Every finding on record at Mid-Valley Health Care Center

Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure residents received routine dental services and failed to obtain required dental clearances necessary to facilitate recommended dental treatment in a timely manner for two of twelve residents reviewed (Residents 14 and 32). Findings Include: Review of the facility's policy, entitled Dental Services, reviewed on February 1, 2026, documented, in part, The facility will assist residents in obtaining routine and 24-hour emergency dental care to meet the needs of each resident. Review of Resident 32's clinical record revealed the resident had been admitted [DATE], with diagnoses that included encephalopathy (a group of conditions that cause brain dysfunction, which may result in confusion, memory loss, personality changes, or, in severe cases, coma). A review of Resident 32's clinical record revealed no evidence that the resident received dental consultations or evaluations for routine dental services from the date of admission on [DATE], through the time of survey. Review of Resident 32's clinical record revealed a nursing progress note dated June 8, 2026, indicating the resident informed staff that she feels something sharp in her left lower jaw area and believed her partial bridge was broken. The facility notified their contracted dental services and on June 9, 2026, the facility received communication that the contracted dental provider did not accept the resident's insurance. The facility then contacted the resident's responsible party and obtained information regarding the resident's community dentist. However, at the time of survey exit on June 11, 2026, the facility had not scheduled a dental appointment or otherwise arranged treatment to address the resident's reported dental concern. During an interview conducted on June 11, 2026, at 9:00 AM, the Director of Nursing was unable to provide additional information regarding arrangements for emergency dental treatment for Resident 32. A clinical record review revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive brain disorder that impairs memory, thinking, reasoning, and the ability to perform daily activities) with agitation (patterns of disruptive or inappropriate behaviors that interfere with daily functioning and emotional regulation), dysphagia (difficulty swallowing), and history of protein calorie malnutrition (a condition that occurs when the body does not receive enough protein and calories to maintain proper health and functioning). 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 February 2, 2026, revealed that Resident 14 had severe cognitive impairment with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A nursing progress note dated February 19, 2026, at 10:45 AM, documented that Resident 14 had a broken molar tooth causing oral pain. On February 20, 2026, at 11:14 AM, the Resident 14 was evaluated by contracted dental services. The dentist identified an infection in tooth number two and prescribed Clindamycin 300 milligrams four times daily for ten days to treat the infection while awaiting physician and responsible party clearance for a tooth extraction (a procedure to remove a tooth because of infection, decay, or damage). The dentist also recommended saltwater rinses twice daily. The clinical record contained a Physician Clearance for Dental Treatment form completed by the attending physician on February 20, 2026, at 2:43 PM. A review of the Medication Administration Record (MAR, a legal record documenting medications administered to a resident) dated February 2026, revealed Resident 14 received all 40 prescribed doses of Clindamycin. A social service progress note dated March 10, 2026, at 10:41 AM, documented that staff contacted the resident's responsible party and advised that forms needed to be signed so the contracted dental provider could perform the recommended tooth extraction during an upcoming visit. A nursing progress note dated May 4, 2026, at 2:46 PM, documented that the dentist evaluated the resident and noted the resident refused care despite multiple attempts. However, the clinical record did not contain evidence that the responsible party had completed the required consent forms needed for the dentist to proceed with the recommended extraction. During an interview conducted on June 11, 2026, at 10:00 AM, the Director of Nursing stated that Resident 14's family resided out of the country, and that the resident's responsible party, a friend from the community, was difficult to contact and struggled with making medical decisions for the resident. The Director of Nursing acknowledged these circumstances contributed to delays in obtaining the recommended dental treatment including a needed tooth extraction. Resident 14's clinical record failed to demonstrate that the facility took timely and necessary actions to obtain the required consent and clearances needed to facilitate the recommended tooth extraction after the physician clearance was obtained on February 20, 2026. As a result, the resident experienced a prolonged delay in receiving the recommended dental procedure for an infected tooth that had been identified by the dentist. 28 Pa. Code 201.18 (a) Management. 28 Pa. Code 211.12 (d) (5) Nursing services.

Based on observations, facility policies, and staff interviews, it was determined the facility failed to maintain a clean and sanitary environment in the resident unit food pantry room.Findings include: Review of the facility's policy and procedure entitled Pantry Cleaning Protocol last reviewed by the facility on February 1, 2026, indicated all staff are responsible for maintaining a clean, sanitary unit pantry. Soiled dishes and plates must not be left on pantry counters. To ensure a clean and sanitary pantry area, staff were to document refrigerator and freezer temperatures daily and ensure all items were properly labeled and dated, discard any foods greater than or equal to seven days old, clean and sanitize countertops, sweep and mop floors, clean microwave, verify ice machine is clean and no scoops left inside, ensure no dietary trays or plates are present, and clean inside drawers and cabinets and remove any expired items. Observations on June 10, 2026, at 11:58 AM, inside the facility's resident panty revealed two resident breakfast trays left on the counter and inside the microwave there was food splatter and debris. The pantry floor felt sticky with spots of red and brown staining on some floor tiles. Observed heavy accumulation of dirt and debris in the corners and along the perimeter of the panty. Underneath the counter, there were several pieces of a white-chalky material accumulated in the left corner and showing evidence of deterioration to the corner of the left wall. During an interview with the Director of Nursing on June 11, 2026, at 9:19 AM, it was reported it was the responsibility of housekeeping to maintain the resident pantry and confirmed the above observations. 28 Pa Code 207.2(a) Administrator's responsibility.

Based on clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions and failed to evaluate the severity of pain prior to the administration of a narcotic pain medication prescribed on an as needed basis one of 12 residents reviewed (Resident 29).Findings include:A review of the facility policy, Pain Management (last reviewed February 1, 2026), indicated the facility will ensure residents are assessed for pain or potential for pain in order to attain or maintain the highest practicable level of well-being. The policy further revealed the presence and severity of pain will be measured using an appropriate scale such as the numeric rating scale (a tool that asks a person to choose a number to show how strong or severe something feels), faces scale (a tool that uses pictures of faces, from a happy face to a very upset face, to help the resident show how much pain they are feeling), or verbal descriptor scale (a tool that asks the resident to choose a word or phrase that best describes how strong their pain or discomfort feels). According to the policy, non-pharmacological interventions (ways to help the resident manage pain without using medicine) will be attempted prior to the administration of pain medication. A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses to include displaced fracture of medial malleolus of left tibia (broken left ankle bone where the pieces have shifted out of place). A review of Resident 29's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2026, revealed that Resident 29 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 15 is the highest possible score, indicating memory and thinking abilities showed no signs of impairment at the time of the assessment). Clinical record review revealed Resident 29 had a physician order dated May 23, 2026, for Oxycodone (a controlled substance, narcotic used to treat pain) 2.5 milligrams (mg) every six hours as needed for moderate to severe pain. A review of Resident 29's May medication administration record (MAR) revealed staff administered the pain medication on:May 23, 2026, at 10:38 AMMay 24, 2026, at 8:59 AMMay 25, 2026, at 10:22 AMMay 25, 2026, at 7:32 PMMay 26, 2026, at 10:09 PMMay 27, 2026, at 8:57 AM Documentation showed that non-pharmacological interventions were not attempted or documented prior to any of these six administrations, nor was the pain assessed for severity using one of the tools mentioned in the facility policy. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on June 10, 2026, at 2:15 PM confirmed the facility failed to follow the facility policy specifically regarding rating Resident 29's pain and using nonpharmacological interventions prior to administration of pain medication. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f)(viii)(x) Medical records. 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 the facility failed to develop and implement an individualized plan to restore bladder continence to the best extent possible for one of 12 residents reviewed (Resident 6).Findings include: A review of facility policy titled Continence Management Program (last reviewed February 1, 2026), revealed the facility will provide services to restore or improve normal bladder function to the extent possible. A plan designed to manage incontinence (involuntary loss or leakage of urine) is developed according to the residents' needs and capabilities. According to the policy, an assessment titled Continence Evaluation will be conducted to determine if a three-day bowel and bladder hourly evaluation is indicated. The policy further revealed that if the hourly evaluation identified a pattern of incontinence or continence (control over the bladder and urine), a new Continence Evaluation will be completed. The information from the evaluation will be used to develop a toileting plan (written guide that explains when and how staff will help the resident use the bathroom) and determine the approaches needed to achieve the stated goal. A review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by a decline in memory, thinking, reasoning, and the ability to perform everyday activities), unspecified severity, without behavioral disturbance (actions or behaviors that may be disruptive, aggressive, resistive to care, or otherwise interfere with the resident's well-being or care), psychotic disturbance (a loss of contact with reality that may include hallucinations, seeing or hearing things that are not present, or delusions, fixed false beliefs), mood disturbance (a disruption in a person's emotional state, such as persistent sadness, irritability, or unusually elevated mood), and anxiety (a feeling of excessive worry, nervousness, or fear that may interfere with daily functioning). A review of Resident 6's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 18, 2026, revealed that Resident 6 was moderately cognitively impaired with a BIMS score of 8 (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 through 12 indicates moderate cognitive impairment indicating the resident is having more trouble than expected remembering things, knowing the date or time, and thinking clearly). A clinical record review of the document titled Admission/ readmission Observation, Genitourinary History dated September 30, 2025, revealed that when Resident 6 was admitted to the facility, Resident 6 was always continent (always able to maintain control over bladder/urinary function). A review of the admission MDS dated [DATE], revealed Resident 6 was occasionally incontinent (during the seven days prior to the assessment, Resident 6 experienced less than seven episodes of involuntary loss or leakage of urine). A review of a care plan-initiated on October 6, 2025, identified Resident 6 was at risk for incontinence due to impaired mobility and generalized weakness. The stated goal of the care plan was for Resident 6 to maintain the current level of bladder continence (control over one's bladder function). Among the approaches initiated on October 6, 2025, included: administer medications as ordered, apply moisture barrier to the skin, complete a bladder record (log used to track urinary habits, also referred to as toileting diary) for three days on admission, quarterly, and as needed. The care plan also included an assessment of reversible problems (e.g. conditions, environment, medications, etc.) that may contribute to incontinence or the involuntary loss or leakage of urine). A review of the document titled '72 Hour Toileting Diary' revealed hourly documentation of Resident 6's bladder activity from October 29, 2025, to November 1, 2025. Review of the hourly documentation revealed Resident 6 experienced bladder incontinence during the day and evening hours (from 7:00 AM until 10:00 PM). According to the toileting diary, Resident 6 did not experience bladder incontinence and was observed to be continent/dry from 11:00 PM until 07:00 AM. A nursing progress note dated November 7, 2025, summarized the toileting diary indicating Resident 6 experienced incontinence during daytime and evening hours, but not during nighttime hours. The notes revealed that Resident 6 would be assisted with toileting every two hours during the day and evening, and additionally as needed. A clinical record review of the nursing care plan included an approach on November 7, 2025, to assist Resident 6 with toileting every two hours during the days and evenings, and as needed. A review of the quarterly MDS dated [DATE], revealed Resident 6 was frequently incontinent of bladder (seven or more episodes of urinary incontinence, but least one episode of continence in the seven days prior to the assessment). The December 16, 2025, MDS revealed an increase in bladder incontinence (frequent incontinence) when compared to the October 6, 2025, MDS when Resident 6 experienced occasional incontinence. Review of the document titled Quarterly Observation Bundle, Continence Retraining/Scheduled Toileting Review, dated December 25, 2025, indicated Resident 6 had medical conditions and medications that contribute to incontinence. The review also noted the resident had long term memory difficulties, neurological conditions, and used a wheelchair for mobility, but remained consistently aware of the need to use the bathroom. Despite the risk factors for incontinence identified in the December 25, 2025 review and the increase in incontinence noted in the December 15, 2025 MDS, there was no evidence of further evaluation, such as a bladder diary, to assess incontinence patterns. The clinical record also lacked documentation of additional care plan interventions or a continence program developed and implemented to address the decline and restore Resident 6's continence to the highest level possible. Review of the quarterly MDS dated [DATE] indicated Resident 6 was always incontinent, with no episodes of bladder control in the seven days before the assessment. This represents a further decline compared to the December 25, 2025 MDS, which documented frequent incontinence but at least one episode of continence. Review of the Quarterly Observation Bundle, Continence Retraining/Scheduled Toileting Review dated March 24, 2026 revealed Resident 6 had no memory or physical conditions that interfere with toileting. The review also indicated the resident was usually aware of the need to use the bathroom. Review of the 72 Hour Toileting Diary revealed hourly documentation of Resident 6's bladder activity from March 26-29, 2026. The documentation indicated Resident 6 was incontinent during the day, evening, and nighttime hours. Nighttime incontinence represented a decline when compared to the October 2025 toileting diary, which showed the resident remained continent and dry during nighttime hours. Despite the increase in incontinence demonstrated by Resident 6 in March 2026, the clinical record contained no assessment to identify the type or possible causes of urinary incontinence. The record also lacked evidence of new interventions or consideration of a toileting program developed and implemented to restore Resident 6's bladder continence to the best extent possible. An interview with the Director of Nursing on June 11, 2026, at 12:15 PM confirmed the facility failed to ensure Resident 6 received individualized services and assistance to maintain bladder continence to the highest extent possible, as required by nursing standards of practice and facility policy. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(a)(d) Resident care policies.

Based on select facility policy review, clinical record review, resident observation, and resident and staff interview, it was determined the facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected a resident's communication needs for one of 12 residents reviewed (Resident 3).Findings include: Review of the facility's Comprehensive Care Planning policy, last reviewed February 1, 2026, revealed a comprehensive care plan should include measurable goals and meet a resident's medical, nursing, mental, and psychosocial needs. The policy indicated the care plan will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. A clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric fracture of right femur (the right thigh bone is broken just below the hip, and the broken parts have moved out of place). A review of Resident 3's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 26, 2026, revealed that Resident 3 was severely cognitively impaired with a BIMS score of 5 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates clear and significant difficulties with cognitive tasks like remembering information and understanding time). At 8:00 AM on June 10, 2026, Resident 3 was observed seated in a wheelchair wearing small devices that fit directly in her ears. Around her neck were small, lightweight speakers that connected to the devices in her ears. During the interview, Resident 3 demonstrated the ability to communicate clearly and effectively, both understanding and expressing verbal information. The Director of Nursing (DON) was present at the time of the observation. Upon interview, the DON indicated the family of Resident 3 supplied the hearing devices and the devices are used daily to assist Resident 3 with hearing and communication. The DON was uncertain when Resident 3 received the hearing devices but stated she believed Resident 3 has had the hearing devices since her admission. Review of the resident's current comprehensive care plan, initially developed September 26, 2025, failed to identify the presence of the hearing devices or staff interventions including storage, assessment, maintenance (including cleaning), verifying for proper function, and assistance with application and removal of the devices. During an interview conducted on June 10, 2026 at 2:30 PM, the DON confirmed the clinical record failed to identify the presence of the communication, hearing assistive devices or the implications associated with the care of the hearing devices. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on clinical record review and staff interview, it was determined the facility failed to develop and implement a discharge planning process to align with the resident's goals for one of twelve residents reviewed (Resident 42). Findings Include: Review of the facility's Discharge Planning Policy last reviewed February 1, 2026, revealed the facility will identify discharge needs of residents and develop a discharge plan for each resident, including regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan will be updated as needed to reflect these changes. Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses to include Type 1 diabetes (a chronic autoimmune condition where the body's immune system attacks and destroys insulin-producing beta cells in the pancreas. This results in little or no insulin production, leading to high blood sugar levels.) A review of Resident 42's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 28 2026, revealed that Resident 42 was cognitively intact with a BIMS score of 14 (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 through 15 indicates intact cognition). A review of Resident 42's closed record revealed the resident discharged to home AMA (against medical advice, resident chose to leave despite recommendations to remain in the facility) on April 28, 2026. Resident 42 managed her diabetes with an insulin pump (a small, computerized device that continuously delivers insulin to help control blood sugar levels). During a hospitalization that occurred prior to the resident's admission to the facility, the insulin pump malfunctioned. Upon admission to the facility, the resident received insulin lispro (a rapid-acting insulin used to lower blood sugar levels) according to a sliding scale order (a physician-directed method of adjusting insulin doses based on blood sugar readings). While residing in the facility, the resident's insulin pump was repaired. The facility informed the resident that residents were not permitted to use insulin pumps in the facility. Following that discussion, the resident chose to discharge home in order to resume use of the insulin pump. There was no documented evidence that the facility assessed or discussed the resident's desire to resume use of the insulin pump once repaired during the admission process, incorporated that preference into discharge planning, or evaluated how the facility's inability to accommodate use of the insulin pump could affect the resident's discharge needs, goals, or preferences. A review of the resident's comprehensive care plan, reviewed during the survey ending June 11, 2026, revealed a care plan last revised on April 28, 2026. The care plan did not include a discharge care plan. There was no documented evidence that the facility developed an individualized discharge plan that addressed the resident's expressed desire to use her repaired insulin pump, her decision to leave the facility, or her potential long-term placement needs. There was no documented evidence that the facility developed, updated, or implemented a discharge plan that addressed the resident's goals of care, treatment preferences, or discharge needs after learning the resident wished to resume use of the insulin pump. During an interview on June 11, 2026, at 12:00 PM, the Nursing Home Administrator confirmed there was no documented evidence of a discharge goal or discharge plan for Resident 42. 28 Pa. Code 201.18 (3)(e)(1) Management. 28 Pa. Code 211.10(a) Resident care policies.

Based on review of the facility's written facility assessment, staff interviews, professional standards, and facility documentation, it was determined the facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents requiring intravenous (IV) therapy through peripherally inserted central catheters (PICCs) or other central venous access devices. Findings include:Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served.The facility assessment dated [DATE], and provided during survey on August 27, 2025, identified that the facility provided specialized services for residents with PICC lines (a long, thin, flexible tube inserted into a vein in the arm and advanced to larger veins near the heart for long-term intravenous therapy) including administration of intravenous medications and routine PICC line care.The facility could not provide documented evidence that licensed nursing staff received initial or ongoing training or competency evaluations (the ability of staff to demonstrate, through education and skills validation, that they can safely and effectively perform specific clinical procedures) in accessing and administering medications through central venous access devices, as required by professional standards and the facility's own assessment.There was no documented policy or procedure in place to guide licensed nursing staff in the safe care and management of central venous access devices, including medication administration, dressing changes, or infection prevention measures.The Director of Nursing (DON) confirmed during an interview on August 27, 2025, that the facility did not have a contract with advanced PICC services, had no established training program for PICC line care, and could not provide documentation of staff competencies specific to PICC line management.The facility failed to ensure its facility assessment was operationalized through staff training, competency evaluation, and implementation of policies and procedures related to intravenous therapy via central venous access devices. As a result, the facility could not demonstrate that licensed nursing staff had the knowledge and skills necessary to provide safe care consistent with regulatory requirements and professional standards of practice. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19 (6)(7) Personnel records. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on a review of clinical records, facility policies and procedures, and staff interviews it was determined the facility failed to develop, implement, and maintain an effective training program for licensed nursing staff (Employees 1 and 2) to care for a resident with a peripherally inserted central catheter (PICC) and ensure staff possessed the skills and competencies necessary for one resident out of twelve residents reviewed (Resident 44).Findings included: Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. Resident 44 was admitted to the facility on [DATE], with diagnoses including sepsis (a severe infection causing widespread inflammation that can lead to tissue damage or organ failure), bacteremia (the presence of bacteria in the bloodstream), pseudomonas aeruginosa infection (a bacterial infection commonly occurring in people with weakened immune systems), and cellulitis (a bacterial skin infection that causes redness, swelling, warmth, and pain). Physician orders dated August 19, 2025, required the administration of the antibiotic cefepime twice daily via a PICC line, with the line flushed with normal saline before and after each dose and weekly dressing changes. A PICC line is a thin, flexible tube inserted into a vein in the arm and advanced toward the heart so that medications can be delivered directly into the bloodstream. A review of Resident 44's August 2025 electronic Medication Administration Record (eMAR commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional), dated August 19 through August 27, 2025, revealed cefepime was administered nineteen times by the facility's licensed nursing staff through the PICC line. Further review of the Medication Administration Record (MAR) showed that on August 22, 2025, at 10:00 AM, Employee 1, a Licensed Practical Nurse (LPN), signed that cefepime was administered through the PICC line as prescribed. Additionally, Employee 2, an LPN, signed the MAR as administering cefepime on five occasions: August 20, 21, 25, 26, and 27, 2025. Review of Employee 1's personnel file revealed a hire date and orientation completion date of June 15, 2024, and an annual licensed nursing competency/skills review completed on June 30, 2025. The file did not contain documented evidence that Employee 1 received mandatory education for PICC line management prior to providing care for residents with PICC lines. Review of Employee 2's personnel file revealed a hire date and orientation completion date of July 1, 2014, and an annual licensed nursing competency/skills review completed on July 15, 2025. The file did not contain documented evidence that Employee 2 received mandatory education for PICC line management prior to providing care for residents with PICC lines. The facility's annual competency/skills review for licensed nurses did not include training related to PICC line care. During an interview on August 27, 2025, at 1:45 PM, the Director of Nursing (DON) was asked to provide training and competency records for licensed nursing staff who provided care to residents with PICC lines. The DON was unable to provide records through the conclusion of the survey on August 28, 2025. During a follow-up interview on August 28, 2025, at 11:00 AM, the DON and the Nursing Home Administrator (NHA) confirmed the facility had not developed or implemented a training program for PICC line care for licensed nurses and had not included PICC line management in annual licensed nursing competency/skills reviews. The NHA and DON further confirmed the facility should have developed, implemented, and maintained an effective training program, including topics such as PICC line management, based on the resident population and the facility assessment, prior to licensed nursing staff providing care for residents with PICC lines, and reviewed this training on an annual basis. Pennsylvania State Board of Nursing regulations (Title 49, Chapter 21) require that Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) performing intravenous therapy, including PICC line care, complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision. The facility did not provide documentation to demonstrate compliance with these requirements before licensed nursing staff accessed and administered IV medications through the PICC line. The facility failed to use its facility assessment to determine training needs and did not develop, implement, or maintain an effective training program to ensure licensed nursing staff possessed the skills and competencies required for PICC line care. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS), for two of 12 residents sampled (Resident 10 and Resident 17).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes mellitus (body has trouble managing the amount of sugar/glucose in the blood) with diabetic neuropathy (nerve damage due to high blood sugar that lasts a long time), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A clinical record review states Resident 10 had an order for Divalproex tablet, 250 mg three times a day for seizure disorder (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) as a coded disease state.A clinical record review of the Medication Administration Record (MAR) dated August 2025 verified Resident 10 had received Divalproex tablet, delayed release 250 mg three times a day. A clinical record review revealed Resident 10 received care at an acute care facility from November 24, 2023, to November 28, 2023. The reason for admission and acute care included seizure disorder according to clinical records from the acute care provider. Discharge instructions to the skilled nursing facility dated November 28, 2023, included a medication list which included Divalproex Sodium 250 mg po (by mouth) three times a day. A clinical record review revealed Resident 10 had a care plan (last reviewed July 23, 2025), addressing Seizure Disorder. A clinical records review by the Psychiatric Mental Health Nurse Practitioner on May 29, 2025, noted Resident 10 received Divalproex 250mg for seizures. A quarterly MDS, section I (section intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nurse monitoring, or risk of death) dated August 5, 2025, revealed Resident 10 did not have seizures indicated as a disease diagnosis. An interview on August 28, 2025, at 1:15 PM with the NHA and Employee 3 revealed the MDS did not accurately reflect Resident 10's diagnosis of seizure disorder. A clinical record review revealed Resident 17 was admitted to the facility on [DATE], with diagnoses to include nonrheumatic aortic (valve) stenosis (narrowing of the aortic valve, which restricts the flow of blood from the heart to the rest of the body) and cellulitis of left lower limb (spreading skin infection, most commonly of the lower leg and caused by bacteria entering through a break in the skin). Review of Resident 17's quarterly MDS revealed the assessment reference date (ARD the date that all the information in the MDS assessment is based on. It sets the time period the facility looks at when reporting a resident's health, abilities, behaviors, and needs. The facility must complete the MDS within a certain number of days after the ARD to meet federal requirements.) was May 14, 2025. The MDS completion date (Z0500B) was May 29, 2025, fifteen days after the ARD date. According to the RAI Manual (2024), the MDS completion date must be no later than 14 calendar days after the ARD (ARD + 14 calendar days). Interview on August 27, 2025, at 1:15 PM with the NHA and Employee 3 licensed practical nurse (LPN) revealed the MDS was not completed within the required time frame. A review of the above information was conducted with the Director of Nursing and NHA on August 27, 2025, at approximately 11:00 AM. The facility was unable to produce documentation to support incorrect MDS coding for Resident 10 and Resident 17. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.5(f)(iv) Medical records. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on clinical record review and resident, and staff interview, it was determined that the facility failed to develop and implement a discharge planning process to align with the resident's goals for one of twelve residents reviewed (Resident 19). Findings Include: Review of the facility's Discharge Planning Policy last reviewed November 15, 2024, revealed the facility will identify discharge needs of residents and develop a discharge plan for each resident, including regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan will be updated as needed to reflect these changes. Clinical record review revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (a complex clinical syndrome characterized by the heart's inability to pump blood effectively due to structural or functional impairment). Review of an annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 21, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating she was cognitively intact. During a resident council meeting on August 27, 2025, at approximately 10:00 a.m., Resident 19 stated she was looking forward to being discharged home soon. A review of Resident 19's progress notes revealed a note dated August 21, 2025, indicating the resident stated during a care plan meeting she was eager to be discharged home. There was no follow up regarding this request until brought to the attention of the facility on August 27, 2025. A review of the residents nursing progress notes revealed no notes regarding the resident's discharge plans and goals since May 23, 2025. A review of the resident's comprehensive care plan, reviewed during the survey ending August 28, 2025, revealed a care plan, last revised on October 31, 2024, that the resident required long term care in the facility, there was no documented evidence that an individualized discharge plan was revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. The facility failed to include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. During an interview with the Nursing Home Administrator on August 28, 2025, at 12:00 PM confirmed there was no documented evidence of a current discharge goal and plan for this resident. 28 Pa. Code 201.18 (3)(e)(1) Management. 28 Pa. Code 211.10(a) Resident care policies.

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement appropriate nursing practices for the administration of an intravenous (IV) medication via central venous catheter for one of 12 residents reviewed (Resident 44).Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements:(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1).(1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as aCRNP, physician, physician assistant, podiatrist or dentist).(g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. A review of a facility policy titled ‘General Dose Preparation and Medication Administration', last reviewed by the facility on November 15, 2024, revealed the facility is to comply with all applicable laws when administering medications. Clinical record review revealed that Resident 44 was admitted to the facility on [DATE], with diagnosis to include sepsis (serious condition in which the body responds improperly to an infection), Methicillin resistant Staphylococcus aureus (MRSA) infection (type of bacteria resistant to many antibiotics, commonly causing skin infections but can also lead to serious health issues), and Pseudomonas aeruginosa (type of bacteria that can cause infections in the blood, lungs, and other parts of the body). Resident 44 was admitted to the facility with a PICC line (a peripherally inserted central catheter, a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). Physician orders dated August 19, 2025, revealed an order to administer Cefepime (antibiotic medication) 2 gram intravenously (IV) every 12 hours through the PICC line for treatment of Pseudomonas infection through September 21, 2025. Review of the Medication Administration Record (MAR) revealed that between August 19 and August 27, 2025, Employee 1 LPN and Employee 2 LPN documented administration of IV Cefepime to Resident 44 through the PICC line. The facility could not produce any documentation verifying that Employee 1 and Employee 2 had completed the IV therapy education and training required under S21.145(b). There was no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration. During an interview conducted on August 27, 2025, at approximately 1:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility had no documentation of required IV therapy education or competency for either LPN regarding administration of medications through PICC lines. The interview on August 27, 2025, also revealed the facility did not maintain a policy specific to PICC line medication administration and no documented competencies existed for RNs or LPNs regarding safe administration through PICC lines. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records and staff and resident interviews it was determined the facility failed to develop and implement care and services, consistent with professional standards of practice, to prevent pressure ulcer development for one resident (Resident 89) and failed to assess and monitor facility acquired pressure injuries for two residents out of 14 sampled (Residents 18, and 8). Findings included: According to the US 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 the 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 second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.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 considering possible surgical repair. A review of the clinical record revealed that Resident 89 was most recently admitted to the facility on [DATE], with diagnoses that included chronic foot drop (difficulty lifting the front part of the foot, which might cause foot to drag on the ground when walking) of the right lower extremity, cellulitis (a bacterial infection that affects the skin and underlying tissues) of the left lower limb, and after care for a fractured left tibia and fibula (leg). A review of hospital discharge orders dated September 6, 2024, revealed Orthopedic Instructions which instructed, strict elevation, compressive ace wrap, continue antibiotics, and keep upcoming appointment with Orthopedic surgeon. A review of Resident 89's admission physician orders dated September 6, 2024, indicated an appointment was scheduled for September 10, 2024, with the Orthopedic surgeon. There was no evidence that a compression ace wrap and/or strict elevation of the resident's surgically repaired left lower extremity was implemented as instructed in hospital discharge orders. A review of facility Admission/Readmission observation dated September 6, 2024, indicated that Resident 89 had 2+ pitting edema (a grade given to swelling caused by fluid buildup in the body, where a slight indentation remains in the skin after pressure is applied and disappears within 15 seconds) of the left lower extremity. The left lower extremity had redness and discoloration (red and inflamed), weight bearing limitations, toe touch weight bearing of the left extremity, the resident complained of pain of the left lower extremity, alterations in skin integrity included surgical incisions of the left lower extremity and a pressure injury to the thoracic spine. Further review of the Admission/Readmission Braden scale (a tool used to predict the risk of pressure ulcers) indicated the resident scored a 14 which indicated a moderate risk for development of pressure ulcers. A review of the facility's Wound Management Detail Report dated September 6, 2024, identified the following skin concerns upon Resident 89's return from the hospital: 1. Pressure ulcer to mid-upper back on the spine which measured 1cm x 1cm, and treatment was initiated. 2. Surgical incision to left knee over patellar (kneecap) region, no measurements and/or observation performed, site covered with surgical dressing. 3. Surgical incision to left shin median (inner) side which measured 2.5cm x 1cm, edges well approximated, and bruising noted. A dry sterile dressing was applied after incision was cleansed with normal saline solution. 4. Surgical incision to left shin with blood blisters present which measured 1.5cm x 0.1cm with edges well approximated, and five staples present, surrounding skin was warm. A dry sterile dressing was applied after observation. 5. Surgical incision to the left ankle just above the ankle medial side which measured 2cm x 1cm with four staples present, and surrounding skin was warm. No treatment initiated according to report. 6. Surgical incision to left shin lateral (outer) lower shin above the ankle which measured 1cm x 0.1cm with two staples present, surrounding skin was bruised, and a dry sterile dressing was applied after observation. An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 10, 2024, revealed the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact), required substantial/maximal assistance from staff for toileting, showers, putting on/taking off footwear, and lower body dressing and was at risk for pressure ulcer development. A review of Resident 89's care plan failed to identify a focus area related to the resident's risk for development of pressure ulcers, therefore, there was no evidence that interventions were implemented to prevent the development of pressure ulcers. A review of nursing documentation dated September 6, 2024, indicated the nurse practitioner ordered to have an ultrasound doppler of the resident's left leg to rule out DVT (deep vein thrombosis formation of a blood clot in a deep vein). A review of nursing documentation dated September 10, 2024, revealed that a doppler study and ultrasound of Resident 89's left lower extremity was completed and was positive for a DVT. Further review of the documentation revealed the attending physician ordered changes to the resident's medication regimen and blood work due to the positive doppler results. A review of nursing documentation completed from September 6, 2024, through September 19, 2024, revealed that Resident 89 continued to be treated with antibiotic therapy for cellulitis of the left lower extremity, and had persistent mild edema. A review of documentation completed by Physical Therapy on September 19, 2024, indicated that Resident 89 had complained of pain in the left heel, nursing identified a DTI (deep tissue injury, is an injury underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die.) on left heel. Resident instructed in positioning in bed and pressure relieving techniques. Documentation dated September 19, 2024, at 11:56 p.m. indicated that Resident 89 had acquired a DTI (deep tissue injury) of the left heel which measured 2cm x 2cm x 0cm. According to the documentation, immediate keep safe intervention was implemented which included a treatment to the area, to offload the weight with pillows under her calf by wearing heel boots. A review of a facility Skin/Skin Integrity event report dated September 19, 2024, revealed that Resident 89 had acquired an unstageable DTI (deep tissue injury) to the left heel which measured 2cm x 2cm, was dark purple in color, and skin was intact. Interventions implemented at time of discovery were heel protectors to be worn at all times except while in therapy, pressure reduction device to bed and/or chair, and therapy consult. Review of a witness statement dated September 19, 2024, completed by the ADON (assistant director of nursing)/Wound care nurse revealed the ADON was informed of the area on Resident 89's heel by the Occupational Therapist and the therapist advised off-loading the heel with pillows under the calf and to use heel bows (heel protectors). Review of witness statement dated September 19, 2024, completed by Employee 5, a Nurse Aide (NA), indicated that Employee 5 was not aware the resident had a pressure sore on her heel due to the presence of a dressing on her heel. A review of the facility's Wound Management Report dated September 19, 2024, indicated that Resident 89 had a pressure injury to the left heel which measured 2cm x 2cm, and treatment orders for Santyl to the wound were initiated as ordered by the podiatrist. A review a wound care consultant documentation dated September 23, 2024, at 1:19 p.m. indicated that Resident 89's left heel DTI had evolved to an unstageable pressure ulcer (pressure ulcers covered with slough or eschar are by definition unstageable) which measured 3cm x 3cm x 0.1cm, 30% slough (moist dead tissue), and 70% eschar (dark, dry, firm dead tissue). Recommendations included to cleanse the ulcer with normal saline, apply betadine on area of eschar, apply Santyl (ointment used to remove damaged tissue from skin) to areas of slough to base of the wound, secure with bordered gauze, change daily and as needed, and float heels while in bed with use of Prevalon boots (device used to help prevent heel pressure ulcers by keeping the heel off of a surface like a bed). Review of clinical record revealed that on September 24, 2024, Resident 89 was transferred to the hospital for evaluation of worsening swelling of the left lower extremity, inability for resident to bend her knee, and increased tenderness of the leg. Resident 89 was admitted to the hospital with diagnosis of a bacterial skin infection. When reviewed at the time of the survey ending October 18, 2024, there was no documented evidence prior to the development of the unstageable left heel pressure ulcer, that nursing staff had implemented interventions to prevent the development of the ulcer despite the resident's numerous risk factors. The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels. Interview with the Director of Nursing on October 18, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the left heel pressure ulcer for a resident at risk for skin breakdown. A review of the clinical record revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include symbolic dysfunction (a type of social communication and language disorder), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), arthritis, and protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health). A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated May 3, 2024, revealed that Resident 18 was at risk for a pressure ulcer development, had pressure reducing devices for her bed and chair, and was not on a turning/repositioning program. Further review revealed the resident was on hospice services (end of life care) and was dependent on staff for all activities of daily living (turning/repositioning, bed mobility, transfers, eating, bathing, toileting). A review of the resident's care plan, initiated May 4, 2024, revealed the facility identified the resident was at risk for skin breakdown related to decreased mobility and weakness. Interventions included to apply barrier cream to bilateral buttocks, keep skin clean and dry, monitor for skin breakdown, elevate heels off mattress, provide skin prep to bilateral heels, provide a pressure reducing mattress, and provide a pressure reducing cushion on the wheelchair. Review of a nurses note dated June 21, 2024, at 10:38 AM revealed the nurse was called to Resident 18's room during morning care by the certified nursing assistant who noticed an open area to her coccyx. The area measured 1.5 cm x 0.2 cm x 0.1 cm. The area was cleansed with normal saline solution and a hydrogel (wound dressing), and a dry dressing was applied. The resident was returned to bed after her meal and repositioned from side to side. The resident did not complain of pain. Call placed to physician, responsible party, and Hospice to make aware. Review of the Wound Consultation documentation dated June 26, 2024, at 11:48 AM indicated that Resident 18 had a Stage 3 pressure wound (a serious wound caused by pressure in which the wound has worn through all skin layers, exposing the fat) to the left inner buttock that measured 2 cm x 0.5 cm x 0.2 cm, exudate was moderate serosanguineous (wound drainage that contains both blood and a clear yellow liquid known as blood serum). Recommendations included: cleanse the wound with normal saline, apply Hydrogel to wound base and apply barrier cream to surrounding skin, the resident is to be out of bed for meals only, continue with pressure redistributing cushion to wheelchair, turning/repositioning precautions per protocol, ensure setting on low air-loss mattress (a mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) was maintained at appropriate levels, and continue ongoing interventions for incontinence management as resident is incontinent of urine and stool. A review of facility documentation Point of Care History (POC- general care nursing tasks completed for the resident) from May 1, 2024, through June 20, 2024, failed to identify that preventative measures were developed and implemented in order to prevent the development of a pressure ulcer. At the time of the survey ending October 18, 2024, the facility was unable to provide documented evidence that staff provided a turn and repositioning schedule and proper and timely incontinence care to prevent a pressure ulcer. Interview with the Director of Nursing on October 17, 2024, at 2:00 PM confirmed that there was no evidence the facility had implemented adequate interventions to prevent the development of Resident 18's pressure ulcer. A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities) with behavior disturbances, diabetes, congestive heart failure (CHF is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply resulting in blood and fluids to collect in the lungs and legs over time and require medication), and anxiety (characterized by excessive, persistent and uncontrollable worry and fear about everyday situations). A clinical record review of Resident 8's admission/readmission observation assessment that was completed by Employee 1, a licensed practical nurse (LPN), dated May 27, 2024, at 1:27 PM, revealed the resident had no skin alterations, no abrasions, no bruises, no burns, no dermatitis, no skin grafts, no surgical incisions, or pressure injuries. Employee 1 commented that Resident 8 had a fluid filled blister (a small bubble on the skin filled with fluid caused by rubbing surfaces together) to the right heel. Additionally, the resident's Braden Scale Score (is a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) was a thirteen 13 which indicated moderate risk of developing pressure injuries due to the risk factors related to very moist skin, bedfast (confined to bed), very limited mobility, friction and shearing (frequently slides down in bed or chair, requiring frequent repositioning with maximum assist). Interventions for skin ulcer/injury treatments such as a turning and repositioning program, pressure reducing device for chair, ointments/medications other than to feet, and applications of dressings to feet (with or without topical medication) was coded by Employee 1 as none of the above were provided. A review of the resident's pressure ulcer healing report completed by Employee 2, a Registered Nurse (RN), dated May 28, 2024, at 7:24 AM, indicated that Resident 8 had a serous (clear to yellow fluid) filled blister to the right heel (no measurements or description noted). Further review of Resident 8's clinical record revealed a functional abilities assessment completed by Employee 3, a RN, and dated May 28, 2024, at 7:38 PM, revealed the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for bed mobility and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or requires the assistance of 2 or more helpers is required for the resident to complete the activity) for all activities of daily living such as toileting, hygiene/care needs, transfers, sit to standing, and all other ADLs (activities of daily living). On May 28, 2024, at 12:25 PM, the Assistant Director of Nursing (ADON) noted an observation of the blister measurements as 7.0 centimeters (cm) in length and 5.5 cm in width and commented the resident's podiatrist would follow up with the blister and does not want the facility wound care team to treat the resident. However, on May 29, 2024, at 9:02 AM, the Director of Nursing (DON) modified the documentation of the wound on the resident's wound history report and noted the right heel was a stage 2 pressure ulcer (is a shallow open wound, abrasions, or blisters due to partial thickness loss of the dermis) instead of a blister. Resident 8's clinical recorded revealed that the consulted podiatrist was at the facility on May 30, 2024, at 11:21 AM, and evaluated the right heel blister. A review of the podiatrist's consult dated May 30, 2024, and faxed to the facility on [DATE], at 11:04 AM, revealed that Resident 8 had a diagnosis of peripheral vascular disease (PVD - is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs) and noted to continue skin prep and dry dressing to the right heel and air pillow heel protectors (cushion to elevate heels to prevent pressure) for bedtime. A review of a wound observation completed by Employee 4, an RN, on May 31, 2024, at 10:09 PM, revealed that Resident 8's intact blister to the right heel ruptured with a small amount serous drainage, no odor noted, and a red beefy moist base with blister shell cleared to one side of wound but still intact. No signs or symptoms of infection. Attending MD, responsible party (RP) and podiatry aware of changes. A review of a wound observation completed by the ADON on June 3, 2024, at 11:19 AM, revealed that Resident 8's right heel measurements were 7.0 cm in length by 8.0 cm in width and 0.2 cm in depth with a heavy amount of serous (clear) exudate and moderate odor from the discharge and noted that the area was at a stage 3 pressure ulcer (have gone through the second layer of skin into the fat tissue with symptoms that include a crater appearance, may have a foul odor, and may show signs of infection such as red edges, pus, odor, heat, and/or drainage with the tissue in or around the sore appearing black indicating dead tissue) with slough present and commented that a sterile border foam dressing was applied after cleaning with betadine. The facility could not provide documented evidence the attending physician, consulted podiatrist, or RP were notified of Resident 8's right heel deterioration from a stage 2 to stage 3 pressure ulcer. Additionally, there was no documented evidence that the area was evaluated to determine if alternate treatments or interventions were indicated to promote healing and prevent infection. Further review of a wound observation completed by the ADON on June 7, 2024, at 3:33 PM, revealed the resident's right heel wound exhibited further deterioration as evidence by changes in the appearance of the exudate from serous (clear) to serosanguineous (pale red to pink, thin and watery) with faint odor and covered with twenty percent necrotic (dead) tissue and irregular wound edges/margins. The area was measured at 7.0 cm in length by 8.0 cm in width with 0.2 cm depth. A review of Resident 8's clinical record revealed that on June 7, 2024, at 3:28 PM, the ADON completed a progress note that a message was left at the podiatrist's office to follow up with the wound as the area has black eschar in the wound bed. A review of the resident Medication Administration Summary report dated May 27, 2024, through June 10, 2024, revealed no documented evidence the facility timely developed and implemented pressure ulcer prevention measures that deterred Resident 8's right heel blister from deteriorating. Further review of the resident's record revealed that Employee 2 completed a progress note dated June 10, 2023, at 2:52 PM (four days later), revealed that the podiatrist was in to examine resident's right heel with new orders noted to change order to thin Duoderm (a flexible waterproof dressing used to cover burns and reduce infection) to the area and change every other day. Resident 8's clinical record failed to reveal documented evidence the resident's right heel blister was timely and thoroughly assessed by a registered nurse to develop and implement effective preventative measures to deter the area from evolving (worsening) from a blister to a stage 3 pressure ulcer. Additionally, Resident 8's clinical record failed to reveal the facility timely notified the resident's attending physician, consulted physician (podiatrist), of deterioration to the resident's right heel and failed to document applied treatments/interventions. An interview with the DON on October 18, 2024, at 2:00 PM, confirmed that upon admission to the facility Resident 8 failed to be timely and thoroughly assessed by an RN to ensure that effective preventative pressure relieving measures were timely implemented to deter the right heel blister from deteriorating to a Stage 3 pressure ulcer. Additionally, the DON confirmed the facility failed to timely notify the resident's attending physician or consultant physician (podiatrist), of Resident 8's deterioration to the resident's right heel and ensure that proper treatments/interventions were applied and documented timely and accurately in the resident's clinical record. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication to one of 14 sampled residents (Resident 18). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled General Dose Preparation and Medication Administration last reviewed by the facility on January 8, 2024, revealed that prior to the administration of medication, facility staff should verify, each time a medication is administered, that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident. Staff are to confirm that the MAR (Medication Administration Record) reflects the most recent medication order. A review of the clinical record revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include symbolic dysfunction (a type of social communication and language disorder), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), arthritis, and protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health). A review of the facility document Consultation Report dated September 4, 2024, revealed the facility's consultant pharmacist conduced a Medication Record Review and reported that Resident 18 had received Lorazepam 0.5 mg PO (by mouth) BID (two times a day) since June 2024 for anxiety. The pharmacist recommended a gradual dose reduction (GDR) of Lorazepam to 0.25 mg PO BID (by mouth two times a day). A review of the physician's response to the pharmacist recommendation dated September 6, 2024, revealed the physician agreed with the recommendation for the GDR with the following modification: decrease Lorazepam to 0.25 mg for the AM dose and maintain 0.5 mg for the PM dose. A review of the physician's order dated June 7, 2024, revealed an order for Lorazepam tablet; administer 0.25 mg PO (by mouth) daily in the AM for anxiety related to end stage disease process. Once a day at 8:00 AM. A review of the physician's order dated June 7, 2024, revealed an order for Lorazepam tablet; administer 0.5 mg PO daily in the PM for anxiety related to end stage disease process. Once a day at 8:00 PM. Review of a nurses note dated September 24, 2024, at 3:39 PM identified that Resident 18 continued to receive the 0.5 mg dose of Lorazepam in the AM instead of the 0.25 mg dose as ordered on September 7, 2024. The nurses note indicated there was no change in the narcotic sheet (controlled medication utilization record- a detailed record that tracks the receipt, distribution, and administration of controlled substances), and no change noted on the medication card (sealed blister pack that contains a specific medication). The note continued to state that there was a failure to match the physician order in the eMAR (electronic Medication Administration Record) to the medication card. The pharmacy received the script for the 0.25 mg on time but did not send the 0.25 mg medication card because of insurance reasons. Nursing called the pharmacy to send the medication. The Director of Nursing, Nursing Home Administrator, Physician, and Resident Representative were notified. Review of the facility document Event Report dated September 24, 2024 at 2:01 PM revealed the facility administered 0.5 mg of Ativan (lorazepam) instead of 0.25 mg of Ativan for the morning dose. The Event Report classified the event as a Medication Error Review with the date of the error identified on September 24, 2024. The error had occurred since September 6, 2024, and was identified by the LPN (licensed practical nurse) working the medication cart. The description of the error revealed that Ativan was reduced from 0.5 mg in the morning to 0.25 mg. It was written in the physician orders and not on the medication card or narcotic record. It was administered as whole tablets to the resident (0.5 mg). The pharmacy was called to send the 0.25 mg medication card. The pharmacy said they received the script but did not send the medication card because of insurance reasons. The type of error was identified as 'incorrect dose, incorrect label, and medication not available. There were no adverse drug reactions identified for the resident. Medication competencies were completed for nursing staff and medication cart audits were completed. A review of the Controlled Medication Utilization Records for Lorazepam 0.5 mg tablet revealed that from September 8, 2024, through September 23, 2024, Resident 18 received 16 doses of Lorazepam 0.5 mg for the AM dose instead of the 0.25 mg dose as ordered by the physician on September 7, 2024. During an interview on October 17, 2024, at 1:00 PM the Director of Nursing (DON) confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in a medication error and failed to administer the resident's Lorazepam as prescribed. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f)(i) Medical records

Based on a review of pharmacy documentation, clinical records and staff interviews it was determined the facility failed to implement procedures to assure timely acquiring and administration of medications to one of 14 sampled residents (Resident 18). Findings include: A review of the clinical record revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include symbolic dysfunction (a type of social communication and language disorder), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), arthritis, and protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health). A review of the physician's response to the pharmacist recommendation dated September 6, 2024, revealed the physician agreed to decrease Lorazepam (an antianxiety medication) to 0.25 mg for the AM dose and maintain 0.5 mg for the PM dose. A review of the physician's order dated June 7, 2024, revealed an order for Lorazepam tablet, administer 0.25 mg PO (by mouth) daily in the AM once per day at 8:00 AM, for anxiety related to end stage disease process. A review of the physician's order dated June 7, 2024, revealed an order for Lorazepam tablet, administer 0.5 mg PO daily in the PM once per day at 8:00 PM, for anxiety related to end stage disease process. A review of a nurses note dated September 24, 2024, at 3:39 PM, identified that Resident 18 continued to receive the 0.5 mg dose of Lorazepam in the AM instead of the 0.25 mg dose as ordered on September 7, 2024, and noted that the pharmacy received the script for the 0.25 mg on time but did not send the 0.25 mg medication card because of insurance reasons. Additionally, it was noted that nursing called the pharmacy to send the medication and that the Director of Nursing, Nursing Home Administrator, Physician, and Resident Representative were notified. A review of the Controlled Medication Utilization Records for Lorazepam 0.5 mg tablet revealed that from September 8, 2024, through September 23, 2024, Resident 18 received sixteen doses of Lorazepam 0.5 mg for the AM dose instead of the 0.25 mg dose as ordered by the physician on September 7, 2024. A review of a facility document Event Report dated September 24, 2024, at 2:01 PM, revealed the facility administered 0.5 mg of Ativan (lorazepam) instead of 0.25 mg of Ativan for the morning dose and was classified by the facility as a medication error. The pharmacy indicated that they received the script but did not send the medication card because of insurance reasons. There was no documented evidence that the pharmacy communicated to the facility that the pharmacy received the new physician order on September 7, 2024, for the 0.25 mg Lorazepam and no documented evidence that the pharmacy communicated to the facility when the 0.25 mg of Lorazepam would be sent to the facility. Additionally, the pharmacy failed to assure timely allocation/delivery to the facility of a physician prescribed medication, Lorazepam. An interview with the Nursing Home Administrator on October 18, 2024, at 2:30 PM, revealed the facility failed to assure timely acquiring and administration of medications to provide medications as ordered to meet the needs of residents. Refer F684 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f)(i) Medical records

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 14 residents reviewed (Resident 2). Findings include: A review of Resident 2s 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 October 18, 2024, 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 Director of Nursing on October 18, 2024, at 10:00 AM 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 clinical record and staff interview, it was determined the facility failed to ensure the presence of documented evidence of clinical necessity for administration of an antibiotic drug for one resident out of 14 sampled (Resident 8). Findings included: A review of Resident 8's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities) with behavior disturbances, and CHF (congestive heart failure is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply resulting in blood and fluids to collect in the lungs and legs (swelling) over time and require medication) and anxiety (characterized by excessive, persistent and uncontrollable worry and fear about everyday situations). A review of Resident 8's clinical record completed by Employee 2, a Registered Nurse (RN), dated September 9, 2024, at 2:25 PM, revealed that the contracted psychiatric CRNP was notified of ongoing behaviors such as constant calling out, crying, rambling speech, nervousness, wringing of hands, requesting that staff sit with her. New orders were received to obtain a UA (urinalysis) and C & S (culture and sensitivity) and attending physician and responsible party aware. A review of a physician order dated September 18, 2024, at 8:12 AM, revealed an order for Macrobid 100 milligrams (mg) give one capsule orally twice per day as prophylaxis (preventative) for UTI (urinary tract infection). A review of a progress note completed by the resident's attending physician dated October 1, 2024, at 8:02 PM, revealed that Resident 8 appeared very anxious with constant, nonstop, nonsensical rambling and was yelling at times and appeared in distress. There was no improvement with treatment of a urinary tract infection and had upper respiratory congestion and tested positive for COVID-19 and received prescribed antiviral medication to manage and currently stable from a COVID standpoint. Physical assessment completed and resident Afebrile (without a fever), blood pressure was 116/62, pulse 72, lungs CTA (clear to auscultation: a term used during physical examinations to indicate normal lung sounds), and edema stable. She had increased behaviors and urinalysis showed pyuria (increased urination) with clumps and was given Macrobid with daily prophylaxis after treatment. A review of Resident 8's Medication Administration Record (MAR) dated September 2024 revealed that Resident 8 received 25 doses of the antibiotic. An interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on October 18, 2024, at 10:18 AM, it was reported that as a part of the facility's infection prevention program, to deter physician's from prescribing unnecessary/inappropriate antibiotic therapy, the nursing staff complete an assessment of the residents condition (SBAR) to determine if the McGreer's Criteria (a standard infection criteria tool) was met to determine if the resident's symptoms and laboratory data meet the criteria for the prescription of antibiotic therapy. Additionally, the ADON/IP also reported that she reported that Resident 8 did not have repeated urinalysis and culture and sensitivity or an SBAR completed due to the resident's attending physician insisting that the resident complete another round of antibiotic (Macrobid) due to the resident's continued escalating behaviors despite no results to justify prescribing continued use of an antibiotic. The facility failed to ensure that Resident 8's medication regimen was free from the use of unnecessary antibiotic (Macrobid) and did not meet the criteria for the use of the antibiotic for prophylaxis. During an interview with the Director of Nursing on October 18, 2024, at 11:00 AM, it was confirmed that the facility failed to ensure that Resident 8's medication regimen was free from an unnecessary medication. 28 Pa. Code 211.2 (3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3) Nursing Services 28 Pa. Code 211.5 (f) (iv)(ix)Medical records

Based on review of clinical records and select reports and staff interviews it was determined that the facility failed to consistently monitor a resident's skin integrity during use of a therapeutic device to prevent the development of multiple unstageable pressure sores and a Stage II pressure sore, for one resident (Resident 1) and failed to provide timely and necessary care to prevent the development of bilateral heel pressure sores, deep tissue injuries, for one resident (Resident 2) at risk for pressure sores out of three residents sampled. Findings include: According to the US 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 the 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 second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.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 considering possible surgical repair. A review of the clinical record revealed that Resident 1 was most recently admitted to the facility on [DATE], with diagnoses that included dementia, diabetes and after care for a fractured left tibia. Admission physician orders dated October 26, 2023, included an immobilizer brace to the resident's left lower extremity at all times, which staff may remove for hygeine and skin checks every shift. An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 30, 2023, revealed that the resident was severely cognitively impaired, dependent on staff assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development. Resident 1's care plan initiated October 27, 2023, revealed that the resident was at risk for skin breakdown related to decreased mobility, weakness, diagnosis of diabetes and an immobilizer in place to the resident's left lower extremity. The planned interventions were for nursing staff to assess the resident for increased edema when giving care, provide diet as ordered, incontinence products per routine and as needed, a pressure reducing surface to the resident's bed and chair, provide/assist/encourage resident to turn in bed frequently and prn (as needed), and to float heels intermittently as the resident allows. A nursing note dated October 27, 2023 at 9:31 PM revealed that the resident sustained an abrasion to the right inner ankle caused by bumping the immobilizer on left lower extremity. The RN assessed the abrasion on the resident's right inner ankle and treatment as provided. The immobilizer was padded to prevent further incident. The physician was updated and a referral made to Physical Therapy for evaluation of the immobilizer brace. When reviewed at the time of the survey ending January 17, 2024, there was no documented evidence that physical therapy had evaluated the resident's use of the immobilizer brace as noted following the abrasion to the resident's right ankle on October 27, 2023. Nursing noted on November 14, 2023, at 10:40 P.M. that three new pressure injuries were found on the resident's left lower leg under the immobilizer. Nursing noted that the resident was anxious with frequent moaning and calling out. Evidence of pain was noted to the resident's right foot, left lower legion, with verbal signs of pain noted. The resident's daughter was present when the new pressure injuries to left lower leg were found under the immobilizer. Wound care was provided and the physician was notified and a treatment was ordered. There was no nursing assessment of the three new pressure sores documented at the time of identification to include size and appearance. A review a skin and wound note dated November 15, 2023, at 11:50 AM revealed three pressure areas were found under Resident 1's left leg immobilizer/brace: -area #1, an unstageable pressure area on the left medial leg measuring 3 cm x 1.5 cm x 0.1 cm, covered in 100% slough ( dead skin, yellow/white in color) with scant amount of serous (Serous drainage is a clear to yellow fluid that leaks out of a wound with tissue damage) and a faint odor; -area #2, an unstageable pressure area on the left posterior lower leg, measuring 3.5 cm x 2 cm , covered in 100% eschar (Eschar, dead tissue that sheds or falls off from the skin. It ' s commonly seen with pressure ulcer wounds. Eschar is typically tan, brown, or black, and may be crusty); and -area #3, a stage 2 pressure area on the left posterior ankle measuring 2.5 cm x 2.5 cm x 0.1 cm with scant serous drainage. A review of a treatment administration record for October 2023 and November 2023 revealed nursing staff documented, once a shift, that the resident wore the Immobilizer Brace to Left Lower Extremity for the closed fracture of the left tibia at all times and that it may be removed for hygiene and skin checks, every shift, since October 26, 2023. However, there was no documented evidence at the time of the survey ending January 17, 2024, that prior to the development of the multiple pressure areas that nursing staff had consistently removed the left lower leg brace to inspect the resident's skin to timely identify skin impairments and prevent the development of the unstageable and stage 2 pressure sores under the brace. A review of facility provided information indicated that the root cause for the development of the pressure area was an ill fitting immobilizer had been provided to the resident prior to admission to the facility for her fractured left leg. There was no evidence at the time of the survey that the facility's therapy staff had assessed the resident's use of the immobilizer after the initial right ankle abrasion on October 27, 2023. During an interview on January 17, 2024 at approximately 2 PM the Nursing Home Administrator confirmed that the facility did not have evidence that nursing staff had removed Resident 1's immobilizer to conduct skin checks prior to the discovery of the three pressure areas on November 15, 2023. The NHA also confirmed that therapy had not conducted the evaluation of the resident's use of the brace as noted on October 27, 2023. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses of dementia and hypertension. A physician order was noted upon admission, dated January 2, 2024, to elevate the resident's heels off the bed, as tolerated, every shift for preventative measures to prevent skin breakdown. The resident's care plan noted that the resident was at risk for skin breakdown related to decreased mobility and weakness dated January 3, 2024, with interventions to keep the resident's skin clean and dry, monitor for skin breakdown and pressure reducing surface to bed and chair. The care plan did not specifically identify the physician order to elevate the resident's heels off the bed as tolerated, dated January 2, 2024. An MDS assessment dated [DATE], revealed that Resident 2 was cognitively impaired, required staff assistance for activities of daily living including transfers and bed mobility and was at risk for the development of pressure areas. A review of the resident's January 2024 TAR (treatment administration record) revealed that nursing staff documented completion of the task of elevating the resident's feet daily during each shift of nursing duty. A change in condition note dated January 10, 2024 at 02:59 AM revealed that The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition, Noted drainage of right heel, blister of bottom of heel opened,with clear drainage noted. Area cleansed and a dressing applied. There was no documented evidence at the time of the survey ending January 17, 2024, of any additional nursing assessment, including the size of the pressure area documented in the resident's clinical record at the time of change in condition on January 10, 2024. A wound and skin note dated January 12, 2024, at 04:15 AM revealed that the resident had developed an additional pressure sore on the left heel. Pressure, a blister located on the left planter area of the foot (incorrect area noted in this entry, the pressure sore was actually located on the resident's left heel) measuring 0.3 cm x 0.4 cm, in house acquired. Wound bed appearance is pink, area is noted as a blood blister. The physician was contacted and a treatment as well as apply heel bows while in bed ordered. Skin impairment was not present on admission. During an interview January 17, 2024 at 11 AM the Director of Nursing confirmed that the wound and skin note was incorrect, as it noted that the Wound Location was the left plantar area of left foot and verified at the time of the interview that the pressure sore was a left heel blood blister. A review of a wound note dated January 12, 2024, at 07:51 AM revealed that on assessment, DTIs (deep tissue injuries) were noted to the resident's bilateral heels. Location: -LEFT HEEL Pressure, DTI, 2.5 cm x 2 cm x 0 cm. Calculated area is 5 sq cm. Wound Base: Localized area of maroon intact skin Wound Edges: Attached Periwound: Intact - RIGHT LATERAL HEEL Pressure Stage/Severity: DTI Wound Status: New Size: 3 cm x 4 cm x 0.1 cm. Wound Base: 1-24% epithelial , Localized area maroon skin - small opening with epithelial tissue exposed Wound Edges: Attached Periwound: Intact Exudate: Scant amount of Serous A review of a facility investigation report dated January 12, 2024, at 9:40 A.M. revealed that on January 10, 2024, a change in condition was completed for the identified blood blister to the resident's right heel that had opened and was draining serous fluid. The immediate action taken by the facility was that the nurse completed the change in condition form on January 10, 2024, notified the physician of the identified area and received an order for a treatment. An interdisciplinary meeting note dated January 12, 2024, revealed that the entry was status post identification of the area to resident's right heel on January 10, 2024, and the left heel on January 12, 2024. On January 10, 2024 a change in condition was completed for a blood blister to the right heel that opened and was draining serous fluid. On January 12, 2024, a report was completed for a blister on the left heel. Nursing noted an intact blister to the left plantar area measuring 0.3 cm x 0.4 cm. The wound care nurse practioner was in the facility and assessed both heels and documented that both were deep tissue injuries. The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels. Interview with the Director of Nursing on January 17, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the bilateral heel pressure areas for a resident at risk for skin breakdown. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5 (f) Medical records

Based on review of controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for two of five residents sampled (Resident 3 and 4) . Finding include: A review of the clinical record revealed that Resident 3 had a physician order dated January 13, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, 2 tablets every 4 hours, as needed for severe pain, pain scale 7-10 (a pain scale, 1-10, 1 least pain, 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on December 20, 2023, at 8:30 P.M, December 21, 2023, at 4 P.M, December 21, 2023, at 8 P.M., December 22, 2023, at 5 P.M., December 23, 2023, at 5 P.M., nursing staff signed out a dose of the resident's supply of Oxycodone 5 mg . However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. A review of a November 2023 MAR revealed that nursing signed out a dose of Resident 3's supply of Oxycodone 5 mg according to the MAR on the following dates: -November 18, 2023 at 11:50 A.M., November 19, 2023 at 07:56 A.M., November 25, 2023 at 08:03 A.M. and November 26, 2023 at 08:31 A.M. --October 1, 2023 at 8 A.M., October 1, 2023 at 12:20 P.M., October 3, 2023 at 8:08 A.M., October 3, 2023 at 1:30 P.M., October 4, 2023 at 5:50 P.M., October 5, 2023 at 4 P.M., October 5, 2023 at 9:30 P.M., October 10, 2023 at 8 A.M and October 10, 2023 at 1 P.M. --September 16, 2023 at 8 A.M., September 16, 2023 at 12:15 P.M., September 17, 2023 at 07:59 A.M., September 17, 2023 at 12:27 P.M., September 19, 2023 at 8:30 A.M., September 19, 2023 at 1:30 P.M., September 25, 2023 at 8:17 A.M. --August 5, 2023 at 08:01 A.M., August 5, 2023 at 12:25 P.M., August 6, 2023 at 07:39 A.M., August 6, 2023 at 1:05 P.M., August 8, 2023 at 07:36 A.M., August 8, 2023 at 1:01 P.M., August 10, 2023 at 4:43 P.M., August 15, 2023 at 08:31 A.M., August 16, 2023 at 08:08 A.M., August 16, 2023 at 1:31 P.M., August 17, 2023 at 5 P.M., August 17, 2023 at 9:01 P.M., August 22, 2023 at 1 P.M., August 24, 2023 at 08:11 A.M., August 24, 2023 at 1 P.M., August 29, 2023 at 07:51 A.M., August 29, 2023 at 1:04 P.M., August 30, 2023 at 3:20 P.M. There were no narcotic sign out records available at the time of the survey ending January 29, 2024, for the months of August 2023, September 2023, October 2023 and November 2023 to reconcile the accounting of the resident's supply of the controlled drug. According to the Medication Administration Records, Employee 1, LPN administered all the doses of Resident 3's prn Oxycodone 5 mg during August 2023, September 2023, October 2023 and November 2023 MARS During an interview, January 17, 2024, at approximately 2 PM the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for the above resident and confirmed the narcotic drug records were missing for the above months and not available to reconcile with the quantity dispensed for the resident and to verify administration to the resident on those date and times. A review of a facility investigation report dated January 9, 2024, at 3 P.M. revealed that on this date and time during shift to shift narcotic count, the day shift RN and the evening shift RN had noticed that one pill from Resident 4's supply of the medication Lacosamide ( a controlled substance, for seizure treatment) 200 mg pills was missing from the from the card and the nursing staff made the Director of Nursing (DON) aware. The DON visualized the controlled substance utilization record as well as the physical card of Lacosamide 200 mg. On the bubble pack in slot 25 there was no pill visible. Bubble packets 26, 27 and 28 were visibly removed and accounted for on the controlled substance utilization record. The remaining pockets were visualized and all pills accounted for. The DON contacted the pharmacy and spoke to the pharmacist to notify them of the incident. The missing pill was identified as a Pharmacy fill error. A review of a pharmacy order invoice revealed that Lacosamide 200 mg by mouth, give one tablet twice daily for seizures. The form indicated that 27 pills were dispensed and delivered to the facility. During an interview January 17, 2024, at 2:15 P.M., the DON confirmed the Pharmacy error and that the licensed nursing staff receiving the controlled medications did not ensure the correct count of the controlled meds upon receipt of the meds at the facility. He also confirmed that licensed nurses completing the shift to shift count of the meds did not ensure all the medications were in the card. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)(2)(k) Pharmacy services.

Based on a review of the facility's abuse prohibition policy, select investigative reports, clinical records, and staff interview, it was determined that the facility failed to ensure that one resident was free from misappropriation of resident property, medications, out of five residents sampled (Resident 3). Findings included: A review of the facility's abuse prohibition policy last reviewed by the facility August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents' belongings or money without the resident's consent. A review of the clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses which include hypertension and peripheral vascular disease. The resident was cognitively intact with a BIMS score of 14. The resident had a physician order initially dated January 13, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg, two tablets by mouth every 4 hours, as needed, for severe pain. On December 27, 2023, at approximately 7 PM the Director of Nursing was notified that a medication card containing 30 oxycodone 10 mg tablets belonging to Resident 3 was missing, along with the narcotic count sheet for that controlled drug dispensed for Resident 3. The pharmacy, physician, and the resident were made aware. The DEA, local police and the Area Agency on Aging were notified. The facility reimbursed the resident for the missing medication, noting that the facility would pay for the new drugs being delivered to the facility. The facility was obtaining staff statements and conducting drug testing of individuals that may have had access to the medication carts. At the current time the facility discovered the missing medication, the facility implemented the following to prevent recurrence of a similar episode of misappropriation of property: To identify like residents that have the potential to be affected the RN supervisor/designee counted all the narcotics in the medication carts and completed a cycle count of narcotics in the Omnicell (emergency medication supply), manifestation sheets going back 7 days to ensure all narcotics delivered to the facility were accounted for, interviewed capable residents to ensure they are receiving their pain medication and have no pain, incapable residents who receive pain medication were observed for signs and symptoms of pain. Education is being completed on the following: current staff on the abuse policy, with focus on misappropriation, on the chain of custody of receiving narcotics, and on the shift to shift count form. To monitor for ongoing compliance the following will occur: -interview 5 random capable residents weekly x 4 then monthly x 2 to ensure they are receiving their pain medication, observe 5 random incapable residents weekly x 4 then monthly x 2 to ensure residents who receive pain medication have no s/s of pain, audit the chain of custody documentation weekly x 4 then monthly x 2 to ensure the process is in place and being followed, and Audit the shift to shift count sheet weekly x 4 then monthly x 2 to ensure the form is filled out correctly to prevent drug diversions. Department of State will be updated. PB 22 investigation to follow. A local detective was in facility on January 2, 2024 to conduct investigation and interview staff. The Detective left facility to conduct interview with Employye 1 (LPN) at police headquarters where Employee 1 (LPN) confessed to stealing the resident's medications. A police report was pending completion. This LPN did have drug testing on file upon hire and was not noted to be or reported by staff to have shown signs or symptoms of intoxication during working hours. Employee 1 (LPN) was terminated by facility. A report with Department of State was submitted to reflect the updated information including LPN's confession. DEA representative to be in the facility on January 3, 2024. A review of Employee 1's emailed to the facility statement dated December 28, 2023, at 11:26 AM revealed that the nurse stated I worked short hall on December 25, 2023, from 7 AM to 3 PM. I do not recall seeing 10 mg card oxycodone for 9 w (Resident 3). There were 19 cards at the beginning of my shift. The sheet said 20 (cards of narcotics) due to a paper (narcotic record sign out sheet) that was zero' d out (all the pills adminstered from the card) on another shift by the ADON (assistant Director of Nursing) that was left in the (narcotic) book. When I counted the cards, I never changed the 20 (cards of narcotics) to 19 (cards of narcotics) before my shift ended. Five cards were taken out for a hospitalized resident and I zero' d out one card on my shift. There were 13 cards at the end of my shift. Employee 1 (LPN) subsequently confessed to taking the oxycodone 10 mg care and the narcotic utilization record during an interview with the local police on January 2, 2024. Upon conclusion of the facility's investigation, Employee 1 was terminated for misappropriation of Resident 3's narcotic medication oxycodone. An interview with the NHA on January 19, 2023, at approximately 11:30 AM confirmed the facility failed to ensure all residents were free from misappropriation of resident property, dispensed medications. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: To identify like residents that have the potential to be affected, -The DON/designee reviewed manifestation sheets going back 7 days to ensure all narcotic delivered to the facility were accounted for - The DON/designee interviewed capable residents who receive narcotic medication to ensure they are receiving their pain medication and have no pain. -to identify like residents that have the potential to be affected incapable residents who receive pain medication were observed for signs/symptoms of pain -the facility will develop and implement appropriate plans of action to correct deficiencies and regularly review and analyze data, including data collected under the QAPI program and data specifically related to controlled substance reconciliation. -The DON/designee educated current staff on the abuse policy, with focus on misappropriation, the chain of custody of receiving narcotics, educate licensed nurses on shift to shift count form -facility corporation staff will educate the Nursing Home Administrator and interdisciplinary team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's Quality Assurance Improvement Program, and its participants, implement effective systems to correct deficiencies. -the DON/designee will interview 5 random capable residents weekly x 4 then monthly x 2 to ensure residents are receiving their pin medications -DON/designee will observe 5 random incapable residents weekly x 4 then monthly x 2 to ensure residents who receive pain medication have no signs/symptoms of pain -the DON/designee will audit the chain of custody documentation, the shift to shift count sheet, weekly x 4 then monthly x 2 to ensure the process is in place and being followed. -the DON/designee will interview 5 employees on the abuse policy weekly x 4 then monthly x 2 with focus on misappropriation -the NHA/designee will audit ad hoc QAPI plans weekly x 4 then monthly x 2 related to pharmacy services (accountability of controlled substances), the results of the auditing and ongoing monitoring reviewed at the Quality Assurance Performance Improvement meetings will be reviewed by the corporate regional vice president of operation to ensure adequate implementation of QAPI plans to maintain ongoing compliance. This plan was completed by January 11, 2024. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights

Based on a review of select facility policy, controlled drug usage and medication administration records and staff interview it was determined the facility failed to implement procedures to promote accurate records of controlled drug medication administration on one of two medication carts. Findings include: A review of the facility's pharmacy policy entitled Receiving Pharmacy Products and Services from Pharmacy dated October 13, 2023, revealed that the reconciliation of medications should be performed by two licensed nurses and both nurses should sign the reconciliation record during the time of the medication reconciliation. A review of the Controlled Substance Log on November 9, 2023, in the presence of Employee 1, LPN (licensed practical nurse), at approximately 7:44 AM, revealed that Employee 1 had signed the controlled substance log as oncoming nurse at the start of her shift at 7:00 AM on November 9, 2023, and had also signed as the off going nurse for this date at 3:00 PM, to indicate that she reconciled the count of controlled medications prior to the shift change that would occur later that day. Interview with Employee 1, LPN, confirmed she had already signed as the off going nurse for the end of her shift on November 9, 2023, prior to the completion of her shift and actually performing the count to confirm an accounting of the controlled medications in the presence of another licensed staff member. Interview with the director of nursing (DON) at approximately 11:30AM confirmed that expectation is the controlled substance records are to be signed by the licensed nurses at each change of shift. The DON confirmed Employee 1 failed to follow proper pharmacy procedure for reconciling controlled medications. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, select facility policy and fall reports and staff interview it was determined that the facility failed to consistently implement planned fall prevention interventions developed for a resident identified at risk for falls to prevent a fall resulting in multiple fractures, serious head injury and lacerations for one residents out of 12 sampled (Resident 84). Findings included: Review of the facility's policy, entitled Fall Prevention and Management Policy last reviewed by the facility June 2021, indicated that it is the facility policy to assess residents for fall risk(s) on admission, quarterly, after any fall, and as needed. If risks are identified, preventive measures will be put in place and care planned. The Fall Risk Assessments are to be completed at admission, quarterly, after any fall, and as needed. Individualized interventions will be implemented based on this assessment and care planned accordingly. Providers will be consulted regarding risks and interventions, feedback, and any further approaches recommended. Review of Resident 84's clinical record revealed admission to the facility on [DATE], with diagnoses to include [CONDITION(S)], unspecified dementia without behavioral disturbances, and repeated falls. Review of a fall risk evaluation dated January 12, 2022, revealed that the resident was at high risk for falls. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 7, 2021, indicated that the resident was severely cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status - a tool to assess cognitive function a score of 0-7 indicates severe cognitive impairment), impaired vision and was known to wander. Review of Resident 84's care plan, initiated February 18, 2020, and revised on December 14, 2021, indicated that the resident was at risk for falls related to [CONDITION(S)], dementia, and corneal ulcer of right eye. Planned interventions to minimize the risk of falls/minimize injuries related to falls were to provide a bed alarm, implement fall interventions/devices, keep roommate the same to not cause disruption, maintain call light within reach and educate the resident to use it, maintain needed items in reach, motion sensor to resident bathroom, 15 minute checks of the resident and visual reminders on the wall to ring for assistance. A fall report dated January 25, 2022, at 3:08 AM revealed that the resident had an unwitnessed fall. Resident was found lying on the floor next to her roommate's Broda chair in the resident's room. The resident was assessed and noted to have 2 lacerations of the left eye and complaints of left hip pain. The resident was transferred to an acute care hospital. The fall report also indicated that the resident is noted with dementia without behavioral disturbances, increased confusion, labs and U/A (urinalysis- test of urine, used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes). drawn and treatment with [MEDICATION(S)] ([MEDICATION(S)]- an antibiotic used to treat infections) 250 mg (milligrams) started on January 24, 2022. Additionally, the fall report indicated that the planned intervention of a bed alarm was not sounding at the time of the resident's fall and the alarm was disconnected. A witness statement provided by Employee 3, a nurse aide, indicated that the resident was last seen asleep at 3:00 AM. Employee 3 indicated that she walked down the hall to go into another room and heard a boom. Employee 3 ran to Resident 84's room and found the resident on the floor, over by the closet, next to her roommate's wheelchair. Review of Resident 84's bed alarm (pressure alarm as documented) functioning and check for placement revealed that staff documented RR on January 25, 2022, for the 11:00 PM- 7:00 AM shift, indicating that the resident refused the intervention. Review of the 15 minute checks completed on January 25, 2022, for the 11:00 PM - 7:00 AM shift revealed that the resident was noted as sleeping from 11:00 PM to 3:00 AM . Interview with the Director of Nursing on February 2, 2022, at approximately 2:00 PM regarding the Resident's Refusal of the alarm being checked revealed that the DON stated that the resident does refuse at time. However, the DON also stated that the resident was asleep at the time according to the documentation and was unable to explain how the resident would have refused to allow staff to check to see if the alarm was plugged in if she was sleeping. Review of Resident 84's January 2022 medication administration record revealed that during the late afternoon of January 24, 2021, the evening prior to the resident's fall on January 25, 2022 at 3:08 AM, the resident received [MEDICATION(S)] 0.5 mg, 1 tablet at 6:20 PM. (an antianxiety medication with possible side effects of drowsiness, dizziness, tiredness and weakness). Progress notes indicated that the medication was administered on January 24, 2021 at 6:20 PM. Review of hospital documentation dated January 25, 2022, at 4:25 AM revealed that the resident had an acute subarachnoid hemorrhage ( Subarachnoid hemorrhage- bleeding in the space between the brain and the tissue covering the brain) left frontal pole ( left frontal pole [anatomical location of the brain]- corresponds to the anterior most rounded point of the frontal lobe) , bilateral nasal bone fractures (broken nose-the bone over the bridge of your nose), fracture of the anterior septum ( thin bone that separates the left and right airways of the nasal cavity) , acute left intertrochanteric femoral neck fracture( fractures of the proximal femur that occur between the greater and lesser trochanter [anatomical locations of the thigh bone]) requiring operative fixation with a cephalomedullary nail (surgical technique designed to help treat fractures of the femur). Additionally, the resident had left eyebrow laceration repair closed with sutures ( number of sutures not documented). The resident was readmitted to the facility on [DATE]. A hospice consult was obtained and orders in place for hospice care as of February 1, 2022. An interview with the Director of Nursing on February 3, 2022, at approximately 2:00 PM confirmed that the facility failed to ensure that planned interventions were consistently implemented, the bed alarm, for a resident identified as high risk for falls and also being treated for a urinary tract infection and with psychoactive medications. The resident got out of bed without staff knowledge, fell , and sustained serious injuries. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, all residents who have a bed, chair or bathroom door alarms will be audited to ensure proper function and placement. To prevent this from recurring all nursing staff will be educated on monitoring alarm placement and functioning. To monitor and maintain ongoing compliance the Director or Nursing/ designee will audit function and placement of alarms weekly x 4, then monthly x 2. All negative findings will be immediately corrected; audits will be brought to monthly QAPI meetings for review. The facility's immediate corrective action plan was completed January 31, 2022. 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services

Based on a review of clinical records, employee personnel records and select facility policy and staff interviews it was determined that the facility failed to ensure the use of safe technique and/or assistance devices necessary to safely transport residents and prevent a fall resulting in a fractured neck for one of 12 residents reviewed (Resident 23). Findings include: A review of Resident 23's quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 5, (YEAR), indicated that the resident required extensive assistance with one person for locomotion in the wheelchair. The resident had diagnoses, that included difficulty walking, muscle weakness and repeated falls. A review of information dated (MONTH) 6, (YEAR), submitted by the facility indicated that an activity aide was transporting Resident 23 in a wheelchair into the dining room. The activity aide did not realize that the resident's feet went under the wheelchair while he was being transported over the threshold entering the dining room. As resident's feet went under the chair, his feet caught on the floor causing the resident to fall forward out of the chair and onto his head. The information indicated that the resident does not always make it into the dining room unassisted, but does propel himself short distances. A review of the facility Incident Report - Investigation Summary dated (MONTH) 6, (YEAR), revealed that at approximately 5:30 PM Employee 3 (activity aide) pushed Resident 23 in the resident's wheelchair. When the resident was wheeled over the threshold into the dining room, the resident put his feet under his wheelchair and toppled over onto the floor. A written statement from Employee 3, the activity aide, revealed that while escorting resident to dining room from hallway, when going over the threshold, resident picked up his feet and fell out of the wheelchair and hit his head. A written statement from Employee 4, an LPN (licensed practical nurse) indicated that as they were going over the threshold he (the resident) picked up his feet, up under the wheelchair, catching them on the floor and fell forward hitting his head. The RN (registered nurse) Employee 5 assessed the resident who was on the floor on his right side with blood pouring from his head, the right side of his head had a large laceration with separation in his scalp skin. The resident was transported via ambulance to the hospital at approximately 5:37 PM on (MONTH) 6, (YEAR). A CT- scan report (diagnostic imaging test using a computerized tomography (CT) scan combines, a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. The CT scan images provide more detailed information than plain X-rays.) from the hospital dated (MONTH) 6, (YEAR), at 7:20 PM indicated the resident had a mildly displaced fracture of his neck in the cervical area (begins at the base of the skull). The resident returned to the facility on (MONTH) 8, (YEAR), at approximately 4:00 PM with a cervical collar (also known as a neck brace, is a medical device used to support a person's neck), which was only to be removed for hygiene purposes. The physician also ordered a pain regimen; the narcotic pain medication [MEDICATION NAME] 5 mg/325 mg one tablet every four hours as needed for moderate pain and two tablets as needed for severe pain. According to the resident's (MONTH) (YEAR) and (MONTH) (YEAR), medication administration records reviewed at the time of the survey ending (MONTH) 12, (YEAR), the resident required pain medication at least 24 times from (MONTH) 8th to (MONTH) 30th, (YEAR) and at least 7 times from (MONTH) 1st through (MONTH) 12, (YEAR). An interview with Employee 3, the activity aide, conducted on (MONTH) 10, (YEAR), at 10:00 AM revealed that she was transporting this resident via wheelchair and when they entered the dining room, she pushed him (the resident) over the threshold and the resident's feet went under the wheelchair and the resident fell on his head onto the floor. Employee 3 stated the facility had not provided her training on transporting residents in a wheelchair and to determine if a resident required leg rests on the wheelchair. A review of the facility's response to this resident incident revealed that Employee 9, the Director of Therapy, arranged for Employee 3 on (MONTH) 7, (YEAR), from 1:30 PM until 3:30 PM to view videos on the use of mechanical lifts, positioning, bed mobility, repositioning in wheelchair, assisting with falls, transfers and multiple videos regarding resident care. A review of Employee 3's personnel record revealed that she was a long standing facility employee who had previously worked in the facility's dietary department for approximately [AGE] years. She was hired as an activity aide on (MONTH) 1, (YEAR). Further interview with Employee 3 on (MONTH) 10, (YEAR), at 10:15 AM revealed that on (MONTH) 1, (YEAR), she was in training, which consisted of watching the full time activity person. On (MONTH) 3, (YEAR), she was needed to cook in the kitchen. On (MONTH) 4, 5, and (MONTH) 6, (YEAR), Employee 3 resumed training as activity staff, which she described as watching other activity personnel. Employee 3 confirmed that prior to the accident with Resident 23 and assuming her job duties as activity aide, she had not been trained on how to transport a resident in a wheelchair or determine if a resident would need leg rests to safely transport a resident in a wheelchair. Employee 3 stated that the facility had educated her on transporting a resident in a wheelchair, how to apply leg rests and where to find them, if needed, on the afternoon of (MONTH) 11, (YEAR), during the survey. There was no evidence the facility had educated Employee 3 on safe transport techniques prior to her assuming job duties as an activity aide until after Resident 23's accident on (MONTH) 6, (YEAR). Interview with Employee 9, the Director of Therapy on (MONTH) 10, (YEAR), at 1:00 PM revealed that Employee 3 was provided video in-servicing as per corporate policy. Interview with Employee 3 on (MONTH) 11, (YEAR), at 1:30 PM revealed that the day after the incident with Resident 23 she sat in a room and watched videos of how to transfer and lift residents, but never showed her how to properly transport a resident in a wheelchair and to determine if leg rests were needed. Employee 3 stated that the facility had not asked that she provide a return demonstration of the tasks after viewing the videos. Employee 3 stated that today (October 11, (YEAR)) therapy staff showed her how to push a wheelchair and how to obtain and apply leg rests to the wheelchair. A review of a policy entitled Transfer Techniques, provided by the Nursing Home Administrator (NHA) for surveyor review on (MONTH) 12, (YEAR), at 9:00 AM revealed guidelines for transporting a resident with a wheelchair, which included: make sure resident is in chair properly, including feet on leg rests and cover legs with lap or robe if necessary; Unlock wheels; Push chair by handles; Use hall mirrors for corner safety; Use center of hallway to avoid collisions at doorway. The NHA, during interview on (MONTH) 12, (YEAR), at 9:30 AM confirmed that Employee 3 was not trained on this policy and its corresponding procedures. A review of Employee 3's job description revealed that it did not indicate that the employee was responsible for transporting residents to activities in wheelchairs. However both the NHA and Director of Nursing (DON) confirmed during interview on (MONTH) 12, (YEAR), at 9:45 AM that as an activity aide it is expected that the employee transfer residents to/from activities with wheelchairs if needed. Further review of the information dated (MONTH) 6, (YEAR), submitted by the facility regarding this incident indicated that Employee 3 had been provided education on safety and demonstration was observed. However, there was no evidence that this employee returned demonstration regarding proper wheelchair transfers prior to or immediately after this resident's injury, which was confirmed by the DON on (MONTH) 12, (YEAR), at 9:00 AM. Employee 3 was not educated on proper transporting techniques in a wheelchair until surveyor inquiry during the survey ending (MONTH) 12, (YEAR). The facility failed to assure activities staff were properly trained in safely transporting residents in wheelchairs. The facility did not provide Employee 3 necessary training prior to assuming duties as an activities aide and transporting Resident 23, during which the resident fell and sustained a fractured neck. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 11/9/17, 10/6/16 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 201.20(a)(b) Staff Development 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 11/9/17, 10/6/16 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/9/17 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 11/9/17, 10/6/16

Based on a review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards and failed to provide sufficient staff assistance with transfers to prevent injury for two residents out of 10 sampled (Residents 19 and CR1). Findings include: A review of the clinical record revealed that Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set assessment (MDS - a standardized assessment conducted at specific intervals to identify resident needs) dated August 21, 2013, indicated that the resident was cognitively intact. The resident utilized half side rails for mobility. An undated side rail assessment indicated that the resident was to utilize bilateral side rails to serve as an enabler and promote independence. A review of a resident incident/accident report dated September 26, 2013, at 10:15 PM revealed that Resident 19 was found on the floor in his room; the resident stated that he reached for the side rail and it broke. The resident sustained [REDACTED]. The incident report noted that clamps were added to the siderails for extra support in response to the incident. An interview with Employee 3, the maintenance assistant, and the nursing home administrator (NHA) on November 13, 2013 at 1:15 PM revealed that at the time of this resident's fall on September 26, 2013, the side rails on the resident's bed were just attached with a strap and were not the appropriate rails for this resident's bed. The side rails in place on the resident's bed were from another bed, which was no longer used in the facility. The facility failed to ensure that proper side rails were used on the bed to allow the resident to utilize the rails as an enabler to change positions. The side rail was not properly attached to the bed and when the resident reached for the rail it broke, causing the resident to fall to the floor and sustain an injury. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance of two persons for bed mobility and transfers. The resident's care plan dated initially August 9, 2010, also indicated that the resident required two person assistance for transfers and the use of a sit to stand or hoyer lift (mechanical). A review of a resident incident/accident report dated December 10, 2012, revealed that Resident CR1 was in the bathroom and was being transferred from the toilet to the wheelchair by one nurse aide. The resident fell to the floor and did not sustain an injury. The resident's care plan in place at the time of this fall revealed that the resident was to be transferred with the assistance of two persons. According to a resident incident/accident dated May 11, 2013, an incident had occurred on May 10, 2013, when Employee 2, a nurse aide, heard Resident CR1 yell "ouch" and went into the resident's room. Upon entering the resident's room the nurse aide observed the resident sitting on the side of her bed with Employee 1, a nurse aide, next to her. Employee 2 then assisted Employee 1 with Resident CR1's care by helping the other nurse aide put the resident on her bed and change her brief. A statement provided by Employee 1, indicated that she lifted the resident by herself and pivoted her, put her on the bed and sat her down. Further review of this resident incident/accident report dated May 11, 2013, indicated that a nurse aide found the resident's right ankle to be swollen with bruising. The resident was sent for an x-ray which revealed a fracture through the anterior tibial margin (ankle fracture). As part of the facility's investigation into the resident's injury, the NHA interviewed Employee 1 on May 13, 2013 and wrote in a statement that this employee transferred the resident by herself on May 10, 2013, because she thought she could do it alone. The resident's plan of care in effect at the time of the injury indicated the resident required two person assistance with transfers, but Employee 1 transferred the resident by herself and the resident sustained [REDACTED]. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 10/1/12 28 Pa. Code 207.2 (a) Administrator's responsibility