerns regarding delayed call bell responses. The resident stated that response times can extend up to 45 minutes to an hour, with longer delays occurring at night. The resident further explained that if assistance is not provided in a timely manner, she may remain in a soiled brief for an extended period before staff is available to assist with hygiene needs. An interview with Resident 6 on March 19, 2025, at approximately 12:30 PM, revealed concerns regarding call bell response times. The resident stated that call bells often go unanswered for 45 minutes to an hour, attributing the delays to insufficient staffing. The resident further shared that, on some occasions, prolonged wait times have resulted in incontinence before assistance could be provided. During an interview on March 21, 2025, at approximately 9:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of clinical records, and staff interview, it was determined the facility failed to implement individualized approaches for incontinence and provide maintenance care to the extent possible for two out of eight sampled residents (Resident 4 and 5). Findings include: A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included overactive bladder and muscle weakness. A review of Resident 4's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 6, 2024, revealed the resident was incontinent of bowel and bladder and was a poor candidate for retraining/scheduled toileting due to cognitive status. A review of the resident's care plan for Bladder and Bowel Incontinence, initiated on December 4, 2024, documented an intervention for the resident to be checked and changed every two hours and as needed (PRN). The term check and change refers to the routine monitoring and changing of a resident's incontinence products (such as adult briefs or absorbent pads) to maintain skin integrity, promote comfort, and prevent complications such as skin breakdown, moisture-associated skin damage (MASD), and urinary tract infections (UTIs). A review of the resident's Bowel and Bladder assessment dated [DATE], confirmed the resident was to be checked and changed every two hours. However, a review of the resident's clinical record did not reveal documented evidence the resident was checked and changed every two hours per the plan of care. An interview with the Nursing Home Administrator (NHA) on March 19, 2025, at approximately 1:45 PM, confirmed that the facility failed to provide documented evidence that incontinence care was provided to Resident 4. A review of Resident 5's clinical record revealed that the resident was admitted to the facility January 4, 2024, with diagnoses including dementia (decline in mental ability that interferes with daily life) and muscle weakness. A review of Resident 5's Bowel and Bladder assessment dated [DATE], revealed Resident 5 remained incontinent of bowel and bladder was not appropriate for retraining/scheduled toileting due to cognitive status. A review of the resident's care plan for Bladder and Bowel Incontinence, initiated on February 23, 2024, documented an intervention for the resident to be checked and changed every two hours and as needed (PRN). A review of Resident 5's progress notes revealed: January 15, 2025 - The resident experienced hematuria (blood in urine) while toileting at 5:00 PM. January 17, 2025 - A urine culture was obtained at 6:30 AM. January 18, 2025 - The resident was placed on an antibiotic due to a confirmed urinary tract infection (UTI) via lab results dated January 17, 2025. A review of the resident's January 2025 Documentation Survey Report revealed that on the following dates the resident was not checked every 2 hours per the care plan intervention recommendations A review of the resident's Documentation Survey Report for January, February, and March 2025 revealed multiple dates during various shift on which the resident was not checked and changed every two hours per the care plan intervention, including: January 4, 5, 7, 10, 17, 19, and 31, 2025 February 16, 20, and 23, 2025 March 14, 15, 16, and 17, 2025 An interview with the Nursing Home Administrator (NHA) on March 19, 2025, at approximately 1:45 PM, confirmed that the facility failed to carry out incontinence checks as planned for these residents to maintain or improve urinary continence and prevent incontinence related complications The facility failed to provide scheduled incontinence care as outlined in the residents' care plans. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and staff interviews it was determined the facility failed to implement procedures to to ensure the timely acquisition and administration of a prescribed medication to one of 7 sampled residents (Resident 1). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die). A review of hospital discharge instructions revealed the resident was to receive diazepam 2mg (Valium an antianxiety medication) one tablet by mouth every night. A review of physician's orders dated February 6, 2025, revealed the physician prescribed diazepam 2mg one tablet by mouth at bedtime for anxiety beginning on February 6, 2025. A review of the Resident's MAR (medication administration record)) showed the diazepam was not administered on February 6 and 7, 2025, as ordered. There were no nurse signatures or documentation indicating the dose was given on those dates. A nursing progress note dated February 7, 2025, at 8:40 PM indicated the bedtime dose of diazepam was not given because the medication was unavailable. Further record review revealed the facility had not received the diazepam from the pharmacy in time for the scheduled doses on February 6 and 7, 2025. An interview with the Nursing Home Administrator on March 19, 2025, at approximately 1:45 PM acknowledged that the facility did not have adequate procedures in place to ensure medications were obtained and administered in a timely manner. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.9 (f)(2) Pharmacy services

Based on review of clinical records and controlled drug records, and staff interview, it was determined the facility failed to implement pharmacy procedures to promote accurate accounting of controlled medications for one resident of 15 sampled (Resident 52). Finding include: A review of the clinical record revealed that Resident 52 had a physician order dated August 6, 2024, for Oxycodone HCl oral tablet 10 mg (an opioid pain medication used to treat moderate to severe pain), give one tablet by mouth every 8 hours as needed for moderate pain 5-7 (pain scale, 1-10, 1 equivalent to least pain and 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on August 8, 2024, at 6:30 AM, and on August 10, 2024, at 1:43 AM, nursing staff signed out a dose of the resident's supply of Oxycodone 10 mg. However, the administration of the controlled medication to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. During an interview on November 7, 2024, at approximately 12:45 PM, the Nursing Home Administrator confirmed the inconsistencies in the accounting and administration of the opioid pain medication for Resident 52 and indicated that the controlled substance record be documented clearly and accurately. 28 Pa Code 211.5 (f)(x) Medical records 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to ensure that one resident (Resident 18) had the right to a dignified dining experience and failed to respond timely to residents' requests for assistance, as evidenced by experiences reported by seven out of the 15 residents sampled (Residents 18, 28, 15, 6, 5, 3, and 13) Findings include: A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include amputation of the left leg above the knee, need for assistance with personal care, and muscle weakness. A quarterly Minimum Data Set assessment (MDS- standardized assessment completed at specific intervals to plan care) dated, September 9, 2024, indicated the resident had a BIMS score of 12 (Brief Interview for Mental Status-a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). Observation of Resident 18's room on November 5, 2024, at 11:35 AM revealed the resident's lunch tray, which consisted of a cheeseburger, cooked carrots, pudding and water, was delivered and placed on top of the resident's over-the-bed table tray. The resident's table tray was pushed against the wall to the right of the resident's bed, not within the resident's reach. The resident was awake and lying in bed on top of a mechanical lift sling (a hammock-type sling that connects to a mechanical device used to lift and transfers residents). Interview with Resident 18 at the time of the observation revealed that she was waiting for staff to come back to get her out of bed for lunch. The resident stated that her lunch tray was delivered a few minutes ago but no one offered to reposition her upright in bed or to get her out of bed into her wheelchair so that she can eat her lunch. Further observation revealed that the resident's call bell was wrapped around the left bed rail and out of reach of the resident. The resident stated that she was unable to locate or reach her call bell and was unable to notify staff that she needed assistance. Continued interview with Resident 18 revealed that when she does have access to the call bell, she frequently waits long periods of time, 45 minutes or more, for the call bell to be answered. She reported that she has urinated in her brief due to excessive wait times for staff to respond to her call for assistance. Continued observation revealed no staff member returned to Resident 18's room to get her out of bed or set her up with her lunch tray. The time was 12:15 PM, 40 minutes after the surveyor entered the room and approximately 45 minutes since her lunch tray was delivered. Interview with the Director of Nursing on November 5, 2024, at 12:16 PM confirmed that Resident 18 was not provided with her lunch meal in a dignified and timely manner and that her call bell was not within reach. During an interview with Resident 28 on November 5, 2024, at 1:20 PM the resident expressed concern and frustration with staff's response to call bells. He reported that sometimes he has to wait 30 minutes or more and reported that a few days ago, he waited almost two hours. He stated that he asked the staff why are you making me wait so long? and they responded you have to wait your turn. Resident 28 stated I can't hold my bowels that long; 10-15 minutes is okay but to wait almost two hours is not okay!. Observation during the time of the interview revealed Resident 28 did not have his call bell within reach. Resident 28 was seated in his wheelchair along the right side of his bed. The resident's call bell was located under the pillow and blankets and out of sight and reach of the resident. During an interview with Resident 28 at the time of the observation he stated, this isn't the first time I can't find my call bell, it happens from time to time. During a group interview with alert and oriented residents on November 6, 2024, at 11:00 AM, five out of the five residents in attendance indicated they rely on staff for care (Residents 15, 6, 5, 3, and 13). All five residents explained they experience long wait times for staff assistance. The residents in attendance indicated that concerns with staffing have been brought up during Resident Council meetings over the past few months, but the long wait times for care remain a problem at the facility. Resident 13 indicated that when she activates her call bell for staff assistance, staff come into her room, turn off the call bell, say that they will be right back, but never come back. She reported that it happens quite a lot. Residents 5 and 6 also indicated that they have waited 30 minutes or longer for staff assistance. Both residents expressed frustration over the long wait times especially when they need to go to the bathroom. Resident 5 further added the adult briefs are thin and when I have a wet diaper and have to wait even longer to be changed, I end up peeing again in my adult brief and then it's a mess. During an interview on November 6, 2024, at approximately 2:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified all residents at the facility should be treated with dignity and respect. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care which is negatively affecting their quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services.

Based on observation and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accessibility for three out of 15 residents sampled (Residents 42, 18, and 28). Findings include: Observation on November 5, 2024, at 11:29 AM revealed that Resident 42 was seated on the left side of her bed, facing the wall. The call bell was observed draped over the headboard on the right side of the bed and not within the resident's reach. The resident was unable to locate or access her call bell to call for assistance. An interview with Employee 2 RN (registered nurse) on November 5, 2024, at 11:32 AM confirmed the observation and that Resident 42 did not have access to a call bell for staff assistance. Observation on November 5, 2024, at 11:35 AM revealed Resident 18 was lying in bed. The resident's call bell was wrapped around the left bed rail and out of reach of the resident. During an interview at the time of the observation, Resident 18 stated that she uses the call bell to alert staff to her needs for assistance and confirmed that her call bell was not accessible to her at the time of the observation. An interview with the Director of Nursing, on November 5, 2024, at 12:16 PM confirmed the observation that Resident 18 did not have access to a call bell to call for staff assistance if needed and verified that call bells are to be placed within reach of the residents at all times. Observation on November 5, 2024, at 1:30 PM revealed that Resident 28 was seated in a wheelchair along the right side of his bed. The resident's call bell was located under the pillow and blankets and out of sight and reach of the resident. During an interview with Resident 28 at the time of the observation he stated, this isn't the first time I can't find my call bell, it happens from time to time. An interview with Employee 3 (registered nurse) confirmed the observation that Resident 28 did not have access to a call bell to call for staff assistance. An interview with the Nursing Home Administrator on November 7, 2024, at approximately 10:30 AM verified that call bells are to be placed within reach of each resident at all times. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services. 28 Pa. Code 201.29 (a) Resident Rights

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to implement effective interventions, timely re-evaluate the effectiveness of planned safety interventions and revise the resident's fall prevention plan to include the provision of supervision necessary to prevent falls for one of 15 residents sampled (Resident 46) and failed to assess resident's safety with the use of motorized wheelchairs for two (Resident 35 and Resident 25) residents out of 15 sampled residents. Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include dementia and a history of falls. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated May 27, 2024, revealed that the resident's cognition was severely impaired, and he was independent with ambulation with a BIMS score of 4 (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. A score of 1-7 indicated severe cognitive impairment). A review of Resident 46's care plan, initiated May 21, 2024, revealed the resident was at risk for falls related to impaired cognition with decreased safety awareness, inability to use call light due to confusion, medications prescribed including psychoactive drug use and wandering. A care plan for activities of daily living dated September 9, 2024 revealed the resident required distant supervision when ambulating throughout facility. Additional Initial interventions included, Non-Skid Footwear, keep bed in lowest position, keep environment free of clutter, family education on resident's safety interventions and maintain call light within reach. A review of nursing documentation and incident reports dated between July 19, 2024, and October 28, 2024, revealed that Resident 46 incurred nineteen falls in the facility during that time period, one in July, two in August, six in September and ten in October. The interventions planned for fall prevention during this timeframe included, providing clear pathways, keep personal belongings within reach on left side of bed, assist resident with toileting every one hour while awake, maintain call light within reach and medication review related to frequent falls. A review of activity of daily living records for August through October 2024 did not indicate that every one hour toileting was attempted by nursing staff. A review of select incident reports during July 2024, and nursing documentation revealed the following: On July 19, 2024 at 7:10 AM, Resident 46 was found on the floor in his room. The resident had an increase in his antianxiety medication July 14, 2024. Select incident reports during August 2024, and nursing documentation revealed the following: On August 28, 2024 at 6:15 AM, Resident 46 was sitting on the side of his bed and slid to the floor. He was incontinent of urine at the time. New interventions at that time to prevent falls were to educate the resident's family regarding fall prevention, On August 28, 2024 at 11:55 P.M., the resident was found on the floor between the two beds with the room armchair tipped over underneath him. He was noted to be incontinent of urine at that time. He was placed back to bed by staff and non skid socks were applied at that time by staff. According to review of select incident reports and nursing documentation completed during September 2024, revealed the following: On September 1, 2024 at 8 AM, Resident 46 was found on the floor in his room. The arm chair again was tipped on its side next to him. He was incontinent of a large amount of urine at the time. No new interventions were put into place at that time to prevent falls. On September 3, 2024 at 7 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. His brief was noted to be saturated with urine and there was a pool of urine on the floor. There were no new interventions put into place at that time to prevent falling. On September 5, 2024 at 2 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. No new interventions put into place at that time, to prevent falling. On September 8, 2024 at 2:15 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. There was no indication that the facility devised new interventions to address the resident's frequent falls. On September 9, 2024 at 7:40 A.M., the resident was found on the floor in his room. He was again noted to be incontinent of urine at that time. A liquid was also identified on the floor at that time. There were no indication that new interventions were put into place at that time, to prevent falling. A new intervention was noted on the resident's care plan dated September 11, 2024, and consisted of assisting the resident with toileting every 1 hour while awake. On September 16, 2024 at 4:45 P.M., the resident was observed in the lobby area by staff. His shorts were falling down. The resident bent over to pick up his pants, lost his balance and fell to the floor. There were no new interventions put into place at that time to prevent falling. According to review of select incident reports and nursing documentation completed during October 2024, revealed the following: On October 14, 2024 at 5:30 PM, Resident 46 was found on the floor in his room in front of the heater. He stated I slid off the bed again. The resident slid off the bed when he leaned over to remove his sneakers. No new interventions were put into place at that time to prevent falls. On October 15, 2024 at 1:29 P.M., the resident was found on the floor in his room. He had been previously in his bed. The resident stated I slid off my bed again. There were no new interventions put into place at that time to prevent falling. On October 18, 2024 at 10:35 A.M., the resident was found on the floor in his room. The resident's bed linens were saturated at that time. A new intervention dated October 18, 2024 to conduct a medication review related to frequent falls, was put into place at that time. On October 19, 2024 at 9:32 AM, Resident 46 was found on the floor in his room. He stated I slid off the bed again. He was noted to have an 8 cm x 8 cm area bruise to his sacrum. No further description of this area was available at the time of the survey. The resident was noted to have a perimeter mattress (A bed mattress with bolsters, designed to minimize the risk of a fall by guiding the sleeper away from the side of the bed and toward the middle of the mattress) in place on top of his bed. He was noted to be incontinent of urine at the time of the fall. New interventions implemented at that time, to prevent falls included, replace underwear with disposable briefs for incontinence care. On October 22, 2024 at 11 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. There were no new interventions put into place at that time to prevent falling. On October 22, 2024 at 6:15 P.M., the resident was found on the floor in his room. Again the resident was noted to be incontinent of urine at that time. The only new intervention in response to that fall, was to order a urology consult in response to family concerns for increased incontinence. On October 24, 2024 at 7:15 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. There were no new interventions put into place at that time to prevent falling. The investigation concluded that the resident's perimeter mattress did not fit the bed frame properly, his bed was not made and he had on silky shorts. During an interview November 6, 2024 at 2 P.M., the Director of Nursing was unaware that Resident 46's perimeter mattress did not fit the residents bed as stated in the incident investigation. On October 27, 2024 at 9:30 A.M., the resident was found on the floor in his room. He was noted to be incontinent of urine at that time. At the time of the fall the resident was dressed in a brief and regular socks. He had been previously dressed by direct care staff. It was noted that the resident had taken his clothing off and he was incontinent of urine. The floor was noted to be wet with urine. When examined it was noted the resident sustained a 2 cm x 2 cm abrasion to his right elbow, a 9 cm x 6 cm ecchymotic (black and blue bruise) area to his right forearm and a 1 cm x 1 cm abrasion to his right knee. Interventions were limited to notification to the Physician and a treatment to the affected areas was ordered. On October 28, 2024 at 6:30 P.M., the resident was independently ambulating in the facility and was found laying on the floor by the main entrance. When interviewed related to the fall he stated that he was tired. The residents physican was notified. On October 29, 2024 at 4:40 PM, Resident 46 was found on the floor in his room on his side with the perimeter mattress flipped up on him on the floor. He was noted to be incontinent of urine. There was no indication that additional interventions were put into place at that time related to this additional fall. During an interview completed on November 6, 2024 at approximately 2 P.M., the Nursing Home Administrator and Director of Nursing confirmed that Resident 46 was incontinent of bladder. The NHA stated that this resident was a big man and nursing staff were intimidated by him. They confirmed that he wandered in the hallways and staff was often afraid to approach him to redirect or to toilet him. The NHA stated that the facility had been attempting to transfer him to a facility with a dedicated dementia unit in an attempt to provide him with the level of care he required. She confirmed that staff supervision was not attempted for this resident with repeated falls. The facility failed to provide effective interventions to include, supervison, a toileting program or a review of resident devices/ mattresses in an attempt to prevent the resident's repeated falls. The facility failed to timely revise the resident's safety plan and include the resident's need for increased staff supervision and a toileting program in response to the resident's known incontinence, behaviors and repeated falls. A review of Resident 35's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included muscular dystrophy (is a group of diseases that cause progressive weakness and loss of muscle mass. In muscular dystrophy, abnormal genes (mutations) interfere with the production of proteins needed to form healthy muscle) and major depressive disorder. Resident 35's comprehensive person-centered plan of care was initiated on February 23, 2024, and revised on April 11, 2024, indicated that the resident had behaviors related to exhibiting behaviors related to unsafe choices such as operating motorized wheelchair at increased speed beyond manufacturers recommendations and failure to observe safe distances from peers. Planned interventions included to monitor and document episodes of inappropriate behaviors and notify physician/NP (nurse practitioner)/PA (physician's assistant) when behaviors persisted or when the resident resisted efforts to deescalate. Planned interventions included attempts to redirect resident when exhibiting behaviors; re-approach when resident deescalated, and offer psychologist/psychiatrist services as needed. Review of Resident 35 ' s Quarterly MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed that the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 12, which indicated that the resident had moderate cognitive impairment. Additionally, the resident used an electric wheelchair for mobility. A review of a Contractual License signed by Resident 35 on June 4, 2023, revealed that nursing or any member of the IDT (interdisciplinary team) may restrict driving privileges due to unsafe practices by the driver which include but not limited to: overall health, alertness, issues with vision, endangering other people in the facility, endangering oneself, excessive speed, failure to stop and ask for assistance when there are obstacles, reckless driving, and after causing an accident. Further review of the contractual license indicated the following actions related to unsafe operating practices with motorized wheelchair use included the following: First offense - license will be suspended for up to three days until an interdisciplinary conference is conducted to determine the course of the offense and course of action. Second offense - license will be suspended, and resident will be reassessed by therapy and finding reported to the IDT for course of action. Third offense - license will be suspended, and therapy will re-evaluate the resident's ability to utilize motorized equipment and if deemed unsafe an alternative mode of transportation and least restrictive seating system would be evaluated. A review of a facility provided witnessed incident report completed by Employee 4, a Licensed Practical Nurse (LPN), dated June 21, 2024, at 11:20 PM, revealed that she heard another resident {Resident 12} yell ouch and looked down the hall and witnessed the resident {Resident 35} in his electric (motorized wheelchair) up against Resident 12 while trying to pass her in the fall. No injuries obtained. Resident 35 stated I didn't do it; she ran into me. The immediate action taken was to take away his motorized wheelchair for three days as per signed {signed by Resident 35} therapy agreement and for the IDT (interdisciplinary team) to address. Subsequently, Resident 35's clinical record failed to reveal that therapy services performed a thorough assessment of the resident's safety while using his personal motorized wheelchair. A review of Resident 25's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, depression, and diabetes. Review of Resident 25 ' s Quarterly MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed that the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 15, which indicated that the resident was cognitively intact. Additionally, the resident used an electric wheelchair for mobility. A review of the resident's clinical record failed to reveal that Resident 25 had periodic safety assessments to evaluate safety while using a personal electric wheelchair. During an interview with the Director of Therapy Service on November 6, 2024, at 2:45 PM, revealed that Resident 35 received therapy services from May 16, 2024, through June 16, 2024, and from August 26, 2024, through September 20, 2024, and reported that treatments included operating and maneuvering his electric wheelchair. Additionally, the PT director reported that the facility did not have a specific policy for the use of motorized wheelchairs in the facility and indicated that therapy included their safety evaluation for safe use of motorized wheelchairs in the resident's therapy evaluations and treatment plan documentation. The facility could not provide documented evidence that periodic safety evaluations/demonstrations were completed with Resident 35 and Resident 25 that utilized motorized wheelchairs. cross refer F690 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the resident's toileting needs, including timely staff assistance with toileting and incontinence management for four residents out of 15 sampled residents (Residents 16, 7, 28, 46 ). Findings include: A review of facility policy titled Urinary Continence and Incontinence - Assessment and Management last reviewed August 27, 2024, revealed that it was the policy of the facility to identify, assess, and provide the appropriate treatment and services to achieve or maintain as much normal urinary function as possible. A three-day bladder diary will be completed for every resident upon admission, readmission, and as needed to determine if the resident requires a toileting plan or a every two-hour check and change program. A review of Resident 16's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included metachromatic leukodystrophy (a rare hereditary (genetic) disorder that causes fatty substances (lipids) to build up in cells, particularly in the brain, spinal cord and peripheral nerves and the brain and nervous system progressively lose function because the substance that covers and protects the nerve cells (myelin) is damaged) and muscle weakness. A review of the resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2024, revealed that the resident was cognitively intact, required substantial/extensive assistance from staff for bed mobility, transfers, and toileting, was always incontinent of urine, always incontinent of bowel, and was not on a toileting program. A review of a completed Bladder and Bowel assessment dated [DATE], revealed that Resident 16 was a candidate for scheduled toileting. However, the facility could not provide documented evidence that a scheduled bladder and bowel program was evaluated to determine a pattern of incontinence or to assess if more frequent check and changes should be offered to the resident to keep her dry. A review of documentation reports for August through October 2024, revealed no documented evidence that the facility implemented or offered the resident more frequent incontinence checks or incontinence care due to the resident consistently being incontinent. The facility completed a Bladder and Bowel Assessment on August 15, 2024, that indicated that Resident 16 was a candidate for scheduled toileting. However, the facility could not provide documented evidence that a scheduled bladder and bowel program was assessed to determine a pattern of incontinence or assess more frequent check and changes offered to resident to keep her dry. A reviewed of survey documentation reports (task record) dated August 2024, through October 2024, revealed no documented evidence that the facility implemented or offered the resident more frequent incontinence checks and incontinence care due to the resident always being incontinent. An interview with the Director of Nursing (DON) on November 7, 2024, at 11:15 AM, confirmed that the facility could not provide documented evidence that a scheduled bladder and bowel program evaluation was completed to determine a pattern of incontinence or to determine if more frequent check and changes were required tto keep the resident dry. A review of Resident 7's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included urinary tract infections (UTI - is an infection in any part of the urinary system), major depressive disorder, and anxiety. A review of the resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2024, revealed that the resident had severe cognitively impairment, required substantial/extensive assistance from staff for bed mobility, transfers, and toileting, was always incontinent of urine, frequently incontinent of bowel, and was not on a toileting program. A review of Resident 7's person-centered plan of care that was initiated on January 5, 2024, and last revised on February 14, 2024, identified that the resident has episodes of bladder and bowel incontinence related to generalized weakness, prostate cancer, stress incontinence, unable to feel urge to have BM (bowel movement), and unable to verbalized need to be toilet. Noted resident goals included for the resident to be comfortable, clean, dry, and free from skin breakdown and that the resident would be at a reduced risk for complications from incontinence through next review. Planned interventions included to provide peri care after each incontinent episode and apply house barrier after incontinence care, periodically evaluate residents pattern of urination and episodes of incontinence, implement toileting schedule as indicated, and check and change every two hours and PRN (as needed). A review of Resident 7's most recent Bladder and Bowel Assessment completed on October 12, 2024, revealed that the resident was to be toileted every two hours and noted that the resident was consistently incontinent of bowel and bladder. The interventions included to continue to check and change every-two hours and apply barrier cream with after each incontinence. Further review of Resident 7's clinical record failed to reveal documented evidence that the planned incontinence management to check and change every-two hours and apply barrier cream with after each incontinence was consistently performed by staff. Additionally, the resident's Kardex (a nursing information system used to obtain specific care information for each resident) failed to include the resident's incontinence management needs. An interview with the DON on November 7, 2024, at 11:15 AM, confirmed that the facility could not provide documented evidence that planned incontinence management to check and change every-two hours and apply barrier cream with after each incontinence was consistently performed by staff. A review of Resident 28's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 8, 2024, revealed that the resident was moderately cognitively impaired, required extensive assistance from staff for bed mobility, transfers and toileting, was always incontinent of urine, frequently incontinent of bowel, and was not on a toileting program. A review of Resident 28's Quarterly Bowel and Bladder assessment dated [DATE], revealed that the resident voided appropriately without incontinence less than daily, was incontinent of stool daily, was immobile or required two person assist to transfer to the toilet, was forgetful but followed commands, was sometimes aware of the need to toilet, and had no redness of skin on private areas. The comment section stated, check and change 2qh (every two hours). The evaluation concluded that the resident was a potential candidate for a scheduled toileting program. A review of the resident's Kardex (a nursing information system used to obtain specific care information for each resident) in effect at the time of the survey ending November 7, 2024, revealed the toileting plan was to monitor for bowel and bladder continence. There was no documented evidence on the Kardex that staff were instructed to provide the resident with a two-hour check and change program. A review of the resident's plan of care in effect at the time of the survey ending November 7, 2024, revealed that the resident was identified as having episodes of bladder and bowel incontinence with interventions to monitor for signs and symptoms of a UTI (urinary tract infection), monitor peri-area for redness, irritation and skin excoriation/breakdown, provide peri-care after each incontinence episode, apply house barrier after incontinence care and report if resident has no output. There was no documented evidence that a two-hour check and change program was developed and implemented on the care plan. A review of the facility Documentation Survey Report v2 (general care nursing tasks completed for the resident) for the task of Monitor B&B Continence for October 2024, revealed Resident 28 was incontinent of urine 83 times out of the 87 documented episodes of bladder function for the month of October 2024. There was no evidence that the facility had developed and implemented a plan to address the resident's toileting needs based on an evaluation of the resident's habits and voiding patterns and assure timely care was provided to meet the resident's toileting needs and manage the resident's urinary incontinence to prevent extended periods of time without toileting, checking for incontinence and changing the resident. A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include dementia and a history of falls. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated August 14, 2024, revealed that the resident's cognition was severely impaired, and he was independent with ambulation, with a BIMS score of 4 (BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. A score of 1-7 indicated severe cognitive impairment) and was occasionally incontinent of bladder. A review of a care plan dated Resident has an ADL self-care performance deficit related to Alzheimer's dementia dated May 14, 2024, revealed, resident 46 had potential for episodes of incontinence related to cognitive impairment and generalized weakness. Interventions were to include, assist resident with toileting needs. His toileting plan was to, offer set-up help if needed. A review of a current care kardex (Kardex is a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) initiated May 14, 2024 revealed the resident to be independent for toileting, offer set-up help if needed. No bladder assessments were available at the time of the survey. There was no evidence of a three-day bladder diary (a bladder diary is kept by nursing for the resident over the course of three to seven days, and allows the healthcare provider to evaluate the patient ' s bladder function) completed for this resident upon admission, readmission, and as needed to determine if he required a toileting plan or a every two-hour check and change program. Further, there was no assessment and determination of the type of incontinence noted for this resident. A review of monthly ADL records dated August through October 2024 were inconclusive as many of the days noted in each month were blank. The urinary activity was not documented. Resident 46 was noted to have had 19 falls from July 2024 through October 2024. It was noted that in 14 of the 19 falls, Resident 46 was noted to incontinent of bladder. A review of a care plan meeting note dated August 28, 2024 at 3:19 P.M., an increase in the residents urinary incontinence was noted. This was to be evaluated by the RN nurse practioner (CRNP). There was no documented evidence at the time of the survey that the CRNP evaluated Resident 46's increase in urinary incontinence. A Physicians order dated August 30, 2024 at 11:46 A.M. revealed, Complete a bladder tracker (three day) and enter it in the electronic medical record. Record bladder function every 2 hours for 72 hours for fall prevention. There was no evidence at the time of the survey that this task was completed. There was no evidence at the time of the survey that Resident 46 was assessed for increasing bladder incontinence and a plan was implemented to maintain or improve his bladder function. Interview with the Nursing Home Administrator on November 7, 2024, at approximately 1:00 PM confirmed that the facility was unable to provide evidence that the facility had consistently provided timely care for the resident's toileting needs, including incontinence management, the type and frequency of physical assistance necessary to assist the resident's incontinence needs. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 15 residents reviewed (Resident 46) Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include dementia and a history of falls. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated May 27, 2024, revealed that the resident's cognition was severely impaired, and he was independent with ambulation. with a BIMS score of 4 (BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. A score of 1-7 indicated severe cognitive impairment). A review of a care plan initiated on July 22, 2024, revealed behaviors related to wandering throughout facility with no sense of direction, expressions of delusions of needing an ambulance due to cancer, intentionally placing linens on floor to discard, exposing himself while urinating on the floor, exhibiting a failure to comply with safety measures (appropriate footwear) related to cognitive impairment, The resident's current care plan, in effect at the time of the survey of November 7, 2024, did not identify all of the resident's specific dementia related behaviors exhibited or individualized person-centered interventions to address each of these behaviors. Interventions were limited to include, administer medications per physician order. Monitor for effectiveness and side effects, apply non-skid socks after dinner, apply sock and sneakers upon resident arising in am, approach resident in a calm manner to avoid frustration and behavior escalation; If the resident becomes agitated and shows signs of escalation, re-approach later, attempt to redirect resident when exhibiting behaviors; re-approach when resident has deescalated, give non-judgmental support, if resistive to redirection: acknowledge resident's concerns, reassure that physician is updated as appropriate, Offer to contact support person (spouse), Offer preferred activities (discussing NY Nicks, snack of choice) Review of Resident 46's nursing progress notes during the months of May 2024 through the resident's discharge to another facility on November 6, 2024, revealed that the resident displayed increasing behaviors of verbal aggressiveness with staff, with seeking behavior and multiple falls in the facility. Resident 1 was the aggressor in all the verbal resident to staff incidents between May 14, 2024 and November 6, 2024. A nursing note dated May 15, 2024 at 08:50,A.M, revealed, Resident 46 came out of his room this AM around 0830 and walked straight to the main doors to exit. The social worker (SW)intervened when resident walked past her office door. Resident stated he wanted a soda. The SW redirected with soda options. The Resident went back out in the lobby heading towards the back door hallway within minutes after receiving the soda in his room. He told this writer he did not need anything and turned back to his room. A nursing note dated May 22, 2024 at 08:56 A.M., revealed, Resident 46 was hovering at nurses medication cart, expressing concerns that too many medications being given to other residents in the facility. He refused to take his medications. The Resident was exit seeking and pacing. A nurses note dated May 22, 2024 at 11:30 A.M. revealed, resident continued to pace and refuse medications, kept pacing around the facility. The therapy staff stated that Resident 46 was ambulating into the therapy department and hovering over the computer screens and making paranoid statements regarding residents in the room. He continued to pace the hallway towards the exit doors. A nurses note dated May 22, 2024, at 12:40 PM revealed, Resident 46 was pacing the hall again. When he approached the nurses station again he stated What is going on with the meds, I did not know there was a problem? He stated: Well look at that big box! pointing to the medication cart, Who needs that many meds?Nursing attempted to explain to the resident that the medication cart contained all the meds in the building for the residents. The resident stated I don't trust anyone! I am not taking those meds!Nursing staff reassured the resident that no one would force him to take medications. He then asked about the nail of the pointer finger on his left hand. He asked nursing staff, Do you have a tweezers, I want to pull this off! Nursing examined finger. The resident denied pain, but insisted that there is something in his finger. Nursing attempted to redirect the resident but he approached everyone in the hallway with the same issues. He was polite, and non-threatening. Yet, due to his size, and the tense stance, he appeared imposing. The staff was told to stay calm and not startle him. A nurses note dated June 12, 2024 at 08:56 A.M., revealed, resident became agitated and anxious this AM regarding his cancer and wanted to go to the hospital immediately. The resident did not have a cancer diagnosis and was fixated on same. The Physician was in and examined the resident and ordered Ativan (antianxiety medication) 1mg every 6 hours as needed for anxiety. A nurses note dated July 7, 2024 at 2:15 P.M. revealed, nurse aide reported that the resident was going through the food cart after lunch, and eating food discarded by other residents. The resident was pacing from his room to the lobby, fixated on his medications and other residents needs. A nursing note dated July 19, 2024 at 08:09 A.M., revealed, resident was noted sitting on the couch in the common area. At 0800 A.M. the resident stood up and walked down the hallway with his penis out and began urinating down the hallway. When attempting to redirect resident began squeezing his penis and yelling What?Resident replaced his penis back in his shorts and went to his room. A nurses note dated July 21, 2024 10:18 A.M., revealed, Resident 46 was extremely anxious and agitated and exit seeking. Nursing documentation dated July 21, 2024 at 1 P.M., revealed, Resident 46 attempted to follow a visitor out facility door, Nursing documentation dated July 21, 2024 at 3:10 P.M., revealed, Resident 46 raced towards the exit door again when visitor was leaving. Nursing stood in front of door and redirected the resident to stay in the facility. The resident then followed the nurse around. Resident 46 put his arm around the nurse twice. Nursing attempted to redirect the resident but he would refused to remove his arm from the nurse. The Resident then stood next to this nurse and put his hand down his pants. The nurse asked resident if he needed to urinate. Resident did not answer and just stared at the nurse. Nursing attempted to redirect the resident. He refused to respond and started manipulating his penis in the hall. Nursing redirected the resident and the involved nurse removed herself from the situation. The resident continued to exhibit behaviors in August and September 2024. A review of nursing documentation and incident reports dated between July 19, 2024, and October 28, 2024, revealed that Resident 46 incurred nineteen falls in the facility during that time period, one in July, 2 in August, 6 in September and 10 in October 2024. The facility was monitoring the resident's behavioral symptoms via nursing documentation during the months of May 2024 through November 2024, however, there was no documented evidence of the behavioral management or behavior modification interventions developed for use by staff to respond to the resident's dementia related behavioral symptoms. The facility failed to fully develop and implement an individualized person-centered plan to address, modify and manage the residents' dementia-related behaviors. The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms. Interview with Director of Nursing and the Nursing Home Administrator on November 6, 2024, at approximately 2 p.m., confirmed that the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors and consistent and accurate monitoring of the resident's dementia related behaviors and any approaches used to manage or modify those behaviors. cross refer F689 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy, resident interviews, and staff interviews, it was determined the facility failed to ensure that one resident (Resident 24) was free from sexual abuse perpetrated by another resident (Resident 35) out of 15 sampled residents. Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on August 27, 2024, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, means the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault. Sexual contact or assault that results from threats, force, or the inability of the person to give consent and involving a range of activities. Additionally, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. Additionally, the facility policy indicated that abuse prevention included assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. The facility will strive to maintain adequate staffing on all shifts to ensure the needs of each resident are met. A review of Resident 35's clinical record revealed admission to the facility on [DATE], with diagnoses that included muscular dystrophy (is a group of diseases that cause progressive weakness and loss of muscle mass. In muscular dystrophy, abnormal genes (mutations) interfere with the production of proteins needed to form healthy muscle) and major depressive disorder. Resident 35's comprehensive person-centered plan of care was initiated on February 23, 2024, and revised on April 11, 2024, and indicated the resident had behaviors related to inappropriate sexual behaviors (making sexually inappropriate statements to caregivers) and desires to be sexually active or show sexual expression. Planned interventions to manage sexual behaviors included to attempt to redirect the resident when exhibiting these behaviors and re-approach when the resident has deescalated, monitor and document episodes of inappropriate behaviors and notify physician/nurse practitioner/physician assistant when behaviors persist or won't deescalate, and to monitor behavior episodes and attempt to determine underlying cause with consideration of location, time of day, persons involved, and situations. Review of Resident 35's Quarterly MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 12, which indicated the resident had moderate cognitive impairment. Additionally, the resident used an electric wheelchair for mobility. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia (most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), anxiety (a feeling of fear, tension, or worry that occurs as a response to real or perceived threats), and major depressive disorder. Additionally, the resident had severe cognitive impairment and utilized a wheelchair for mobility as indicated by her quarterly MDS assessment dated [DATE] as evidenced by a BIMS score of 2 (score of 00-07 severe cognitive impairment). A review of nursing documentation on September 28, 2024, at 3:07 PM for Resident 35's revealed social services was alerted due to the resident caressing a nurse aide's (NA) arm while providing care, making her feel uncomfortable. However, Resident 35's clinical record failed to reveal documented evidence that social services followed up with the resident post the inappropriate sexual behavior toward the staff member and failed to reveal that his person-centered plan of care was reviewed and revised with new goals and approaches to manage his sexual behaviors. A review of a facility provided documentation completed by the Director of Nursing (DON), dated October 21, 2024, at 2:55 PM, revealed that Employee 1, a NA, alerted the IDT (Interdisciplinary Team) staff to resident Resident 35 who was in the activity area holding the hand of female Resident 24 and rubbing his private parts and top of thigh over clothing with Resident 24's hand. Three other residents were in the activity area at time of the incident. Resident 35's description of the incident, I didn't do anything. The report indicated the incident was unwitnessed with no injuries noted. Further review of the incident investigation report revealed the facility's immediate action taken was immediately removing the female resident, Resident 24, from the area and Resident 35 was sent back to his room. Resident 35 was placed on 1:1 (one-to-one staff supervision) while statements were obtained from involved parties in the area during the time of the incident. Resident 35 sat with a NA in the Social Services Department office while interviews were being conducted. The Department of Aging and State Police were notified and the responsible party (RP) of female resident Resident 24 was notified. The facility's immediate interventions were to replace Resident 35's motorized wheelchair for a manual wheelchair while awaiting a therapy evaluation and every fifteen-minute checks were also initiated while Resident 35 was OOB (out of bed). A review of Employee 1's, nurse aide witness statement dated October 21, 2024, no time specified, revealed that on Monday October 21, Employee 1 was walking down the north hall and observed Resident 35 holding Resident 24 by her wrist and rubbing his private area and the top of his leg. Employee 1 called out to Resident 35 who then removed his hand from Resident 24. Resident 24 was removed from the situation and Employee 1 asked Resident 35 to return to his room. The facility failed to protect and ensure that Resident 24 was free from sexual abuse from Resident 35 who had a known documented history of sexual inappropriate behaviors. Applying the reasonable person concept, in the case of Resident 24, who is unable to speak for herself, and the assessment of how most people would react to the situation of being sexually abused by Resident 35, Resident 24 would have suffered psychosocial harm and humiliation. An interview with the Director of Nursing (DON) and in the presence of Nursing Home Administrator (NHA) on November 7, 2024, 2024, at 1:05 PM, revealed that that they were not aware of Resident 8's history of sexually inappropriate encounters/behaviors with female staff and residents as noted in his person -centered plan of care and clinical record by staff and contracted psychiatric services. Further interview with the DON and NHA confirmed the facility failed ensure proper staff supervision of Resident 35, a resident with a known history of sexually inappropriate behaviors and ensure that Resident 24 was free from sexual abuse. The facility failed to fully investigate this incident of sexual abuse of Resident 24. The facility failed to develop and implement necessary interventions for a resident with a known history of sexual inappropriate behaviors to prevent the sexual abuse of Resident 24. The facility failed to develop and implement interventions after the sexual abuse occurred to prevent further incidents of sexual abuse. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls and known unsafe behaviors that increased the resident's risk for falls, to prevent a fall with serious injuries, facial and foot fractures, to one resident out of 13 sampled (Resident 46). Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses of dementia, protein anxiety and a history of repeated falls. A Quarterly Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score of 6 and required extensive staff assistance with activities of daily living. The resident's care plan initially dated June 8, 2023, indicated that the resident was at risk for falls related to impaired decision making and impulsive movements, with initial planned interventions for the use of bed and chair alarms, bed bolsters, maintain needed items within reach, monitor for changes in mobility, take resident for short walks throughout the day, diversional activity items, camera in room for monitoring, and maintain call light within reach, and educate resident to use call light. A review of a facility investigation report dated June 22, 2023, at 3:05 AM, revealed that a nurse aide found the resident sitting on the floor of the resident's room at the end of his bed. The resident's bed alarm was on the bed but not sounding. No injury was sustained, and the resident was unable to state what had happened. Interventions implemented as the result of this fall included replacement of the bed alarm, bed bolsters applied to mattress, and a camera was placed in the resident's room for staff observation, as previously care planned on June 8, 2023. A review of a facility investigation report dated July 20, 2023, at 10 PM. revealed that the resident stood up from the chair and proceeded to walk. When the nurse aide heard the resident's chair alarm and went to help him back into the chair, the resident pushed staff away and fell to the floor. Interventions implemented in response to this fall were for staff to take resident for short walks as previously care planned on June 8, 2023. A review of a facility investigation report dated July 21, 2023, at 3 AM, revealed that Resident 46 was found on the floor in his room next to the foot of the bed lying on his left side in front of a puddle of urine. A large hematoma to the left side of his forehead was observed. The resident was unable to state what he was attempting to do. Bolsters were on the resident's bed and staff last checked the resident, a half hour prior, at 2:30 AM. The resident was sent to the emergency room for further evaluation. No injuries/concerns were identified during emergency room evaluation. Interventions implemented upon the resident's return to the facility was for toileting to be offered every hour while awake, a bedside commode to serve as a visual cue to use for meeting toileting needs and a new bed alarm was applied. Review of an employee witness statement dated July 21, 2023, indicated that a nurse aide heard a loud noise down the East hall while she was at the nurse's station completing computer work. The witness (nurse aide) found Resident 46 on the floor in his room, the (bed) alarm was not ringing, and he had nothing on. A review of a facility investigation report dated July 23, 2023, at 7:20 AM, revealed that another resident notified facility staff that Resident 46 was on the floor in the resident's room. Staff found Resident 46 on the floor next to the bed in his neighbor's room. No apparent injuries were identified. The resident's bed alarm was in place but did not sound. According to the facility's investigation, the bed alarm did not sound off, and the bolsters were on the resident's bed, but (the resident) was able to get around them/ Camera/ child monitor was monitored for safety; however, {the resident's}activity was not monitored when staff was completing assignments. Intervention implemented included placement of a sensor alarm (to the resident's bed). A review of a facility investigation report dated October 3, 2023, at 12:35 AM, revealed that facility staff witnessed Resident 46 walking down the hall, lose his footing, stumble, lose his balance and fall backward onto his bottom. According to investigation, the resident's nonskid socks were turned slightly, preventing the grips from functioning as intended. There was no documented evidence of the development and implementation of measures to prevent future similar falls while ambulating, including assuring the correct placement of the resident's non-skid socks or appropriate non-skid footwear or providing assistance with ambulation as required. Review of facility investigation report dated October 16, 2023, at 7:20 PM, revealed that Resident 46 attempted to sit in a wheelchair located in the hallway, but the wheels of the chair were not locked. The wheelchair rolled enough for the resident to fall, to a seated position on the floor between the leg rests of the wheelchair. No injuries were identified. The resident had been walking independently while being visualized by staff at the time of the fall, despite the resident's fall while independently ambulating that occurred on October 3, 2023. Interventions implemented as a result of this fall were to educate staff that vacant wheelchairs are to have the wheels locked. Review of a facility investigation report dated October 24, 2023, at 1:40 AM revealed that Resident 46 was found in the club room laying on his left side, still in a seated position, with the chair (he had been seated in) also laying on its side on the floor. The resident sustained a bloody nose, swelling to the left side of his forehead, his left eye, and left hand/wrist/fingers. The resident was sent to the emergency room for an evaluation. The findings of CT scan (diagnostic imaging studies) performed in the emergency room revealed a nondisplaced left orbital roof fracture (bones in the eye socket) extending into the anterior and middle cranial fossae and left frontal sinus, barely perceptible left frontal and subdural hematomas, large left periorbital and temporal scalp hematoma, and complex hemorrhagic collections in the left frontal ethmoid maxillary and sphenoid sinuses. Probable nondisplaced medial orbital and orbital floor fractures. Upon the resident's return to the facility on [DATE], a follow-up CT scan was scheduled, along with an eye consultation. Interventions implemented to prevent additional falls as a result of the resident's fall on October 24, 2023, were completion of a therapy screen, a wheelchair alarm, and placing the resident on every 15 minute checks for monitoring of the resident. The resident's care planned interventions proved ineffective in preventing multiple falls, including alarms and in-room camera monitoring. However, the facility did not develop and implement measures to increase staff supervision and staff monitoring of the resident and the resident's activities out of the resident's room, until after the resident's fall with facial injuries on October 24, 2023. Review of facility investigation report dated November 6, 2023, at 6 PM, revealed that the resident was found laying on the floor, flat on his back in the west hallway, near the medication room. According to the investigation, the resident stated that he didn't fall, I just laid down. Staff assisted the resident to a sitting, then to a standing position, incontinence care was provided. Staff last saw the resident in the main lobby, sitting on couch at approximately 5:45 PM. Prior to that observation, at approximately 5:30 PM, staff observed the resident urinating in the hallway and refused to have his clothes changed. Review of a facility investigation report dated November 8, 2023, at 5:35 AM, revealed that the resident was found on the floor in the nurse's station. There was no documented evidence that staff were present in the nurse's station supervising the resident at the time of the resident's fall as it was noted that staff found the resident on the floor. According to the report, attempts were made throughout the night to place the resident in bed, but were unsuccessful and the resident was resistive/combative with care. According to the investigation dated November 8, 2023, Resident 46 had complained of left leg pain on November 7, 2023, after the unwitnessed incident on November 6, 2023. The physician ordered an x-ray of the left knee, fib/tib, ankle and foot. X-ray results noted a fracture involving the first MTP joint, (joint connects one of your toes (a phalangeal bone or a phalanx) to a long bone in your foot (a metatarsal bone), also noting that the resident had osteoporotic bones. The identified follow-up action included monitoring the resident for pain and medicated as needed and offered rest periods, but did not specifically address the resident's need for increased and direct supervision, and the frequency of the supervision the resident required to prevent repeated falls and injuries. During an interview December 7, 2023 at 1 P.M., the Nursing Home Administrator confirmed that the facility failed to demonstrate that staff consistently provided necessary staff supervision, at the level and frequency required, of resident with increased unsafe behaviors known to staff, and multiple falls, to prevent repeated falls with serious injuries. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records and select facility policy, observations and staff interviews, it was determined that the facility failed to timely assess and consistently provide recommended and/or prescribed treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores, which resulted in the development of facility acquired pressure sores and related pain for one resident (Resident 10) and lack of evidence of consistent monitoring of one resident's pressure sores for healing progress (Resident 1) out of four residents reviewed with pressure ulcers Findings include: According to the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians [ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. A review of the facility's policy entitled, Pressure Injuries Overview, last reviewed by the facility January 25, 2022, indicated that the purpose is to implement interventions to prevent pressure ulcers and/or enhance the wound healing process, to accurately assess/monitor a residents risk for alteration in skin integrity, to maintain and promote healthy skin integrity of residents and to establish guidelines for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing will complete a wound evaluation, if the facility is using a wound company, wound care documentation must be uploaded into the system and a progress note is to be written. The facility policy also indicated the facility will develop a plan of care, identify risks to reduce the risk of pressure injury development. The physician will help identify factors contributing or predisposing residents to skin breakdown. A root cause analysis and an incident report should be completed. Weekly body audits to be completed to identify any other areas of skin impairment. A review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 17, 2021, revealed that Resident 10 was at risk for developing pressure sores and required staff assistance for activities of daily living to include bed mobility, transfers and toilet use, and had no current pressure ulcer/injury. The resident was always incontinent of bladder and bowel. The resident's cognition was severly impaired with a BIMS score of 3 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment). A review of the resident's plan of care, initially dated November 6, 2017, to address skin integrity related to history of pressure ulcers, impaired mobility, incontinence and impaired cognition indicated interventions/tasks of encourage and assist to reposition, encourage and assist to suspend/float heels as able when in bed, observe for changes in skin condition and report abnormalities. The plan of care to address incontinence for the resident directed staff to provide incontinence care and comfort every 2 hours while awake and every 3 hours during hours of sleep. A review of the resident's Kardex (care card) revealed that the resident was on a program since October 2017, for turning and repositioning every 2 hours when in bed and every hour when in wheelchair. Staff were turn the resident side to side when in bed. The resident was to be returned to bed after meals to off-load sacrum. A review of a turn and reposition record for December 2021 and January 2022, revealed the form was incomplete and revealed numerous days and times throughout the months that the resident was not turned and repositioned every two hours while in bed and/or every hour while in her wheelchair. A review of documentation of the residents toileting program for December 2021 and January 2022, revealed that form was incomplete and that the resident was mostly incontinent. There was no documented evidence to indicate the facility had consistently implemented and monitored staff to ensure that all pressure sore prevention interventions were in place during the months of December 2021 and January 2022. A review of a facility pressure ulcer investigation dated January 22, 2022, revealed an open wound was found on the resident's coccyx area. According to the Director of Nursing (DON) during interview on February 13, 2022 at 1 PM revealed that she added wound measurements this investigation, noting that the area measured 4 cm by 2 cm. There was no other description of the appearance of the wound documented in the pressure ulcer investigation or in nursing progress notes. The investigation included a statement written by Employee 3 (nurse aide) that on January 20, 2022, she noticed a reddened area on the resident's coccyx and reported the area to the LPN on duty. Interview with Employee 3, nurse aide, on February 13, 2022, at 1:18 PM, revealed that she reported the reddened area to the resident's coccyx area to the LPN on duty on January 20, 2022. The facility did not initiate the pressure ulcer investigation until January 22, 2022 and the physician was not notified and a treatment order obtained until January 22, 2022, two days after the wound was found. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of January 2022's TAR (treatment administration record) revealed the above physician ordered pressure sore treatment was not initiated until January 23, 2022. A review of wound care specialist documentation, dated January 24, 2022, revealed that the resident had 4.0 cm x 0.1 cm, stage II pressure ulcer/ injury of the coccyx. The wound had moderate non-odorous serous drainage, edges adherent to the wound base. According to the wound care specialist the resident was demonstrating evidence of pain during the wound assessment process. Recommendations were made to : - Cleanse site with 1/4 strength Dakins solution - Apply silver alginate AG to open area (s) daily and prn - Apply skin prep to periwound - Cover with composite dressing Monitor site for signs and symptoms of infection- bogginess, drainage, [CONDITION(S)] and notify medical with any concerns - Off-load pressure to affected areas - Continue repositioning in accordance to assessed needs - Toileting regimen per facility protocol - Reposition every two hours in bed with side to side repositioning - Reposition every hour in chair - OOB for meals and therapy only to assist in off loading - Monitor nutritional intake A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of the survey ending, February 15, 2022, the facility was unable to provide evidence of the pressure sore investigation in this pressure ulcer according to facility policy. This was confirmed by the Nursing Home Administrator (NHA) during interview on February 14, 2022. According to the NHA, the pressure ulcer was found by the wound care specialist, not facility staff, during wound rounds on February 7, 2022. During an interview with the DON on February 14, 2022, at 11:10 AM, the DON stated the wound care specialist will complete and record her visit and forward the information to the NHA and DON, and they will read, print and upload the information into the system. According to the DON, after reading the wound care specialist notes, she contacted the physician about the recommendations provided by the wound care specialist to treat the new wound on the resident's right foot. The DON stated the facility's investigation should have been conducted, however, the facility failed to do so. A review of wound care specialist documentation, dated February 7, 2022, revealed a full thickness wound of the right foot measuring 1.0 x 1.5 x 0.0 cm. Purple/maroon localized are of discolored intact skin with blood filled blister. Recommentdations were made to: -cleanse infected area with NSS or wound cleanser -apply skin prep to affected area every shift and prn -monitor site for signs and symptoms of infection-bogginess, drainage, [CONDITION(S)], and notify medical with any concerns -off load pressure to affected areas -continue repositioning in accordance to assessed needs -reposition every 2 hours in bed During an observation with Employee 4 (Registered Nurse) on February 15, 2022, at 11:50 AM, while the resident was lying in bed, the resident's right foot presented an intact dark maroon/purple colored oval shaped area on the side of her great right toe, which appeared to be an old blood blister. At the time of the observation, the affected area of the foot was lying directly on the bed and the foot was not elevated. Employee 4 stated the foot should have been elevated to reduce pressure off the foot wound. Observation of the resident's coccyx area revealed a triangle shaped moist red open area. While removing the dressing the resident expressed concerns of pain through moaning and saying it hurts. The pillow was observed under the resident, but not off loading the affected area of the resident's coccyx. A review of weekly skin audits, dated February 7, 2022, at 11:40 PM, and February 10, 2022, at 10:26 PM, indicated there was no new skin alterations identified, failing to identify the wounds to the resident's right foot. This inaccurate wound documentation was confirmed during interview with the NHA on February 15, 2022, at 12 PM who stated the forms should have revealed the new area to the resident's right foot. A review of the resident's care plan addressing skin integrity, also included an intervention in place since September 28, 2018, to encourage and assist the resident to suspend/float heals while in bed. However, the facility was unable to provide documented evidence at the time of the survey ending February 15, 2022, that the resident's heels were being elevated while the resident is in bed. According to interview with the NHA on February 15, 2022, at 12 PM elevating the residents feet is a standard practice and that staff are aware of this practice although the practice was not observed to be in place when observed on February 15, 2022, at 11:50 AM. The facility was unable to demonstrate the consistent implementation of prescribed approaches and sufficient preventative measures for Resident 10 to show that pressure sore development was unavoidable. The facility failed to timely identify declines in the resident's skin integrity and failed to promptly implement and monitor adequate measures to prevent the development of a new pressure sore, for residents identified at risk for pressure sore development. Interview with the NHA and DON on February 15, 2022, at 11:15 AM, revealed the facility was unable to provide evidence that all planned interventions, for a resident identified at risk for pressure sores, were consistently implemented and monitored on a regular basis to prevent pressure sores and prevent worsening. Review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to documentation in the resident's clinical record, on November 15, 2021, it was identified that she had developed 3 skin concerns: a right heel bruise measuring 0.5 cm x 0.5 cm x 0.5 cm, a left heel DTI (deep tissue injury) darkened fluid filled blister measuring 6.6 cm x 7.8 cm x 0 cm, and a non-blanchable area, non-pressure, on her right buttock measuring 0.5 cm x 0.5 cm x 0 cm. Review of Wound Care progress note dated November 22, 2021, indicated that the resident had a Stage II pressure ulcer of the coccyx measuring 0.7 cm x 0.8 cm x 0.1 cm with scant, non-odorous serous (clear) drainage and an unstageable pressure ulcer of the left heel due to deep tissue injury which measured 7.0 cm x 6.5 cm x 0 cm with purple/maroon localized area of discolored intact skin with blood-filled blister roof. Review of Wound Care progress noted dated February 3, 2022, indicated that the resident's left heel deep tissue injury measured 2.0 x 4.5 x 0.2 cm, wound base 10% granular (new tissue) and 90% stable eschar (necrotic/dead tissue) with scant non-odorous serosanguineous drainage. The Wound Care progress note did not include information related to the healing progress of the resident's Stage II pressure ulcer of the coccyx or of the right heel bruise. Observation of Resident 1's skin concerns performed on February 15, 2022, at approximately 11 AM in the presence of Employee 1, LPN, revealed that the left heel skin was necrotic, no drainage was observed. The resident's right heel did showed no skin concerns and the resident's right buttock had 4 small tear drop open areas with raised edges. There was no documented evidence that the open areas on the resident's right buttock were being monitored by the facility nursing staff or Wound Care. There was no further documentation by facility nursing staff regarding the status and healing progress of these facility acquired skin impairments at the time of the survey ending February 15, 2022 Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2022, at approximately 1:00 PM confirmed that the only documentation regarding Resident 21 and 1's pressure ulcers was completed by the Wound Care Nurse Practitioner. The NHA verified that no monitoring of the pressure ulcers and documenting healing progress or current status is completed by the facility's nursing staff. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(a)(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, manufacturer's guidelines and select facility reports and staff interview, it was determined that the facility failed to utilize safe technique during resident transfers to prevent an accident with serious injury, a fractured hip, to one resident out of 14 residents reviewed (Resident 21). Findings include: A review of the clinical record revealed that Resident 21 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at periodic intervals to plan resident care) dated July 25, 2017, revealed that the resident had severe cognitive impairment and required the assistance of two staff members for transfers, toileting, and ambulation. Review of the resident's initial care plan dated July 24, 2017, revealed that the resident had a problem/need of functional status deficit and fall risk. The planned interventions included the use of a Hoyer (a mechanical patient lift with a sling lift used for patients whose mobility is limited) lift for toileting and transfer assistance related to self-care and mobility impairments. The resident's care plan did not direct the staff to leave the Hoyer sling under the resident after transferring the resident to a chair. Review of the facility Fall Risk Screening evaluation dated September 11, 2017, revealed that Resident 21 had a total score of 18, which indicated that the resident was, at risk for falls. A physical therapy (PT) evaluation dated September 18, 2017, revealed that the resident presented with lower extremity weakness, dependence on the staff for bed mobility, had a significant decline in functional transfers, had impaired sitting and standing balance, poor safety awareness and inability to ambulate. PT indicated that the resident required a Hoyer lift for functional transfers and bed mobility. A facility Incident/Accident Report dated September 20, 2017, at 2 p.m. revealed that the resident was found on the floor at the foot of her bed on her right side and her wheelchair to the left of her. She had nonskid socks on her feet and she was incontinent of bowel movement. The sling from (Hoyer) lift was on her wheelchair cushion. The resident stated, I slid out of my wheelchair. The physician was notified of the resident's fall on September 20, 2017, and the resident's increased complaints of pain on September 21, 2017, at which time an X-ray was ordered. Review of Resident 21's X-ray report, dated September 21, 2017, revealed a right femoral neck fracture (broken hip). Interview conducted with the Director of Physical Therapy (DPT), Employee 4, on November 1, 2017, at 12: 15 p.m revealed that Employee 4 stated that the Hoyer sling left under the resident may have contributed to her sliding out of her wheelchair. Interview conducted with Employee 1, Nurse Aide, on November 1, 2017, at 1 p.m. revealed that the employee stated that the (Hoyer lift) sling was under the resident's wheelchair (on the day of ) the unwitnessed fall. Employee 1 confirmed that leaving the (Hoyer lift) sling under Resident 21, while seated in her wheelchair was not care planned for the resident at that time. Employee 1 was unable to explain why the sling was left under Resident 21 when the resident was transferred to the wheelchair seat on September 20, 2017. Interviews conducted with Employees 2 and 3, Nurse Aides, on November 1, 2017, at 1:15 p.m. revealed that each employee stated that (Hoyer lift) pad/slings are removed from beneath the resident after transfer and are not to be left under the resident, unless specified on the resident's care plan. Review of the Hoyer Lift Manufacturers Manual revealed in the section, Leaving Slings Positioned Under Patients in Wheelchairs, that patient's posture must be evaluated by a nurse or professional rehabilitation department staff member to see if leaving the sling under the patient might contribute to the patient sliding out of or falling off a wheelchair or chair. Secondly, the resident's clothing, the sling fabric and the surface of the chair or wheelchair must be assessed for slipperiness. If leaving the sling under the resident while he or she is in the wheelchair poses risk for sliding out of or falling off the wheelchair, it may not be left under the resident. There was no documented evidence of a professional evaluation had been conducted to determine if it was safe for the lift sling to remain positioned under Resident 21 while seated in her wheelchair. PT had noted on September 18, 2017, that the resident had impaired sitting balance and poor safety awareness. However, the facility staff failed to ensure that the resident's seating arrangement was safe and appropriate when transferred to the wheelchair with the sling remaining beneath the resident and on top of the resident's wheelchair cushion. Interview with Nursing Home Administrator on November 1, 2017, at approximately 9:30 a.m. confirmed that the facility failed to provide care in a safe manner to prevent an accident with serious injury to a resident at risk for falls. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 12/1/16, 8/11/16, 4/27/16, 11/19/15

Based on a review of clinical records and interviews with facility staff it was determined that the facility failed to timely identify declines in skin integrity, conduct consistent and accurate wound assessment and provide prompt treatment and services to prevent deterioration of pressure sores for one of four sampled residents (Resident 26) Findings include: A review Resident 26's clinical record revealed that upon admission to the facility on [DATE], the resident was assessed to be cognitively intact with [DIAGNOSES REDACTED]. A Braden assessment, a tool that identifies a resident's risk for pressure sore development, dated December 2, 2015, indicated that the resident was at high risk for developing pressure sores. The resident was admitted with skin shearing (mechanical force that acts on an area of skin in a direction parallel to the body's surface. Shear is affected by the amount of pressure exerted, the coefficient of friction between the materials contacting each other, and the extent to which the body makes contact with the support surface. Shearing is a contributing factor to pressure sore development, according to the National Pressure Ulcer Advisory Panel) to the bilateral area of his buttocks. The facility did not document the specific appearance of these area of shearing upon admission. A physician's orders [REDACTED]. The resident was sent to the hospital on December 3, 2016, for observation of a GI bleed. The resident returned to the facility on [DATE] at 11:45 AM. The resident had shearing to left upper buttock and sacral area measuring 10 cm x 7 cm x less than 0.25 cm deep. A physician's orders [REDACTED]. The wound was to be cleansed first with normal saline solution (NSS) and covered with an Optilock dressing (super absorbent dressing). A review of the facility's documentation entitled Other Alterations in Skin Integrity Weekly Measurement Tool, completed for skin alterations other that skin alterations caused by pressure, revealed that this record completed by the LPN (licensed practical nurse). Interview with the DON (director of nursing) on April 27, 2016 at 10:00 AM indicated the facility does not consider skin shearing as a pressure sore therefore the facility's wound nurse, the assistant director of nursing , does not do weekly evaluations or measurements of those areas, which would be the responsibility of the nurses caring for the resident. Documentation by an LPN, Employee 1, on December 12, 2015, indicated that the resident's wound measured 9.8 cm x 7 cm and had a red wound bed. The wound had brown drainage as indicated by nursing documentation in the clinical record. The Hydrogel treatment continued. Nursing documentation dated December 15, 2015, at 1:44 PM written by an LPN Employee 2, indicated the wound bed was now flat and black with pink/red surrounding tissue. Nursing documentation of December 16, 2015, indicated that the resident's wound treatment was changed to cleanse wound with NSS and apply [MEDICATION NAME] (wound care dressing which includes honey to promote removal of dead tissue) to wound bed only. Documentation by an LPN, Employee 2, on December 19, 2015, indicated that the resident's wound measured 9.8 cm by 7 cm with a black/red/pink wound bed according to the Other Alteration in Skin Integrity Weekly Measurement Tool. Nursing documentation dated December 20, 2015, at 11:09 AM indicated that the wound had bloody drainage and a wound bed that was black/red/pink. Nursing documentation dated December 30, 2015 at 2:33 PM indicated that the wound had a large amount of serosanguinous (combination of blood and thin and watery liquid) drainage. The wound treatment remained the same. On January 2, 2016, the wound measured 9.4 cm by 7.4 cm with a large amount of serosanguinous drainage, the black area appeared larger on the north side of the wound. On January 4, 2016, the facility now categorized the wound as a pressure area due to its deterioration according to interview with the wound care nurse, ADON during the survey ending April 27, 2016. The facility determined the wound to be an unstageable pressure area with foul smelling drainage measuring 9.4 cm by 7.4 cm. The treatment to this area was changed to cleanse wound with NSS and apply a small amount of Santyl (ointment which removes dead tissue from a wound) to the wound bed and [MEDICATION NAME] (used for draining wounds to manage bacterial growth) to the surrounding tissue. Juven (nutritional drink to support tissue building) was also added to take twice daily during medication administration. The wound continued to deteriorate and according to documentation of January 14, 2016, the wound measured 10.3 cm x 8. 5 cm had large amounts of drainage, which was foul smelling. On January 15, 2016, the resident's pressure sore was debrided (surgical removal of dead tissue) by the wound care physician with new treatment orders for irrigation and packing. A review of the resident's plan of care dated December 2, 2015, indicated that the resident was to be turned and repositioned every two hours while awake and every three hours while sleeping and as needed. The resident would also be checked for incontinence at these times. The resident utilized a pressure relief mattress and had a catheter to collect urine from the bladder and was to be checked for bowel incontinence as needed due to frequent incontinence of his bowels. A full air mattress was not placed on the resident's bed until the pressure sore further deteriorated on January 4, 2016. The DON was interviewed on April 27, 2016, at 1:30 PM regarding the deterioration of this resident's pressure sore. The DON stated that the resident is frequently incontinent (of bowel) and does not eat well. A review of the facilty's documented evidence that the resident is checked and changed for incontinence planned for completion every two hours revealed no evidence to confirm that the resident had been checked and changed at specific every two hours intervals. The documentation only indicated that during each shift the resident was checked and changed. The facility failed to demonstrate that this resident's pressure area was timely evaluated by a registered nurse, that adequate measures to promote healing and prevent worsening were implemented timely and that the decline in the resident's pressure sore was promptly identified and acted upon. The facility did not consult with the physician regarding a possible treatment change when the wound bed became black. It was not until the pressure sore further worsened that the facility's RN wound care nurse evaluated the area and then contacted the physician for surgical intervention. The facility also was unable to demonstrate that the frequency of the resident's incontinence care was adequate to promote healing or that the resident was checked and changed as planned every two hours. 28 Pa. Code 211.11(a)(c) Resident care plan Previous;y cite 11/19/15 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previous;y cite 11/19/15