Every finding on record at Milford Rehabilitation and Healthcare Center

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized, person-centered care plan to address dementia-related behaviors and cognitive decline for one of 17 residents reviewed (Resident 36).Findings include:A review of Resident 36's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), cerebral infarction (a stroke), and communication deficit disorder.A review of Resident 36's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 11, 2026, revealed the resident was severely cognitively impaired.A review of the resident's current care plan, initially dated March 24, 2026, revealed the resident had the potential to be physically aggressive related to dementia and poor impulse control. The care plan indicated the resident would not harm himself or others. Interventions included modifying the resident's environment, maintaining constant visual observation when out of his room, and monitoring and documenting observed behaviors and attempted interventions in a behavior log.Review of nursing documentation and facility investigative documentation revealed Resident 36 demonstrated repeated dementia-related behaviors from December 2025 through May 2026, including verbal aggression, physical aggression toward staff and residents, sexually inappropriate behaviors, unsafe attempts to stand and ambulate, wandering into restricted areas and other residents' rooms, pulling the fire alarm, attempting to access medication carts, and behaviors that did not consistently respond to staff redirection.Nursing documentation dated December 14, 2025, at 2:26 PM revealed Resident 36 had several behavioral outbursts during the shift. The resident shouted profanities, made verbal threats toward others, exhibited inappropriate behaviors toward female residents, became aggressive when redirected, entered other residents' rooms, and spit on the floor. Nursing documentation dated December 30, 2025, at 4:16 PM revealed Resident 36 exhibited increased behaviors, agitation, and combative behavior. Resident 36 transferred himself by wheelchair into the central bathroom and used his wheelchair and a linen/brief cart to block the door in an attempt to prevent staff from entering the room. When nursing staff attempted to redirect the resident, he struck staff. A nurse's note dated December 31, 2025, at 6:20 PM revealed that during medication pass, the nurse observed Resident 36 in the dining room. The resident stood from his wheelchair and fell to the floor. No injuries were noted.Investigative documentation provided by the facility dated January 3, 2026, at 5:40 PM revealed Resident 36 was found on the floor in the television room. The resident stated he was attempting to stand and walk. The chair alarm was not sounding at the time of the fall. The resident had been placed in a regular chair prior to the fall. The report indicated Resident 36 frequently attempted to self-ambulate despite education and was noncompliant with safety measures.Investigative documentation dated January 9, 2026, at 2:30 PM revealed Resident 36 and Resident 50 were seated in the second-floor television lounge after lunch. Employee 7, housekeeping staff, observed Resident 36 approach Resident 50 and placed his hand on Resident 50's exposed right breast. Employee 7 separated the residents and notified nursing staff. Resident 50 was admitted to the facility on [DATE], with diagnoses including dementia. Resident 50's Quarterly Minimum Data Set Assessment, dated November 17, 2025, revealed Resident 50 was severely cognitively impaired. Nursing documentation dated January 10, 2026, at 4:43 PM revealed Resident 36 was under close supervision related to the January 9, 2026, incident. Documentation revealed the resident became increasingly agitated with staff redirection and exhibited behaviors including cursing, punching and kicking staff, moving furniture, slapping counters, and licking walls. A nursing note dated January 10, 2026, at 8:27 PM revealed Resident 36 exhibited ongoing and escalating behaviors including wandering into restricted areas, verbal aggression, attempting to access medication carts, smearing food, and pulling the fire alarm. Staff redirection was largely ineffective. Documentation indicated staff would continue close supervision and monitor the resident's response to interventions. A physician's order dated January 11, 2026, revealed Seroquel (an antipsychotic medication) 25 milligrams by mouth twice daily was ordered in response to increased behaviors. The resident had previously received Seroquel 25 milligrams by mouth daily for cognitive communication deficit disorder. The dose was increased due to ongoing behaviors including striking staff, verbal threats toward others, and kicking furniture. Close supervision continued in addition to the medication increase. Nursing documentation dated January 16, 2026, at 11:15 AM revealed Resident 36 exhibited increased agitation and aggressive behaviors that did not respond to redirection. The resident cursed at and struck staff members. Nursing documentation dated January 16, 2026, at 6:34 PM revealed Resident 36 exhibited aggression and agitation toward staff providing care. Resident 36 struck a staff member while care was being provided to another resident in close proximity. A nurse's note dated January 20, 2026, at 8:34 PM revealed Resident 36 removed his brief in the hallway and exposed his genitals. The resident also pulled the cover off the fire alarm and continued attempting to bang on and pull the alarm cover. The resident became verbally aggressive when redirected by staff. Nursing documentation dated January 22, 2026, at 6:20 PM revealed Resident 36 became physically violent and exhibited sexual behaviors toward staff during the shift. Documentation revealed the resident used vulgar language toward staff and became violent when redirected. The resident attempted to stand from his wheelchair and fought with staff during redirection. The physician was notified and ordered Seroquel 25 milligrams by mouth twice daily. Documentation further revealed Resident 36 punched a nurse aide on the thigh while she was seated completing documentation. The resident wheeled into other residents' rooms and cursed at staff when redirected. Nursing documentation dated January 27, 2026, at 10:18 AM revealed Resident 36 exhibited aggressive and sexually inappropriate behaviors toward staff. The resident touched and grabbed female staff members' genital areas during care. Staff redirection resulted in increased agitation. Nursing documentation dated January 28, 2026, at 7:06 PM revealed Resident 36 exhibited inappropriate behaviors including touching and grabbing staff during care and attempting to stand without assistance. Redirection was ineffective. Nursing documentation dated January 29, 2026, at 10:34 AM revealed Resident 36 was seated in his wheelchair near the nurses' station and propelled himself toward a nurse, kicking her leg. At 11:35 AM, the resident propelled his wheelchair toward staff, kicking, hitting, and grabbing them while making verbal threats and profane statements. Additional nursing documentation revealed that at 12:47 PM, Resident 36 was seated in the dining room and stood, attempting to walk while holding onto a table. When staff attempted to assist the resident back into his wheelchair, Resident 36 threw a chair toward another resident. The chair struck the resident's leg rest and did not strike the resident. Resident 36 then made threatening and inappropriate statements. The physician was contacted and increased the resident's Seroquel to 50 milligrams by mouth twice daily in response to the resident's behaviors. Nursing documentation dated February 2, 2026, at 6:32 PM revealed Resident 36 grabbed the buttocks of a contracted nursing staff member. Nursing documentation dated February 12, 2026, at 9:52 AM revealed staff attempted to refasten the resident's brief after he had undone it. The resident became agitated, shouted profanities, attempted to punch staff with both fists, and struck a staff member. The resident was situated near the nurses' station and continued leaning over his wheelchair attempting to strike others. Facility investigative documentation dated February 14, 2026, at 6:15 PM revealed Resident 36 struck another ambulatory resident twice in the abdomen while seated in his wheelchair. The residents were separated and the physician was notified. Continued negative behaviors, including striking staff, were documented. Nursing documentation dated February 21, 2026, at 7:30 AM revealed staff redirected Resident 36 away from a cleaning cart. The resident grabbed the cart, struck staff, yelled profanities repeatedly, and grabbed other residents' wheelchairs while exhibiting escalating behaviors. Facility investigative documentation and nursing documentation dated February 23, 2026, at 7:50 PM revealed Resident 36 attempted to enter the central shower room. A nurse attempted to redirect the resident backward. The resident resisted and fell to the floor, sustaining two small skin tears to the left forearm. Nursing documentation dated February 24, 2026, at 2:37 PM revealed Resident 36 exhibited aggressive behaviors during care and attempted to strike staff. Staff redirection was ineffective. Facility investigative documentation dated March 23, 2026, at 6:35 PM revealed Resident 36 was observed arguing with another male resident. The residents were in close proximity and made brief physical contact. Staff immediately separated the residents. The physician was notified. Resident 36 was maintained in line-of-sight supervision and later placed in bed for the evening. Facility investigative documentation dated March 25, 2026, at 7:14 AM revealed Resident 36 was found on the dining room floor at 6:25 AM with a small skin tear. The physician was notified and the resident was returned to bed. Nursing documentation dated April 28, 2026, at 7:30 PM revealed Resident 36 struck a nurse in the hip during care. Nursing documentation dated May 12, 2026, at 1:47 PM revealed Resident 36 grabbed the telephone from the nurses' station and attempted to punch a nurse in the face when she attempted to retrieve the phone. The resident made threatening and profane statements toward staff. Nursing documentation dated May 14, 2026, at 6:52 AM revealed Resident 36 grabbed a nurse inappropriately as she walked past him and made sexually inappropriate statements. The facility failed to develop and implement an individualized, person-centered plan to address, modify, and manage Resident 36's dementia-related behaviors. The resident's care plan identified physical aggression related to dementia and poor impulse control; however, the care plan did not include individualized interventions based on assessment of the resident's preferences, social and past life history, customary routines, interests, triggers, or effective approaches to manage, modify, or decrease the resident's dementia-related behavioral symptoms. During an interview on May 14, 2026, at 10:00 AM, the Nursing Home Administrator confirmed the facility was unable to provide evidence of the development and implementation of an individualized, person-centered plan to address Resident 36's dementia care. 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on select facility policy, clinical record review, observations, and staff interview, it was determined the facility failed to implement infection prevention practices and adhere to the facility policy for identifying, treating and preventing the transmission of scabies for two of 17 residents reviewed (Resident 16 and Resident 72) and for implementing enhanced barrier precautions for one of 17 residents reviewed (Resident 16). Findings include:According to the Centers for Disease Control and Prevention (CDC) guidance titled Public Health Strategies for Scabies Outbreaks in Institutional Settings (updated December 18, 2025), residents with confirmed or suspected scabies (a skin condition caused by microscopic mites that burrow into the skin and lay eggs, resulting in intense itching, often worse at night, and a pimple-like rash) should be placed on contact precautions, including the use of gowns and gloves and avoidance of direct skin-to-skin contact. The guidance further stated that roommates or close contacts with prolonged skin exposure should be identified, offered prophylactic treatment, and monitored but do not require room isolation. A review of the facility policy titled Scabies Identification, Treatment, and Environmental Cleaning, adopted on February 9, 2026, indicated the facility would treat residents infected with scabies and prevent transmission to other residents and staff. The policy required residents with scabies to remain on contact precautions (use of gowns and gloves) for 24 hours after treatment. It further required staff who may have been exposed to report any rash development to the infection preventionist. The policy also required that roommates of infected residents be carefully assessed and treated if symptoms were present or monitored daily if asymptomatic until resolution. Clinical record review revealed Resident 72 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a condition in which the heart is unable to pump blood effectively to meet the body's needs) and rash and other nonspecific skin eruption (a generalized or localized rash without a definitive diagnosis). A review of Resident 72's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026, revealed that Resident 72 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 range of 12-15 means normal thinking and memory, reflecting little to no cognitive impairment). Observation and interview with Resident 72 on May 12, 2026, at 11:30 AM revealed the resident continued to report intense itching, worse at night, resulting in interrupted sleep. Contact precautions signage was posted outside the room, and gowns and gloves were available at the entrance. Review of hospital discharge documentation dated April 24, 2026, revealed Resident 72 had chronic pruritic dermatitis (long-term itchy skin inflammation) and had been treated with topical medications including triamcinolone (a corticosteroid used to reduce inflammation) and nystatin (an antifungal medication). The hospital record also recommended outpatient dermatology follow-up. admission documentation dated April 24, 2026, identified a rash on the resident's upper shoulders at time of admission. Nursing documentation dated April 27, 2026, revealed progression of the rash to the arms, legs, and torso, with the resident reporting worsening symptoms over approximately four months. A physician note dated April 28, 2026, described a maculopapular erythematous rash with excoriations (red, raised and flat rash with scratch marks from itching) on both upper extremities. A review of clinical records revealed on May 5, 2026, the resident left the facility for an outside medical appointment without additional infection control precautions. A specialty wound care evaluation dated May 7, 2026, documented scabbing rash involving the back, sacrum, chest, abdomen, and bilateral arms. Dermoscopy (a magnified skin examination using a handheld device with light) confirmed a diagnosis of scabies. Treatment with permethrin 5 percent cream (a topical scabicidal medication used to kill mites causing scabies) was ordered. Nursing documentation dated May 8, 2026, confirmed application of permethrin cream. The resident's personal clothing was discarded at his request, linens were changed and placed in a red biohazard bag (used for potentially infectious materials), and clean garments were provided. A physician order dated May 10, 2026, initiated contact isolation precautions requiring all care to be provided in the resident's room due to scabies, with reassessment after treatment initiated on May 8, 2026. Infection control documentation titled Infections for April 2026 did not include Resident 72's rash identified on admission. A separate infection control tool titled Revised McGeer Criteria (standardized infection surveillance guidelines used to determine whether a resident meets criteria for a suspected healthcare-associated infection) for Infection Control Surveillance Checklist was incomplete, undated, and did not include completed scabies surveillance criteria. This information was reviewed with the Nursing Home Administrator (NHA) on May 12, 2026, at 1:00 PM. The resident continued to exhibit symptoms consistent with scabies, and timely implementation of appropriate precautions and infection control measures was not evident. During an interview on May 14, 2026, at 11:40 AM, the NHA acknowledged that the facility did not timely identify scabies, did not consistently implement CDC-recommended precautions, and did not ensure appropriate treatment and infection prevention measures were followed for Resident 72. Clinical record review revealed Resident 16 was admitted on [DATE], with a diagnosis of acute respiratory failure with hypoxia (a condition in which the lungs cannot adequately oxygenate the blood, resulting in low oxygen levels). The admission MDS dated [DATE], indicated Resident 16 was cognitively intact with a BIMS score of 14, reflecting no significant cognitive impairment. During an interview on May 12, 2026, at 11:45 AM, Resident 16 reported being in quarantine due to the roommate's skin condition and denied any symptoms of rash or itching. Nursing documentation confirmed a full skin assessment on May 8, 2026, showed no evidence of scabies, and the resident received permethrin treatment on May 9, 2026. According to CDC guidance, roommates of residents diagnosed with scabies should be identified as close contacts, evaluated, offered prophylactic treatment as indicated, and monitored; however, room isolation is not required. An interview with the infection control nurse and Nursing Home Administrator on May 13, 2026, at 2:10 PM confirmed uncertainty regarding the duration and necessity of isolating Resident 16, and inability to justify the extended precautions applied. Review of Resident 16's clinical record revealed a physician order dated April 17, 2026, for Enhanced Barrier Precautions (EBP) due to the presence of an indwelling catheter. A review of the facility policy titled Enhanced Barrier Precautions (EBP), adopted February 9, 2026, indicated gowns and gloves are required during high-contact care activities for residents with indwelling medical devices, including urinary catheters (a flexible tube inserted into the bladder to drain urine into a collection bag). Observation on May 12, 2026, at 11:45 AM revealed Resident 16 was transferred by two nursing assistants without the use of required gowns and gloves. On May 12, 2026, at 1:45 PM, the Nursing Home Administrator and infection control nurse were notified of the observation and acknowledged that Enhanced Barrier Precautions were not implemented during the care of Resident 16. 28 Pa Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of select facility policies, observations, and staff interviews, it was determined the facility failed to implement and adhere to established procedures to ensure appropriate storage and compliance with use-by dates for multi-dose medications in one of two medication rooms (first-floor medication room)Findings include:A review of the facility policy titled Medication Labeling and Storage, adopted on February 9, 2026, indicated that medications and biologicals (treatments derived from living organisms or their products) are required to be stored in locked compartments under appropriate temperature, humidity, and light controls. The policy further stated that expired medications and/or biologicals are to be managed by contacting the dispensing pharmacy for return or destruction instructions. Additionally, the policy required that multi-dose vials be dated upon opening and discarded within 28 days unless otherwise specified. An observation of the first-floor medication room on May 13, 2026, at 10:24 AM, in the presence of Employee 1, Registered Nurse (RN), revealed the following expired or improperly stored medications available for resident use:One bottle of Geri-Lanta (an over-the-counter liquid antacid and antiflatulent medication) with an expiration date of August 2025.One opened multi-dose vial of Tuberculin Purified Protein Derivative (a diagnostic solution used for tuberculosis skin testing) with no date indicating when the vial was opened.Two bottles of All-Relief Naproxen Sodium (an over-the-counter nonsteroidal anti-inflammatory drug used for pain and fever reduction) with an expiration date of December 2025. During an interview conducted on May 13, 2026, at 10:30 AM, Employee 1 RN confirmed the identified medications were expired and that the Tuberculin vial was undated while stored in the medication room and available for resident use. During an interview on May 13, 2026, at 1:44 PM, the Nursing Home Administrator reviewed and acknowledged the findings, confirming the facility failed to adhere to established medication storage requirements, including proper dating, monitoring, and removal of expired medications and biologicals from use. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen for one resident out of five residents reviewed for unnecessary medications (Resident 3).Findings include:A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a mental health condition characterized by excessive and persistent fear or worry that interferes with daily functioning and is difficult to control). A review of a consultant pharmacist report dated December 7, 2025, revealed Resident 3 was prescribed the following psychoactive medications:Lexapro 10 milligrams (mg) one tablet daily, an antidepressant classified as a selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety disorders.Klonopin 0.5 mg one tablet daily, a benzodiazepine medication used to relieve symptoms of anxiety. The consultant pharmacist documented that Resident 3 required periodic review of psychoactive medications and consideration of a gradual dose reduction (GDR, the stepwise tapering of a medication dose to determine whether symptoms or conditions can be managed with a lower dose or whether the medication may be discontinued, in accordance with CMS requirements regarding unnecessary medications) if clinically appropriate. Review of Resident 3's clinical record failed to reveal documentation indicating the attending physician reviewed, acknowledged, or responded to the consultant pharmacist's recommendation. The clinical record additionally failed to reveal evidence that a gradual dose reduction was attempted or documentation supporting a clinical contraindication for why a gradual dose reduction could not be implemented. The facility failed to ensure the attending physician reviewed and addressed the consultant pharmacist's recommendation regarding psychoactive medication use and consideration of gradual dose reduction for Resident 3. As a result, the facility failed to ensure ongoing monitoring and evaluation of psychoactive medications to determine continued clinical necessity and compliance with requirements related to unnecessary medications. During an interview conducted on May 14, 2026, at 1:00 PM, the Nursing Home Administrator (NHA) confirmed the facility was unable to provide documentation showing the attending physician reviewed or acted upon the consultant pharmacist's recommendation. 28 Pa. Code 211.9 (k) Pharmacy services.28 Pa. Code 211.12 (c) Nursing services.28 Pa. Code 211.2 (d)(3) Medical Director.

Based on select facility policy, clinical record review, and staff and resident interviews, it was determined the facility failed to monitor and manage hydration status in accordance with a physician ordered fluid restriction to ensure proper fluid balance for one of 17 residents reviewed (Resident 72).Findings include: A review of the facility policy titled Restricting Fluids, adopted on February 9, 2026, indicated that the facility is required to provide an appropriate amount of fluids to support an optimal level of health. The policy states that when a resident is placed on a fluid restriction (a specific daily limit on how much liquid a person can consume, including all drinks and high fluid foods such as soups, ice cream, gelatin, and ice), free water (available water at the bedside) is not to be provided unless specifically included in the resident's total daily fluid allowance. The policy required documentation of the resident's fluid intake and adherence to the prescribed allowance to determine whether the resident met the designated fluid limit. A review of the facility policy titled Measuring and Recording Intake of Food and Fluids, adopted on February 9, 2026, showed that the purpose of the procedure is to obtain an accurate record of the food and fluids consumed by the resident. The policy stated the amount of food and fluid taken during meals and between meals will be recorded in the electronic medical record (digital version of a patient's medical chart), and that all fluids will be documented in milliliters (mL). The policy requires that if a resident on a fluid restriction exceeds the prescribed allowance, the provider, registered dietitian, and resident representative will be notified. A clinical record review revealed resident 72 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs) and rash and other nonspecific skin eruption (generalized or localized rash with no definitive diagnosis). A review of Resident 72's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026, revealed that Resident 72 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 range of 12-15 means normal thinking and memory, reflecting little to no cognitive impairment). Clinical record review revealed a physician's order dated April 24, 2026, for a 1500 mL daily fluid restriction, including 840 mL with meals, 220 mL on day shift, 220 mL on evening shift, and 220 mL during nursing care and medication administration. A nutritional risk care plan initiated on April 25, 2026, identified the resident required a fluid restriction related to fluid overload (a condition in which the body retains excess fluid, potentially causing swelling, respiratory symptoms, and worsening cardiac function). The care plan goal indicated Resident 72 would avoid significant weight changes associated with fluid retention and consume 75 percent or more of meals. Interventions included monitoring for signs and symptoms of excess fluid intake, including anxiety, behavioral changes, increased respiratory rate, shortness of breath, fatigue, cough, and congestion. During an interview conducted with Resident 72 on May 12, 2026, at 10:30 AM, the resident stated he was unaware of the physician ordered fluid restriction. Observation of the bedside area revealed a white Styrofoam cup containing water and a clear plastic bottle of orange soda accessible to the resident. Resident 72 stated he experienced thirst and consumed available liquids. A review of the nutrition evaluation completed by the clinical nutritionist on April 24, 2026, acknowledged the resident's 1500 mL fluid restriction; however, the clinical record failed to reveal evidence the resident's adherence to the prescribed fluid restriction was monitored or documented in accordance with facility policy. During an interview conducted on May 13, 2026, at 1:30 PM, the Assistant Director of Nursing (ADON) confirmed there was no documentation in the electronic medical record reflecting Resident 72's daily fluid intake from admission on [DATE], through the time of survey. The ADON acknowledged the facility failed to monitor and document the resident's fluid intake, hydration status, availability of fluids at bedside, and adherence to the prescribed fluid restriction in accordance with facility policy. The facility failed to ensure monitoring and documentation of fluid intake for Resident 72, a resident with a physician ordered fluid restriction related to congestive heart failure. The facility further failed to ensure staff implemented and monitored compliance with the ordered fluid restriction and failed to ensure the resident was aware of the prescribed fluid limitation. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on observations, review of facility policies, clinical records, facility-provided investigations, and staff interviews, it was determined the facility failed to provide adequate supervision and implement effective fall prevention interventions to prevent recurrent falls for one of 17 residents reviewed (Resident 4).Findings include:A review of the facility policy titled Falls and Fall Risk, Managing, adopted by the facility on February 9, 2026, indicated based on previous evaluations and current data, staff were to identify interventions related to the resident's specific risks and causes to attempt to prevent falls and minimize complications related to falls. The policy further indicated that staff, with input from the attending physician, were to implement a resident-centered fall prevention plan to reduce specific fall risk factors for each resident identified as at risk for falls or with a history of falls. If falls recurred despite initial interventions, staff were to implement additional or different interventions or document why the current interventions remained appropriate. If underlying causes could not readily be identified or corrected, staff were to trial various interventions until falls were reduced, prevented, or determined unavoidable.A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (PTSD, a serious mental health condition that can develop after an individual experiences or witnesses a traumatic event) and Alzheimer's disease (the most common cause of dementia and a progressive brain disease caused by changes in the brain, including buildup of proteins, resulting in memory loss, cognitive decline, and impaired functioning).A review of the resident's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process used to assess residents and develop individualized care plans) dated February 14, 2026, revealed Resident 4 was unable to complete the Brief Interview for Mental Status due to being rarely or never understood because of cognitive impairment. Section GG (functional abilities and goals) revealed the resident required partial/moderate assistance (helper does less than half the effort and assists with lifting, holding, or supporting trunk or limbs) and supervision or touching assistance with walking 10 feet and walking 50 feet (the helper provides verbal cueing, steadying, contact guard assistance, or intermittent physical assistance during ambulation).A review of Resident 4's care plan, initiated on April 25, 2024, identified the resident was at risk for falls related to sensory deficits and use of antipsychotic medication (a class of psychotropic medications primarily used to manage psychosis, including symptoms such as hallucinations, delusions, paranoia, or disordered thinking). Resident goals included minimizing risk for falls and fall-related injuries. Planned interventions included assistance with transfers and ambulation, reinforcement to request assistance, and standby assistance/contact guard with use of a wheeled walker when unsteady.A review of the resident's physician's order entered by the facility's Director of Nursing (DON) on April 10, 2026, at 5:18 PM, directed staff to maintain close observation of the resident during ambulation.A review of facility investigative documentation dated April 29, 2026, at 2:30 AM, revealed Resident 4 was observed tripping over a tray table near the nursing station. The resident sustained a skin tear measuring approximately 1 centimeter (cm) by 1 cm. Documentation indicated the resident did not hit his head, vital signs were stable, range of motion was within normal limits, and the resident denied pain or discomfort. Resident 4 was unable to describe the incident.A review of a post-fall nursing note dated April 29, 2026, at 2:44 PM, revealed interventions included monitoring gait (a person's walking pattern) during ambulation and ensuring pathways remained clear.A review of the resident's Morse Fall Scale Assessment ( a standardized tool used to evaluate a resident's risk for falling based on factors such as prior falls, mobility, use of assistive devices, gait and mental status), dated April 30, 2026, at 2:03 PM, identified Resident 4 as a high fall risk due to poor recall, impaired judgment, impaired safety awareness, decreased muscular coordination, one to two falls within the past three months, and multiple predisposing conditions including dementia and wandering behaviors.A review of facility investigative documentation completed by Employee 2 Registered Nurse (RN), dated May 3, 2026, at 12:05 AM, revealed staff responded to a noise in Resident 4's room and observed the resident on the floor bleeding from the forehead area. The resident was unable to describe the incident. The physician was notified and an order was obtained to transfer to the resident to the emergency room for further evaluation and treatment.A review of documentation provided by the facility indicated on May 3, 2026, at 6:08 PM, the resident had a fall in the facility and was transferred out to the hospital. The facility indicated planned interventions post fall to prevent recurrence included an evaluation by physical therapy (PT) and occupational therapy (OT) upon the resident's return from the hospital. It was indicated Resident 4 returned to the facility on May 4, 2026, at 3:00 PM, with two staples (metal clips used to close wounds or lacerations) to the forehead area.The facility failed to implement the planned interventions as documented in the report. The clinical record revealed no documented evidence PT or OT completed a timely evaluation following the resident's return from the hospital.A review of a PT evaluation and plan of treatment dated May 6, 2026, revealed Resident 4 demonstrated decline in functional ambulation, mobility, dynamic balance, gait mechanics, and posture deficits, contributing to decreased gait safety and two falls within a two-week period. Documentation described a shuffled gait pattern and increasingly rounded kyphotic posture (an excessive forward curvature of the upper spine), which compromised mobility and overall conditioning.Further review revealed the resident's care plan was not revised to reflect the resident's decline in mobility or to include additional interventions to address increased fall risk and impaired ambulation.A nursing progress note dated May 9, 2026, at 1:50 PM, documented Resident 4 appeared weak, hunched over, and unable to maintain gait while ambulating. The resident was returned to bed to rest. Vital signs were stable and the resident was afebrile (without fever).Clinical record review revealed documentation dated May 10, 2026, at 9:50 PM, indicating the resident became weak while ambulating and was lowered to the floor by staff, sustaining a skin tear to the right hand.A review of facility investigative documentation completed by Employee 3, Licensed Practical Nurse (LPN), dated May 10, 2026, at 9:50 PM, revealed staff reported Resident 4 became too weak to continue ambulating and no wheelchair or additional staff assistance was immediately available. Resident 4 sustained a skin tear measuring 3 cm by 2 cm to the top of the right hand. Vital signs were within normal limits. The resident required assistance from two staff members to transfer from the floor into a wheelchair and was returned to bed. The physician was notified and PT/OT evaluation for ambulatory status was ordered.A review of the resident's fall care plan revised by the DON on May 11, 2026, revealed interventions included staff assistance with ambulation when visible and wheelchair follow when possible.A review of facility investigative documentation completed by the Assistant Director of Nursing (ADON) dated May 12, 2026, at 11:15 AM, revealed Resident 4 was observed by Employee 3, Speech Therapist (SLP), attempting to rise from a chair in the second-floor television lounge and subsequently fell, striking the right side of the head on the floor. Documentation indicated the resident was prescribed Eliquis (a prescription anticoagulant, also referred to as a blood thinner, used to prevent and treat blood clots and reduce the risk of stroke). Resident 4 sustained abrasions to the knees and right shoulder, along with a skin tear to the right knee measuring 1.5 cm by 1.5 cm. The physician was notified and ordered transfer to the ER (emergency room) for evaluation and treatment, including a computed tomography (CT) scan (a diagnostic imaging test used to identify injuries and medical conditions) of the head due to the fall with head strike.A witness statement completed by Employee 3 dated May 12, 2026, indicated the employee observed Resident 4 rise from a chair and fall, striking the right forehead area with audible impact.A review of the emergency department Discharge summary dated [DATE], at 3:23 PM, revealed diagnoses that included closed head injury (a type of traumatic brain injury in which damage occurs to the brain without penetration or fracture of the skull), abrasion of the right shoulder area, and right shoulder contusion (a bruise resulting from blunt force trauma).The facility failed to ensure adequate supervision and implement effective fall prevention interventions for Resident 4, a resident identified as high risk for falls due to impaired cognition, poor safety awareness, and declining mobility. The facility further failed to timely revise and update the resident's care plan to reflect recurrent falls, declining ambulation status, and increased need for supervision and safety interventions. These failures resulted in repeated falls with injuries, including a closed head injury requiring emergency room evaluation and treatment.During an interview conducted on May 14, 2026, at 12:40 PM, the facility's Nursing Home Administrator (NHA) reviewed and confirmed the above findings related to the facility's failure to ensure Resident 4's safety through increased supervision and effective fall prevention interventions.28 Pa. Code S211.10(c) Resident care policies28 Pa. Code S201.18(b)(1) Management28 Pa. Code S211.12(d)(3)(5) Nursing services

Based on a review of clinical records, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of quality by failing to ensure prompt clinical evaluation and timely treatment of an injury for one of 17 sampled residents (Resident 13).Findings include:A clinical record review revealed Resident 13 was admitted to the facility on [DATE], with a diagnosis of fracture of the unspecified part of the neck of the left femur (a break in the neck of the left femur located just below the ball of the hip joint).A review of Resident 13's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to assist in planning resident care), dated February 26, 2026, revealed Resident 13 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5. (The BIMS is a screening tool within the Cognitive Patterns section of the MDS used to assess attention, orientation, and the ability to register and recall information. A score of 0-7 indicates severe cognitive impairment and reflects significant difficulty with memory, orientation, or both).A review of the clinical record revealed a nursing progress note dated April 15, 2026, at 2:43 PM, documented as a late entry for an incident that occurred on April 14, 2026. The documentation indicated that while seated in the dining room for lunch, Resident 13 independently self-propelled in her wheelchair to obtain coffee from a cart located at the front of the dining room. A kitchen staff member assisted by pouring the coffee into the cup the resident was holding. As Resident 13 returned to her table while holding the cup, the coffee spilled onto her clothing and upper legs. Nursing documentation indicated that the resident's wet garments were removed and an assessment was completed, which noted mild redness on both thighs and a flattened blister measuring 2 centimeters (cm) (length) and 2 cm (width) on the mid left thigh. A cool compress was applied, and the resident was evaluated by the nurse practitioner who was present in the facility. The provider recommended continued cool compresses and application of Silvadene (a cream that keeps harmful germs out and helps the burn heal safely).A review of an incident note completed by the Director of Nursing (DON), dated April 14, 2026, at 12:10 PM, documented as a late entry note on April 15, 2026, at 2:43 PM revealed Resident 13 was seated in the main dining room for lunch when she self-propelled to the coffee cart. The note indicated Resident 13 attempted to pour herself a cup of coffee from the carafe when a dietary aide offered assistance. The dietary aide then poured the coffee into the cup while the resident held it. The note further documented that while attempting to return to her table, Resident 13 spilled the hot coffee onto herself. The resident's wet garments were immediately removed and the resident was assessed for injury. The resident was noted to have mild redness to both thighs and a flattened blister measuring 2 cm by 2 cm to the mid-thigh area. Cool compresses were applied, and the nurse practitioner evaluated the resident while on site. The note documented the nurse practitioner recommended continued cool compresses and application of Silvadene cream. The note indicated the DON, physician, and Nursing Home Administrator (NHA) were notified of the incident.The facility failed to document in the clinical record on April 14, 2026, at the time the incident occurred. In addition, there was no evidence that a physician's order for treatment related to the resident's burn injury was obtained on the date of the incident.A review of the physician's orders revealed an order dated April 17, 2026, for Silvadene 1% external cream to be applied topically to both thighs every day shift for five days for treatment of a hot-liquid burn.A review of the electronic Medication Administration Record (eMAR) revealed the Silvadene cream was not initiated until April 18, 2026, four days after the burn injury occurred, and continued through April 22, 2026.A review of the facility document entitled Medication Error, Wrong Time indicated the resident was burned on April 14, 2026, and referenced application of Silvadene from stock medication on April 14 and April 15, 2026. The document also referenced the ordered written on April 17, 2026, and documented administration of Silvadene from April 18 through April 22, 2026.A review of the eMAR revealed no documented evidence that Silvadene was administered on April 14, 2026, through April 17, 2026.A review of the clinical record revealed the facility did not complete additional clinical assessments or obtain a skin evaluation by a wound care specialist following the burn injury. There was no documentation indicating that a comprehensive assessment of the burn, including evaluation by a wound care specialist, was conducted after the incident. This failure, in addition to inconsistencies and delay in treatment, failed to provide appropriate care and monitoring of the resident's injury.28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of select facility policy, clinical records, and staff interview, it was determined the facility failed to review and revise a comprehensive plan of care in response to a fall for one resident out of 17 residents reviewed (Resident 11).Findings include:A review of the facility's policy titled Care Plans, Comprehensive Person Centered, adopted February 9, 2026, the policy indicated that the care plan describes the services necessary to help the residents attain or maintain their highest practicable physical, mental, and psychosocial well being and must reflect currently recognized standards of practice for identified problems and conditions. The policy also specified that resident assessments are ongoing and that care plans must be revised as new information becomes available or as the residents' condition changes. A clinical review revealed Resident 11 was admitted to the facility on [DATE], with a diagnosis of primary generalized osteoarthritis (wear and tear in several joints throughout the body). A review of Resident 11's quarterly) Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 20, 2026, revealed the resident 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 range of 12-15 means normal thinking and memory, reflecting little to no cognitive impairment). A review of facility investigative documentation dated May 6, 2026, at 2:30 PM revealed Resident 11 fell from the bed in her room. The documentation description indicated the resident reported she was reaching for an item when the fall occurred. Further review of the documentation indicated the immediate action taken to prevent additional falls included placing a sign instructing the resident to call for assistance. A review of facility investigative documentation dated May 10, 2026, at 2:40 PM revealed Resident 11 experienced another fall in her room and was found seated on the floor. The resident reported she fell while attempting to transfer into bed. Additional review of the documentation indicated that immediate fall prevention measures included the use of a chair clip alarm (small clip that is attached to a person's clothing or belt and connects to an alarm device alert staff of unassisted transfers).A review of the resident's Care Plan Report, revealed a care plan for the resident being at risk for falls due to impaired cognition, impaired coordination, and medication side effects. The care plan was initiated on November 25, 2025, and included the goal of reducing the fall risk. Review of the resident's plan of care revealed the facility failed to review and revise the resident's fall-risk care plan to include the interventions implemented following the falls that occurred on May 6, 2026, and May 10, 2026. An interview was conducted with the Nursing Home Administrator on May 14, 2026, at 10:15 AM to acknowledge the concerns identified with resident care plans.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa Code 211.12(d)(3) Nursing services.

Based on review of select facility policy, clinical records, and staff interview it was determined the facility failed to develop a comprehensive care plan to meet the individualized needs of two residents of 17 residents reviewed (Resident 13 and Resident 16)Findings include:A review of the facility's policy titled Care Plans, Comprehensive Person Centered, adopted February 9, 2026, showed that a comprehensive, person centered care plan must be developed and implemented for each resident. The policy stated that the care plan describes the services necessary to help the residents attain or maintain their highest practicable physical, mental, and psychosocial well being and must reflect currently recognized standards of practice for identified problems and conditions. The policy also specified that resident assessments are ongoing and that care plans must be revised as new information becomes available or as the resident's condition changes.Clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses which included fracture to the neck of the left femur (a break in the leg bone just below the ball of the hip joint).A review of Resident 13's admission Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 26, 2026, revealed that Resident 13 was 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 range of 0-7 indicates severe cognitive decline indicating Resident 13 has significant challenges with memory, orientation, or both).A review of the resident's clinical record revealed a document dated May 7, 2026, entitled, Specialty Physician Wound Evaluation & Management Summary. The documentation indicated the presence of a Stage 3 pressure wound (deep sore that is through all layers of the skin and reached the layer of fat underneath) on the right heel. An observation on May 14, 2026 at 10:00 AM of the resident room included the availability of gowns and gloves for Enhanced Barrier Precautions (an infection control strategy recommended by the CDC for nursing homes and skilled nursing facilities. They mandate the use of gowns and gloves during high-contact resident care to prevent the spread of multidrug-resistant organisms). The observation also included a sign communicating the presence of enhanced barrier precautions and the need for gowns and gloves during high risk activities such as dressing, bathing, transferring, and wound care.A review of the resident's current plan of care revealed the care plan failed to identify the resident's Enhanced Barrier Precaution status and lacked appropriate interventions to address the resident's needs.A clinical record review reveals Resident 16 was admitted to the facility on [DATE], with a diagnosis of acute respiratory failure with hypoxia (sudden inability of the lungs to supply adequate oxygen to the bloodstream, leading to abnormally low oxygen levels). A review of Resident 16's (admission) MDS dated [DATE], revealed that Resident 16 was cognitively intact with a BIMS score of 14 (a range of 12-15 means normal thinking and memory, reflecting little to no cognitive impairment). A clinical record review revealed a physician order dated April 17, 2026, for Enhanced Barrier Precautions due to the presence of an indwelling catheter (soft, flexible tube designed to stay in place inside the bladder and continually drain urine into a bag).A review of the resident's current plan of care revealed the care plan failed to identify the resident's Enhanced Barrier Precaution status and lacked appropriate interventions to address the resident's needs.An interview was conducted with the Nursing Home Administrator on May 14, 2026, at 10:15 AM to acknowledge the concerns identified with resident care plans.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa Code 211.12(d)(3) Nursing services.

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 in accordance with 42 CFR S483.35 and Pennsylvania Code Title 49, Professional and Vocational Standards, State Board of Nursing, S21.11(c), by permitting registered nurses to access and administer intravenous (IV) medication through an implanted venous port (a surgically placed device located completely beneath the skin that connects directly to a large vein for long-term intravenous therapy) without documented evidence of specialized training and demonstrated clinical competency. This deficient practice occurred for one of six residents reviewed (Resident CR1). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (c) The registered nurse may not engage in areas of highly specialized practice without adequate knowledge of and skills in the practice areas involved. A review of the facility policy titled Implanted Venous Port Accessing, last reviewed April 23, 2025, required that medical personnel who access or de-access an implanted venous port complete additional training and demonstrate proven clinical competency prior to performing the procedure. Clinical record review revealed that Resident CR1 was admitted on [DATE], with diagnoses including malignant neoplasm of the colon (cancer of the large intestine). The resident had a port-a-cath (an implantable vascular access device consisting of a small reservoir with a self-sealing silicone top attached to a catheter that enters a central vein) surgically placed in the upper chest to allow direct access to the bloodstream. Review of Resident CR1's clinical record revealed a nursing progress note dated January 8, 2026, documented that staff were unable to establish a peripheral IV (a short catheter inserted into a vein in the arm or hand for temporary intravenous access) to administer antibiotics. The physician authorized nursing staff to access the resident's port-a-cath using a Huber needle (a specialized non-coring needle designed to puncture the silicone septum of an implanted port without damaging it) to administer intravenous antibiotics. Physician orders dated January 9, 2026, directed staff to administer Ceftriaxone Sodium Injection Solution Reconstituted 250 mg, give 1 gram intravenously once daily for five days for pneumonia (a lung infection that causes inflammation of the air sacs and may fill them with fluid or pus). Review of the January 2026 Medication Administration Record (MAR) (the legal document used by nursing staff to record medication administration, including the date, time, dosage, route, and signature of the administering nurse) showed that from January 9, 2026, through January 13, 2026, Employee 1 (Registered Nurse), Employee 2 (Registered Nurse), and Employee 3 (Registered Nurse) documented administration of the IV antibiotic through the implanted port. Accessing an implanted venous port requires strict sterile technique (methods used to prevent the introduction of microorganisms into sterile body areas) because improper access can introduce bacteria directly into the bloodstream, potentially resulting in a central line-associated bloodstream infection (a serious infection that occurs when bacteria enter the bloodstream through a central venous catheter), catheter occlusion (blockage of the catheter), infiltration (leakage of fluid into surrounding tissue), bleeding, or air embolism (air entering the bloodstream, which can obstruct blood flow and cause serious harm). The facility failed to provide documentation demonstrating that Employee 1, Employee 2, or Employee 3 completed additional training or validated competency specific to accessing an implanted venous port with a Huber needle for medication administration. The facility did not provide evidence of initial or ongoing competency validation (formal documentation showing that a nurse demonstrated the knowledge and technical skill necessary to safely perform a specific clinical procedure), skills checklists, return demonstrations, formal education records, or internal training specific to port-a-cath access. During an interview on February 20, 2026, at approximately 10:50 AM, the Director of Nursing confirmed that the facility did not maintain evidence of education, specialized training, or competency validation for registered nurses administering medications through a port-a-cath using a Huber needle. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review a facility policy entitled Food Receiving and Storage last reviewed by the facility on April 23, 2025, indicated that opened food items would include a use by date and all dry foods and goods should be stored in a manner that maintains the integrity of the packaging until ready to be used and all bulk food item should be removed from their original packaging, placed in bins, and labeled with a use by date. The initial tour of the dietary department conducted on June 28, 2025, at 10:41 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Inside of the cook's reach-in cooler, observed open bottles of chocolate syrup and caramel syrup that did not have an open date noted. In the dry storage room, eight cranberry bowls of pre-portioned cold cereals were not dated. Two crates containing gallon jugs of water were placed in direct contact with the floor. An open package of brown gravy mix was observed without an open date, along with a brown cardboard box containing an opened, unsealed bulk bag of thickener powder with an uncovered ladle resting on top. Further inspection of the dry storage area revealed a dirty hand broom and dusters were stored among food items and pots on the second shelf of a wire rack. In the janitor's closet, two yellow mop buckets containing dirty water and mops were stored with brooms placed across the tops of the buckets. A ceiling fan located in the dish room was noted to be corroded with accumulated dust and debris. Additionally, during the same tour, Employee 1 (dietary staff) was observed using the 3-compartment sink to soak, clean, and sanitize sheet pans and cooking equipment but was unable to locate the litmus strips needed to test sanitizer strength and did not demonstrate knowledge of the proper sanitizing procedure. When tested, during observation by the surveyor, the sanitizer concentration measured 0 ppm (parts per million), whereas proper concentration must be greater than 150 ppm, indicating that no sanitizer was present in the sanitizing sink compartment. Employee 2 (Human Resources Director and former Dietary Manager) then emptied the 3-compartment sink, restarted the cleaning process, and tested the sanitizer concentration, which measured greater than 150 ppm. The facility subsequently developed and implemented a plan to educate dietary staff on correct sanitation procedures for using the 3-compartment sink. On June 30, 2025, at 12:15 PM, during an observation of lunch tray line service, Employee 3 (server) was seen dipping his gloved hands into a red bucket next to a cutting board on a preparation table. When instructed by the food service manager to change gloves, Employee 3 reported it was only sanitizer and immediately handled a pile of Styrofoam containers before applying new gloves. During an interview with the Nursing Home Administrator (NHA) on July 1, 2025, at 10:45 AM, the above observations were confirmed. The NHA acknowledged the dietary department must be maintained in a sanitary manner to prevent potential food contamination and foodborne illness. The above findings were reviewed with the Nursing Home Administrator on July 1, 2025. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on clinical record review and staff interviews, it was determined the facility failed to ensure that residents' drug regimens were free from unnecessary medications by failing to discontinue an unnecessary antibiotic for one resident (Resident 22); failing to provide clinical justification for the use of duplicate antidepressant medications for one resident (Resident 42); and failing to ensure that one resident's (Resident 48) medication regimen was free from unnecessary psychoactive medication, including administering an as-needed antianxiety medication beyond 14 days without adequate clinical justification and without documentation of attempted non-pharmacological interventions, for three of eighteen sampled residents. Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life) and chronic kidney disease (a condition where kidneys are damaged and lose their ability to filter waste and fluids from the blood). A review of a physician order dated May 4, 2025, for Bactrim DS 800-160mg tablets- Give 1 tablet by mouth every morning and at bedtime for Urinary tract infection (an infection in any part of the urinary system, usually caused by bacteria.) for 10 days. A review of a facility policy Antibiotic Stewardship last reviewed by the facility on April 23, 2025, revealed appropriate indications for antibiotic include minimum criterial met for clinical definition of active infection by utilizing McGreer Criterial (a set of definitions used in long-term care facilities to standardize the identification and classification of infections) A review of Resident 22's clinical record revealed a McGreer Criteria Checklist completed on May 5, 2025. The checklist indicated it was reviewed by the medical doctor, director of nursing, and infection control preventionist. The checklist documented that Resident 22 had no urinary tract-related symptoms and did not meet criteria for antibiotic use. A progress note dated May 9, 2025, at 6:08 PM, documented the resident was still receiving oral antibiotic therapy for a urinary tract infection while denying any symptoms. No evidence was found that a urinary specimen was obtained to confirm infection. A review of the Medication Administration Record (MAR) for May 2025 confirmed Resident 22 received twenty (20) doses of Bactrim DS without documentation of a culture or other evidence indicating infection. During an interview with the Director of Nursing on July 1, 2025, at approximately 11:00 AM, the DON confirmed the facility could not provide any additional documentation to support the antibiotic use for Resident 22. A clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnosis to include dementia the loss of cognitive functioning that affects a person's ability to perform everyday activities) and anxiety (a feeling of fear or dread often triggered by stressful situations). Physician orders included Trazodone HCL, 25 mg (antidepressant) by mouth at bedtime for increased depression (initiated February 2, 2025), and Remeron, 7.5 mg (antidepressant) by mouth at bedtime for appetite/depression (initiated January 17, 2025). The clinical record did not include documentation justifying the concurrent use of duplicate antidepressant medications. An interview was conducted with the Director of Nursing (DON) on July 1,2025, to review the above findings related to antidepressant therapy, the DON confirmed there was no clinical justification available for the duplicate antidepressant medications. A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include post-traumatic stress disorder (PTSD a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance of reminders of the trauma; negative cognitions and mood; hypervigilance and sleep disturbance) and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 48's physician orders revealed an order dated February 5, 2025, for Ativan (a benzodiazepine that work by enhancing the activity of certain neurotransmitters in the brain and used to treat anxiety disorders) 0.5 mg by mouth every twenty-four hours as needed (PRN) for agitation during care. Review of Resident 48's electronic medication administration record (eMAR a technology that automates data entry for the administration of medication to patients in healthcare settings and the digital records contain details about the prescribed medication regimen, dosage, timing, and administering staff) dated February 5, 2025, through May 22, 2025, revealed that Ativan was administered on the following dates and times on February 8, 2025, at 1:26 PM, on March 29, 2025, at 5:52 PM, on April 12, 2025, at 6:48 AM, on April 21, 2025, at 10:01 PM, on April 23, 2025, at 10:01 PM, and on May 21, 2025, at 6:02 PM, without documentation that non-pharmacological interventions were attempted before administration. The facility failed to ensure the PRN antianxiety medication order was limited to 14 days and failed to provide documented evidence that the attending physician assessed and justified its continued use. Additionally, the facility could not provide document evidence that licensed nursing staff attempted non-pharmacological interventions prior to administration of a PRN antianxiety/benzodiazepine medication, Ativan. Further review of Resident 48's clinical record revealed a monthly pharmacy review completed by the consultant pharmacist dated April 6, 2025, indicated that the resident had been receiving Prazosin 2 mg by mouth daily (a medication used to treat high blood pressure, symptoms of an enlarged prostate, and nightmares related to post-traumatic stress disorder), Remeron15 mg, give one tablet daily ( medication used to treat a certain type of depression called Major Depressive Disorder in adults), Seroquel50 mg by mouth daily (a psychotropic medication used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder), Risperdal 25 mg by mouth daily ( atypical antipsychotic used to treat schizophrenia and bipolar disorder, as well as aggressive and self-injurious behaviors associated with autism spectrum disorder) and Ativan 0.5 mg, one tablet every twenty-four hours. The consultant pharmacist made the request to the attending physician to review the resident's psychoactive medications and consider an attempted gradual dose reduction (GDR) or trial discontinuation, as deemed appropriate, and if deemed clinically contraindicated to please document the clinical rationale. The clinical rationale must address the reason(s) why an attempted GDR would likely impair the resident's function or cause psychiatric instability, by exacerbating an underlying medical or psychiatric disorder. A review of the physician signed response dated April 22, 2025, revealed to disagree with the consultant pharmacist recommendation and the noted clinical rationale was, depression, PTSD, anxiety will be impaired with a gradual dose reduction. The facility could not provide documented evidence the resident's physician provided sufficient clinical justifications for the continued use of the psychoactive medications. These findings were reviewed with the Director of Nursing on July 1, 2025, at 11:15 AM. The facility could not provide documented evidence to support PRN use of Ativan beyond 14 days, that non-pharmacological interventions were attempted prior to administration, or sufficient clinical justification for the continued use of multiple psychoactive medications. 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of clinical records, select facility policy and staff interview it was determined the facility failed to ensure the pharmacist conducted medication regimen reviews at least monthly for two residents out of five sampled.(Resident 48 and 42). Findings include: A review of a facility policy entitled Medication Regime Reviews last reviewed by the facility on April 23, 2025, indicated the facility's consultant pharmacist conducts monthly medication regime reviews (MRR) for each resident at least monthly. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and re-solve medication related problems, medication errors and other irregularities, for example medications ordered in excessive doses or without clinical indication, medication regimens that appear inconsistent with the resident's stated preferences, duplicative therapies or omissions of ordered medications, inadequate monitoring for adverse consequences, potentially significant drug-drug or drug-food interactions, potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences, incorrect medications, administration times or dosage forms, or other medication errors, including those related to documentation. A review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities) and anxiety (a feeling of fear or dread often triggered by stressful situations). A review of Resident 42' s clinical record conducted at the time of the survey July 1, 2025, revealed no evidence the pharmacist had conducted drug regimen reviews at least once a month between February 2025, and March 2025. A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include post-traumatic stress disorder (PTSD is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance of reminders of the trauma; negative cognitions and mood; hypervigilance and sleep disturbance) and dementia. A review of Resident 48's clinical record conducted at the time of the survey ending July 1, 2025, revealed no evidence the pharmacist had conducted drug regimen reviews at least once a month between February 2025 and March 2025. During an interview with the Director of Nursing (DON) on July 1, 2025, at approximately 11:35 AM, it was confirmed that there was no evidence the pharmacist conducted monthly medication regimen reviews as required for Residents 48 and 42. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of 18 sampled residents (Resident 15). Findings include: A review of facility policy labeled Administering Medications last reviewed April 23, 2025, revealed medication are administered in accordance with prescriber orders including any required time frame. A review of Resident 15's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities). A review of physician's orders dated May 13, 2024, revealed the physician prescribed Lactaid Fast oral Tablet 9000 units (an enzyme used to help break down lactose the natural sugar in milk and dairy products). Give one by mouth with meals for lactose intolerance (inability of the body to digest lactose). A review of the June 2025 medication administration record (MAR) showed that the Lactaid was not administered on June 3,2025 at 8:00 AM. The MAR was coded with a 7 to indicate other/see progress note. Further review of the clinical record revealed no documented evidence to indicate why the medication was not administered. Continued review of the MAR revealed the medication was not administered thirty-three times between the dates of June 3,2025, to June 25,2025, with no documented evidence to indicate why the medication was not administered to the resident. A nursing progress note dated June 28,2025 at 1:20 PM indicated the Director of Nursing (DON) made the MD aware the Lactaid was unavailable for several weeks. Resident only has intolerance to milk and doesn't receive milk on any of his trays. An interview was conducted with the Director of Nursing on Monday June 30,2025 at approximately 10:00 AM to review the above findings related to failure to ensure the timely acquisition and administration of the prescribed medications for this resident. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.9 (f)(2) Pharmacy services.

Based on a review of grievances, select facility policy and resident and staff interviews it was determined the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for one resident out of 5 sampled. (Resident 1) Findings include: A review of the facility policy entitled Grievances/Complaints, dated as reviewed April 29, 2024, revealed, residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Any resident, family or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including rationale for the response. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident or person filling the grievance and/or complaint on behalf of the resident, will be informed, verbally and in writing, of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator, or designee, will make such reports orally within 5 (five) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include a history of falls, anxiety and a need for rehabilitation therapy services. The resident was discharged to home on January 21, 2025. An admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 30, 2024 revealed the resident to have a BIMS score of 13 (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) and required assistance of staff for activities of daily living. A review of Physicians orders dated December 24, 2024, revealed Xanax (antianxiety medication) 1 mg by mouth every 8 hours as needed for anxiety for 14 days. Corresponding medication administration records dated December 2024 indicated that the resident received the as needed Xanax on: December 28, 2024 - 8:55 P.M. December 30, 2024 - 5:03 P.M. December 31, 2024 - 5:53 P.M. January 1, 2025 - 8:55 P.M. January 5, 2025 - 7:16 P.M. January 6, 2025 - 8:00 P.M A review of a grievance lodged by Resident 1, dated January 5, 2025, revealed Resident 1 reported to staff that Employee 3 (RN Supervisor) failed to administer their prescribed Xanax when requested and exhibited unprofessional behavior. This grievance was reported to Employee 1(LPN) and Employee 2 (RN Supervisor) who filled out the grievance form at that time for the resident. The resident stated that on January 4, 2025, at the change of shift (7:30 P.M.), the resident asked Employee 3 (7 P.M. to 7 A.M. RN Supervisor) for a Xanax (antianxiety medication). The staff member did not give the medication to her. The staff member had a very bad attitude. Staff members documented the grievance and noted previous complaints from other residents and staff about Employee 3's behavior, including inattentiveness and inappropriate phone use during shifts. A review of education entitled Conduct and Behavior revealed that Employee 3 (RN Supervisor) received this training in response to the above noted grievance. This education was dated as completed on January 26, 2025. The complaint remarks revealed, Patient was discharged , notified by phone. The resident was discharged home on January 21, 2025. There was no evidence at the time of the survey the resident was notified verbally and in writing within 5 working days, as stipulated in facility policy. During an interview on February 19, 2025, the Director of Nursing (DON) confirmed that the resident and their family were only verbally notified by phone after the resident's discharge on January 21, 2025. No written documentation of the grievance resolution or outcome was provided, violating the facility's policy requiring both verbal and written communication within 5 working days. A review of a facility grievance form dated January 17, 2025, revealed that Resident 1's daughter filed a complaint regarding concerns about the resident's care. The form was completed by Employee 4 (RN Supervisor) and the Assistant Director of Nursing (ADON). However, the grievance form did not provide any additional details about the specific concerns raised by the resident's family. Furthermore, there was no documentation of an investigation conducted by the facility. The plan to resolve the complaint simply stated that staff would receive education on providing proper care. The grievance form indicated the facility considered the complaint resolved on January 17, 2025. Despite this, there was no documented evidence the resident or her family had been informed of the grievance outcome. Additionally, the resident's daughter did not sign any acknowledgment confirming receipt of the facility's response or awareness of the actions taken to address the issue. In an interview conducted with the Nursing Home Administrator (NHA) on February 28, 2025, at approximately 4:00 PM, the NHA was unable to provide documentation confirming the facility had followed up with the resident or her representative in a timely manner. There was also no evidence to show the facility evaluated whether its efforts effectively resolved the grievance. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident rights

Based on observation and staff interview, it was determined that the facility failed to properly dispose of garbage and refuse. Findings include: Observation on August 13, 2024, at 10:20 AM in the presence of the food service director revealed that the facility's dumpster, containing bags of garbage, was not covered. One of the two lids on the dumpster was observed open. There were food containers and debris scattered on the ground surrounding the dumpster. Interview with the food service director at this time confirmed that the dumpster lid was to be kept closed and that the area surrounding the dumpster should be maintained in a sanitary manner. 28 Pa Code 201.8 (e)(2.1) Management

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents reviewed (Residents 51). 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 collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. Review of Resident 51's clinical record revealed admission to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of an incident report dated July 2, 2024, indicated the resident had a skin tear on her right shin measuring approximately 7cm centimeters x 6cm. A review of the resident's physicians orders revealed an order for a wanderguard bracelet (a bracelet that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) due to the resident's risk of elopement. Further review of the physician's order revealed no indication of where the bracelet was to be placed on the resident or to check the resident's skin below bracelet routinely. A review of a nursing progress note dated July 14, 2024, revealed the area on resident's right shin had worsened due to swelling and the wanderguard bracelet digging into the skin on the right shin above the ankle. There was no documented evidence the facility staff assessed that the placement of the wanderguard was appropriate after the resident developed skin tear. The facility failed to monitor the resident's skin where the wanderguard was placed resulting in worsening of the resident's wound. An interview with the Nursing Home Administrator, and the Director of Nursing on August 15, 2024, at 11:10 AM, confirmed the facility failed to evaluate and assess the resident's wanderguard placement had to prevent further injury to Resident 51's skin. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, select facility reports, observations and staff interview it was determined the facility failed to consistently provide care and services to to prevent the development and/or worsening of pressure sores and promote healing for one resident out of 16 residents sampled (Resident 6). 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 Resident 6's clinical record revealed that the resident was admitted to the facility was on June 10, 2022, with diagnoses that included end stage renal disease with dependence on renal dialysis, diabetes, amputation of bilateral legs above the knees and obesity. A review of Resident 6's care plan initiated August 29, 2023, revealed the resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, and history of scratching, with interventions which included encourage and assist to reposition, encourage resident to remove stump socks at bedtime, provide preventative skin care after each incontinent episode and as needed, pressure reduction device on chair, encourage/assist to suspend/float upper legs to keep stumps off pressure surface, and administer preventative skin treatment per physician orders. Review of a facility investigation dated August 3, 2024, at 8:00 PM, revealed that Resident 6 had a wound that was identified in the left groin. According to the event description, the area was a small hole in patient's groin. Slight bleeding was noted. No pain was indicated. The wound tunneled about a half inch inwards, but diameter was too small to pack. Wound was cleansed with normal saline solution and covered with a dry dressing, Further it was indicated a pending assessment will be completed by treatment team. Review of Change in Condition Evaluation form dated August 3, 2024, at 10:01 PM, indicated that Resident 6 stated she did not scratch the site accidentally and she was unaware it was there. The physician was notified and ordered the resident to be seen by treatment team. The facility failed to provide evidence that Resident 6's tunneling wound acquired on August 3, 2024, was evaluated by the facility's treatment team. There was no evidence that the wound was evaluated for size, drainage, or condition of surrounding tissue. According to additional tracking/monitoring of the wound completed by the DON, the open area on Resident 6's left groin was stable, and as of August 12, 2024, the wound measurements were less than 0.1cm x less than 0.1cm and had no depth or drainage. The form further indicated that the resident would be seen by wound care consultant on August 15, 2024. An interview with the Director of Nursing on August 14, 2024, at approximately 11 AM indicated that the initial description of the wound was based on perception and the initial nurse's evaluation of the wound was inaccurate. On August 14, 2024, at approximately 2:30 PM, the Director of Nursing presented surveyor with a paper Wound Evaluation Flow Sheet which was not found in the resident's clinical records initially dated August 3, 2024, which indicated that the wound measured less than 0.1cm x less than 0.1cm and had no depth, despite the documentation that the wound tunneled approximately a half inch. According to the wound evaluation form completed by the Director of Nursing, the wound did not have drainage, and the surrounding tissue was WNL (within normal limits). Observation of Resident 6's left groin on August 15, 2024, at approximately 8:45 AM, in the presence of Employee 1, registered nurse, revealed an open area which measured approximately 1cm x 1cm with visible depth. Employee 1 did not have depth measuring tool at time of observation. The wound bed was deep red, and surrounding tissue was excessively moist with white substance that appeared fungal in the skin folds. There was no treatment in place at time of observation. Review of wound care consultant evaluation completed on August 15, 2024, revealed that the full thickness(damage extends past the epidermis and dermis, and into the subcutaneous tissue, muscle, bone, or tendons) wound in the left groin measured 0.5cm x 1cm x 0.5cm with a moderate amount of serous (clear) drainage, and 100% granulation (healthy) tissue. Recommendation to discontinue current treatment of dry dressing to wound and apply alginate calcium (highly absorbent and non-occlusive dressing that forms a soft gel when in contact with wound drainage) daily with a gauze island with boarder for 30 days. Interview with the Director of Nursing on August 15, 2024, at approximately 2:10 PM, confirmed that the facility failed to properly assess Resident 6's pressure area and implement interventions to prevent worsening and promote healing in a timely manner. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, and staff interview, it was determined the facility failed to address a resident's skin condition on the comprehensive care plan for one out of 16 sampled residents (Resident 23). Findings include: A review of the clinical record revealed Resident 23 was admitted to the facility on [DATE], with diagnoses which include congestive heart failure, cerebrovascular accident (CVA- stroke, interruption in the flow of blood to cells in the brain), and rheumatoid arthritis. A physician order dated June 27, 2024, noted an order to apply Zinc to buttocks every shift for skin protectant/moisture barrier. A wound progress note dated August 1, 2024, indicated the resident's sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis) was assessed and was noted to have MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, or perspiration) of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants measuring 3 cm (centimeters) x 5 cm x 0.1 cm. The area is open with light serous exudate (clear, thin, watery plasma that is a normal part of wound healing). The treatment plan was to apply Zinc ointment twice daily for 30 days. Further recommendations included, limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able. A wound progress note dated August 8, 2024, indicated that the MASD on the resident's sacrum now measures 3 cm x 4 cm x 0.1 cm. the area is open with light serous exudate and noted to be improved. The dressing treatment plan was to continue to apply Zinc ointment twice daily for 30 days. Further the recommendations were to continue to limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able. A review of Resident 23's comprehensive plan of care (a tool used to organize aspects of patient care) conducted during the survey on August 14, 2024, revealed the resident's care plan did not address the resident's moisture associated skin disorder, treatment, and specific interventions to prevent recurrence. Interview with the Director of Nursing on August 14, 2024, at approximately 10:30 AM confirmed the resident received treatment for the MASD, and the MASD was not addressed on the resident's care plan along with preventative measures to address the resident's identified risk factors to promote optimal healing and prevent recurrence. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to timely notify the physician and the resident's representative of an incident with the potential to require physician intervention for one resident out of 16 sampled (Resident 115). Findings include: A review of the facility Change in Resident's Condition or Status Policy last reviewed, June 2024, revealed it is the policy of the facility to promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. A review of the clinical record revealed Resident 115 was discharged from the facility to the hospital on July 27, 2024, and readmitted to the facility on [DATE], with diagnoses which included a urinary tract infection, cerebral infarction (stroke), and seizures. A Midline catheter (a long, thin, flexible tube that is inserted into a vein in the upper arm to safely administer medication or fluids into the bloodstream) was present in the resident's arm upon readmission to the facility. A nurses note dated August 12, 2024, at 5:38 PM noted the Midline catheter was assessed after the flush showed leaking around the dressing. The Midline catheter was dislodged. It was removed and measured eight centimeters. Further it was noted the tubing was intact. The area was cleansed and dressed with a dry sterile dressing and Tegaderm (dressing used to protect catheter sites) was applied. A late entry nurses note dated August 14, 2024 (two days after the incident), noted the physician was notified that the Midline catheter was dislodged, removed, and was intact. Further review of the clinical record revealed no documented evidence the resident's resident representative was notified of the dislodgement and discontinuation of the Midline catheter. An interview with the Director of Nursing (DON) on August 14, 2024, at approximately 11:00 AM failed to provide documented evidence the facility timely notified the resident's attending physician of the dislodgement and removal of the resident's Midline catheter. The DON confirmed there was no documented evidence the resident's resident representative was notified of the dislodgement and removal of the Midline catheter. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to develop and implement effective fall prevention interventions for a resident with known unsafe behaviors to prevent a fall resulting in serious injury, a fractured clavicle, for one out 11 sampled residents (Resident 3). Findings include: A review of Resident 3's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included a history of a fracture of the left femoral neck [is a type of hip fracture of the thigh bone (femur) which is just below the ball of the ball-and-socket hip joint], difficulty walking, and cognitive communication deficit [difficulty with any aspect of communication that is affected by disruption of cognition]. Upon admission the resident had a noted surgical site to her left hip that measured 15.5 cm in length by 2.0 cm in width by 0.0 cm in depth. A review of the resident's baseline plan of care dated November 13, 2023, identified that the resident was at risk for falls due to a fractured hip with impaired mobility with a goal to minimize injuries related to falls. Planned interventions to meet this goal were the use of a bed alarm sensor pad, and to provide assistance with transfers and ambulation as needed. A review of an incident report completed by Employee 4, a registered nurse (RN), dated November 17, 2023, at 9:15 PM, indicated that she heard a thud in Resident 3's room. Employee 4 found Resident 3 sitting on the floor in her room, next to her bed. Employee 5, a nurse aide, reported to Employee 4 that she {Resident 3} was sitting on the side of her bed and tried to get up into her wheelchair, but her knees buckled, and she fell to the ground because the brakes on the wheelchair were not locked. The resident stated, I wanted to pick up the drink I spilled. No injuries were noted and the immediate intervention to prevent recurrence was to educate the resident to always lock her wheelchair brakes when unattended. A review of a witness statement completed by Employee 5, a nurse aide, dated November 17, 2023, at 9:15 PM, revealed that she was doing hall rounds on the short hall when the resident rang (the call bell). Employee 5 stated that When I walked into her {Resident 3} room she was sitting at the side of the bed and told me that she had spilled water in her bed. As I walked to the other side of her bed to assess if it was the just the chuck (incontinence pad) wet or the sheets, too. Then, the resident unexpectedly stood up and then fell to the ground. I couldn't get round the bed fast enough to keep her from falling. Nearby nurse heard the commotion and came immediately into the room to assess the resident and we safely returned her back to bed. No injuries. A review of an incident reported completed by Employee 5, a RN, dated November 18, 2023, at 5:39 AM, indicated that Resident 4 {Resident 3's roommate} reported that Resident 3 fell to the floor on to her buttocks while getting out of bed. The resident denied complaints of pain. The RN assessed the resident, and her vital signs were within normal limits and ROM (range of motion) within normal limits. No injury was noted. Resident 3 stated I just scooted off the bed. Immediate interventions were that the nurse aide assisted the resident back to bed. A review of a witness statement completed by Employee 6, a nurse aide, dated November 18, 2023, at 5:15 AM, revealed that she saw that {Resident 3's} call bell came on and went to answer and saw the resident sitting on the floor. The resident stated, I'm okay, I just needed the bathroom. Call bell was in reach of the resident, but Resident 4 {her roommate} activated her call bell to call for assistance for her {Resident 3}. Bed alarm was not on, but in place. Resident re-educated about call bell position and to press when something was needed. A review of a post-fall investigation form completed by Employee 7, a RN, dated November 18, 2023, revealed that Resident 4 {Resident 3's roommate} observed Resident 3's fall. Resident 3 was last toileted/observed at 5:10 AM. The resident's bed alarm were not sounding. The resident did not use assistive device attempting to toilet self. Employee 7 noted that the resident's fall was related to the bed alarm not sounding, a toileting schedule was needed and the resident's non-complaint behavior with ringing her call bell for assistance. A chair alarm and to maintain bed in the lowest position were added to her plan of care for fall management. A review of Resident 3's clinical record conducted at the time of the survey ending January 3, 2024, revealed no documented evidence that the facility had re-evaluated the resident's current toileting needs and abilities in response to the resident's fall while attempting to self-toilet on November 18, 2023. There was no indication that the facility re-evaluated the efficacy of the bed alarm in preventing falls and timely alerting staff to the resident's unsafe acts. A review of Resident 3's Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) assessment dated [DATE], revealed that Resident 3 was cognitively intact, required a wheelchair and/or a walker as her mobility device, supervision/touch assistance with sit to standing position, supervision/touch with chair/bed-to-chair transfer [ability to transfer to and from a bed to a chair (or wheelchair)], partial to moderate assistance with toilet transfer. The resident was occasionally incontinent of bladder and always continent of bowel with no toileting plan in place. An incident report completed by Employee 8, a RN Supervisor, dated December 1, 2023, at 11:40 PM, revealed that Employee 9, a nurse aide, found Resident 3 sitting in bed with blood on her arm and leg and then alerted Employee 8, RN. Resident 3 stated I started walking with the walker and fell with the walker. The incident investigation revealed that Resident 4 {Resident 3's roommate} reported that she heard a crash and saw that Resident 3 knocked over something and was trying to pick it up. Resident 3 told staff that the roommate's observations were true and then she gave up and went to bed because she was in pain. A review of Employee 9's witness statement dated December 1, 2023, at 11:40 PM, revealed that as she walked out of room [ROOM NUMBER], she noticed that the call bell was on in the bathroom {in Resident 3's room} and went into the room [ROOM NUMBER] and saw {Resident 3} sitting on her bed with an open wound on her left hip and was bleeding. The resident was last observed in her room sitting on the bed at 10:30 PM (one-hour and ten minutes prior). Employee 9 also indicated that the bed alarm had malfunctioned. Employee 9 noticed that there was blood in the resident's bathroom, and her bedside table was flipped over with her bed alarm disconnected. A witness statement completed by Employee 8, RN, dated December 1, 2023, at 11:40 PM, revealed that she was in the middle of getting shift-to-shift report and noted that her {Resident 3} bathroom light was going off, but the nurse aide was there. No alarm was on. Employee 8 entered the room and saw the resident sitting on the side of her bed, bare foot, and was bleeding from a 3-inch area that opened on her left hip surgical incision on the bottom. Employee 8 observed that there was blood tracking from the resident's bathroom and that the resident's bedside table was flipped over. Resident 3's walker was not in reach. Employee 8 noted that Resident 3 was a poor historian but able to say that she hit her shoulder and that it hurt. Employee 8 notified the resident's attending physician and new orders were given to transfer the resident to the emergency department for x-rays and sutures (if needed) to the incision opening. Resident 3's clinical record revealed that the resident sustained a fractured to her left clavicle (collarbone) and required additional sutures to her left hip surgical incision site due to dehiscence (the incision, a cut made during a surgical procedure, reopens) as the result of the fall on December 1, 2023. A review of Resident 3's Treatment Administration Record (TAR - is the report that serves as a legal record of the ordered treatments administered to a patient at a facility by a health care professional) dated December 2023 revealed that on December 1, 2023, at 3:41 PM, was the last time that nursing staff documented that the resident's bed alarm was checked and properly functioning. According to the clinical record Resident 3 had another unwitnessed fall on December 2, 2023, at 9:15 PM. Employee 5, nurse aide, found the resident on the floor in the hallway, near her room, with no clothes on, on the top of blankets. The resident crawled out of her bed and was found in hallway floor with no clothes on. The resident's bed alarm was on the floor, under the resident's bed in her room, and the cord ripped off. Three staff members assisted the resident back to bed via Hoyer lift (mechanical lift). Staff dressed the resident, re-applied her left arm sling (in place due to the fractured clavicle) and a new sterile dressing was applied to her left hip incision site with staples. Employee 5 noted that the resident's bed alarm was not sounding and was last documented as in place and functioning by nursing staff on December 2, 2023, at 4:04 PM. The facility failed to implement effective fall interventions for a resident with known unsafe behaviors of self-transferring to ambulate and toilet herself. The planned safety measures of the use bed and chair alarms were not consistently functional and failed to promptly alert staff to the resident's unsafe actions and prevent the resident's falls and injuries. An interview with the Nursing Home Administrator (NHA) on January 3, 2024, at approximately 2:45 PM, confirmed that the facility failed to provide Resident 3 with known unsafe behaviors with adequate supervision, and effective fall interventions to prevent falls and a right clavicle fracture, and need for sutures to her left hip surgical site. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and select facility investigative reports and staff interview it was revealed that the facility neglected to provide the care necessary to prevent physical harm, a serious injury, a diagnosed fractured neck and possible [CONDITION(S)], sustained during an avoidable fall, by one of six residents reviewed (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's annual (MDS) Minimum Data Set Assessment (a federally mandated standardized assessment tool completed at various intervals to plan resident care) dated April 4, 2021, revealed that the resident was severely cognitively impaired and required extensive assistance of two staff members with all activities of daily living, including bed mobility and transfer. A review of the resident's current comprehensive care plan and Kardex (a desktop file system that gives a brief overview of each patient and is updated every shift, which is the electronic medical information system where staff find care information for residents) in effect at the time of the following incident revealed that Resident 1 required the assistance of two staff members for all activities of daily living (ADLs). A review of a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property and information submitted by the facility dated May 15, 2021, at 7:30 PM revealed that on Saturday May 15, 2021, at 7:30 PM, Employee 1, a temporary nurse aide, was providing PM/Incontinency care to Resident 1. Employee 1 rolled Resident 1 onto her right side and the resident continued to roll off the bed. Employee 1 tried to stop Resident 1 from falling, but was unable to stop the fall. Resident 1 hit the night stand and sustained a bruise to her right cheek. Resident 1 landed on her back. Employee 2 (RN supervisor) came to assess the resident. The physician was notified and orders were received to send the resident to the hospital for evaluation and treatment. The investigative report noted that Resident 1 was an assist of 2 staff for ADLs (activities of daily living), including bed mobility. The resident's family and the county Area Agency on Aging were notified. Employee 1 was suspended pending further investigation. The facility's investigation concluded that Employee 1 provided Resident 1's care independently. The local police and the Pennsylvania Department of Aging were notified of the incident of neglect that resulted in serious bodily injury. The findings of the facility's investigation concluded that Resident 1 was an assist of 2 staff with all ADLs. Employee 1 did not look up the care required in the Kardex or care plan, or ask any other staff about Resident 1's care. Employee 1 admitted to providing care independently. A review of the employee witness statement, dated May 15, 2021, no time indicated, from Employee 1 revealed that Employee 1 stated that, I was care to Resident 1. I rolled her to her side to change her brief. I rolled resident away from me and proceeded to change her brief. While I was changing her, she rolled further away from me. I tried to catch her, but was unable, Resident 1 fell . Further review of the facility's investigation report revealed that Resident 1 was care planned to be an assist of 2 staff for all ADL's. The initial investigation revealed that Employee 1 was providing care independently. Employee 1 was immediately suspended pending further investigation. Facility documentation revealed that Employee 1 did not work after her suspension and was terminated from employment at the facility on May 28, 2021. Review of nursing documentation by Employee 3 (RN Supervisor) dated May 15,2021, at 7:51 PM revealed the employee stated, Called up to second floor for witnessed fall. The resident was lying on her back, in between her bed and her roommates bed in the center of the room. She was alert, she was moving extremities slightly, she was trembling and speaking, calling mama. The resident was assessed on the floor, skin was intact, she was stiff contracting arms, difficult to assess bp (blood pressure), afebrile (no fever), she was moving extremities to touch as she is unable to follow directions due to dementia, PERRLA (pupil, equal, round, reactive to light and accommodation - an eye and neurological evaluation). 02 (oxygen saturation - amount of oxygen in the blood-normal 100%) sat 89%, room air, temp 96.8. She was rolled as a unit slightly to her side to place in Hoyer lift pad, and lifted with neck supported onto the bed, the Physician called and ordered 911 to be called for transport to ER as the aide reported that she did hit her head on the bedside table. Examination of face, and head, with skin intact and no apparent bruising except for small discoloration on cheek bone on right side of face. The resident's, husband Nick, DON (Director of Nursing) called and informed of the fall. Responsible party will meet EMS at hospital. A review of a hospital to skilled nursing facility transfer report dated May 15, 2021, revealed that the resident's discharge condition (from the SNF) was noted as, an elderly female resident from a skilled facility with a history of advanced dementia with behavioral disturbance who was admitted (to the Hosptial) on May 15, 2021, after she fell out of her bed when bathed in her bed. {Resident 1} was noted to have a closed femoral neck fracture status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Advanced dementia with behavioral disturbance, bedbound with drop feet. A review of hospital significant findings included an X-ray of the pelvis dated May 15, 2021, that revealed findings as, A single view of the pelvis interpretation. No prior pelvic films are available for comparison. There is a fracture of the right hip in the region of the femoral neck (the top of the hip). There is significant superior migration of the femoral shaft in relation to the femoral head. Findings: A single cross table view of the right hip is submitted for interpretation. No prior studies are available for comparison. The study is quite limited by technique. The possibility of a fracture cannot be excluded. A CT scan of the pelvis (A computerized tomography [CT] scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do) dated May 16, 2021, revealed a, right subcaptial femoral neck fracture ([CONDITION(S)]) with mild proximal lateral displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the distal fracture fragments with partial resorption (process by which bones are absorbed and broken down by the body) of the right femoral head and right femoral neck fracture fragments. A CT scan of the spine dated May 15, 2021, revealed a minimally displaced fracture of the cervical 7 (neck fracture) vertebral transverse process (The transverse processes of C7 are directed downward and outward). Clinical record review revealed that Resident 1 was readmitted to the facility on [DATE], following hospitalization during which Resident 1 was diagnosed with a minimally displaced left cervical 7, vertebral transverse process (fracture of the neck area) and a right closed femoral neck (hip) fracture, which may be an old fracture from a fall February 7, 2020, which was never repaired. The resident had a soft neck collar in place with every 2 hour checks for skin integrity upon readmission. The resident's pain was to be monitored every 2 hours by nursing staff. Follow up orthopedic appointment in two weeks was to be set up. When interviewed on June 2, 2021, at 1:45 p.m. the Nursing Home Administrator confirmed that Employee 1 had neglected to provide the care planned for Resident 1 for bed mobility by failing to ensure the presence of another staff member and failed to use safe technique during care as evidenced by the employee rolling the resident away from her in bed, resulting in an avoidable fall and serious injury to the resident. 483.13 Resident Behavior and Facility Practices 10-1-1998 Edition 28 Pa. Code 201.18(e)(1) Management Previously cited 1/14/21 28 Pa. Code 201.29(a)(c)(d) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 9/6/19, 2/19/20, 1/14/21

Based on a review of clinical records and select resident incident and event reports and staff interview, it was determined that the facility failed to provide sufficient staff supervision and implement planned safety measures to prevent accidents and serious injury for one resident out of four sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 17, 2016, indicated that the resident required extensive assistance with two staff for most ADLs (activities of daily living), except eating, and was totally dependent with two staff for transfers. The resident was cognitively intact. The resident's plan of care for functional status deficit related to impaired mobility, dated as revised by the facility June 16, 2015, indicated that Resident 1 was dependent for all ADLs and required the use of a Hoyer (brand name) mechanical lift with the assist of two staff for transfers. A review of a Fall Report dated as initiated January 19, 2016, indicated that while out of the facility on an appointment, and during transport in the van, the resident slid out of her wheelchair onto her knees and the resident's left calf was wedged between the seats of the van. The nurse aide contacted 911 who responded and assisted with transferring the resident back to her wheelchair. The resident, at that time did not wish to go to the emergency room , for evaluation. A review of a facility Event Report regarding the above incident indicated that the resident sustained [REDACTED]. The Event Report further stated that Resident 1's care plan indicated that she was to be provided with two person assistance with transfers. The resident required two staff members for transfers and repositioning. However, two staff members were not present with the resident in the van for the outside appointment. A statement provided by Employee 7 (Nurse Aide) and dated January 20, 2016, indicated that while she was driving the van to the resident's appointment, Resident 1 started sliding in her seat. When Employee 7 pulled the van over and unfastened the seatbelt to reposition the resident in her wheelchair, Resident 1 fell to the floor of the van with her legs in a bent position. An interview on January 26, 2016 at 2:45 p.m. with the Nursing Home Administrator and the Assistant Nursing Home Administrator, revealed that it was the facilit's usual practice to send residents, who required two person assistance with repositioning and transfers, to appointments with only one staff member (Nurse Aide) who was also the van driver. These administrative staff members were unable to explain how only one Nurse Aide accompanying the resident on an appointment, would be able to safely assist a resident requiring the assistance of two people, The NHA and ANHA confirmed that this situation was not a safe practice. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 10/14/15, 9/1/15

Based on a review of clinical records, resident incident and event reports and staff interview, it was determined that the facility failed to ensure the use of effective accident prevention interventions and the consistent implementation of planned safety measures to prevent injuries from falls for one resident out of 16 sampled residents (Resident 13). Findings include: A review of the clinical record revealed that Resident 13 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 31, 2013, indicated that the resident was severely cognitively impaired. The resident's BIMS was 5 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired) indicated that the resident had cognitive impairment. The resident required extensive assistance with one person for transfers and required limited assistance with one person assistance with rollator walker (walking frame is a tool for disabled or elderly people who need additional support to maintain balance or stability while walking) for ambulation. The resident was identified at high risk for falls. The resident's plan of care dated July 16, 2013, indicated that the facility planned to ensure the use of the resident's walking aids and provide close observations of her whereabouts. Review of nursing documentation dated September 18, 2013, indicated the resident was having loose stools and had been diagnosed with [REDACTED]. A review of a resident incident/accident report dated October 5, 2013, indicated that the resident slid and fell to the floor trying to use the bathroom. The report indicated that the resident's bed alarm did not sound to alert the staff that she was trying to ambulate without assistance. The resident did not use her call bell to request assistance, according to the report, but was heard yelling and was found on the floor. After this fall, the facility implemented the use of bilateral (both sides) floor mats to be placed on each side of her bed when in bed to prevent an injury if a fall occurred. A review of a resident incident accident report dated October 8, 2013, revealed that at 5:10 PM, the resident's bed sensor pad alarm (pad placed in bed under the resident when the pressure is released the alarm sounds to alert staff that the resident is not on the pad) was sounding and when the nurse arrived the resident was found on the floor lying on her left side at the foot of the bed by the bathroom. The resident was sent to the emergency room and admitted to the hospital with [REDACTED]. A review of the incident accident report and event report submitted to the State Survey Agency failed to indicate that the bilateral fall mats, planned three days earlier to prevent injury due to falls, were in place at the time of this fall. Interview with the Nursing Home Administrator and the Director of Nursing on August 20, 2014, at 1:30 PM, confirmed the lack of evidence that the resident's fall mats were in place at the time of the resident's fall with injury on October 15, 2013, or that the use of the alarms were an effective intervention to prevent falls. 483.25(h) Accidents Previously cited 7/18/13 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing Services. Previously cited 7/18/13, 2/4/14, 4/3/14, 5/1/14

Based on review of facility policies and procedures and clinical records, observation and staff interviews, it was determined that the facility failed to timely identify skin impairment and implement measures to prevent the worsening of pressure sores for one of 16 sampled residents (Resident 51). Findings include: The facility's policy entitled, "Alteration in Skin Integrity" last reviewed by the facility May 2014, revealed that if a wound is facility acquired, the nurse will complete an incident and accident investigation as to the root cause of the wound, and implement interventions as indicated to prevent further breakdown and promote healing. The pressure ulcers that have necrotic or eschar (tan, black or brown) tissue present such that the tissue layers (layers of skin) involved with the pressure ulcer cannot be determined, the pressure ulcer should be classified as unstageable. A Suspected Deep Tissue Injury (SDTI); depth unknown presents as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful---firm, mushy, boggy (soft to touch), warmer or cooler as compared to adjacent tissue (skin). Review of the clinical record of Resident 51 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's Braden score (an assessment tool that determines the risk of pressure sore development) was 16, indicating that the resident was at low risk for the development of pressure ulcers (Braden score 15-18 indicates low risk). Review of a 30 day Minimum Data Set assessment (MDS - a federally mandated standardized assessment tool completed at specific intervals to plan resident care) dated February 14, 2014, revealed that the resident was severely impaired in cognition and decision making, was highly impaired visually and required total assistance from staff for bed mobility. The resident was not at risk for the development of pressure ulcers. Review of the facility's, "Body audit skin check" dated March 8, 2014, revealed that the resident's skin was intact with no open areas noted on that date. There was no documented evidence of any additional weekly body audits completed prior to the discovery of the SDTI on the resident's left heel on March 17, 2014. Review of the facility's, "Pressure Ulcer Weekly Assessment" revealed that on March 17, 2014, a 3 centimeter (cm) x 4 cm Suspected Deep Tissue Injury (SDTI) described as a blackened, purple area with red surrounding skin was found on the resident's left heel. Review of nursing documentation dated March 18, 2014, at 2:11 PM, revealed that the resident had a wound on her left heel measuring 3 cm x 4 cm, dark black area with pink edges intact. The area surrounding the wound site (peri wound) was non blanchable (did not return to a pink color on soft touch). The physician was contacted on March 18, 2014, and an order was received for skin prep (a preparation that protects the skin from further damage) to be applied every shift, to off load the heels (elevate the heels and alleviate pressure) and for an occupational therapy screen for positioning. A nutritional evaluation was sent to the dietitian for further recommendation, nutritionally, to promote wound healing. Interview with the Director of Nursing (DON) on August 19, 2014, at approximately 10:00 AM, confirmed that the last documented body audit completed was on March 8, 2014, and the resident's skin was intact. The DON also verified that the staff were to complete these body audits weekly and document their findings. The DON was unable to explain why the physician was not contacted on March 17, 2014, when the pressure ulcer was first discovered. Interview with Employee 3, Regional Director of Clinical Operations, on August 19, 2014, at approximately 10:30 AM, revealed that the facility's policy was to investigate the cause of the development of pressure ulcers. Employee 3 confirmed that the facility did not conduct an investigation into the cause of the resident's facility acquired pressure ulcer. The facility failed to timely identify changes in skin integrity and implement adequate measures to deter pressure sore development. The facility failed to implement its established procedures by failing to evaluate the circumstances surrounding the resident's skin breakdown. The facility failed to consistently and timely monitor the resident's skin integrity to promptly identify and act upon changes to deter further breakdown. The facility failed to notify the physician promptly to ensure timely treatment for [REDACTED]. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. Previously cited 7/18/13, 2/4/14, 5/1/14 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 7/18/13, 2/4/14, 4/3/14, 5/1/14

Based on clinical record and select policy review and staff and resident interviews, it was determined that the facility failed to provide the necessary care and services, in a timely manner, to promote adequate bowel activity and prevent constipation with resulting pain and discomfort for one of 16 sampled residents (Resident 34). Findings include: A review of the clinical record revealed that Resident 34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. blocked section of the coronary artery and improve the blood supply to the heart). The physician's orders [REDACTED].{eliminating solid waste from the body}) one tablet by mouth as needed for moderate pain every four hours and [MEDICATION NAME] Suppository (medication inserted in the rectum to relieve constipation)10 mg one daily as needed for bowel management. A specific bowel management program or regimen was not ordered for this resident upon admission or included in the resident's comprehensive plan of care. According to the resident's MAR (Medication Administration Record) for the month of July 2014, the resident received [MEDICATION NAME] 5/325 mg four times and in August 2014, more than ten times. An interview with this resident on August 20, 2014, at approximately 10:00 AM, revealed that the resident complained of pain because he was unable to have a bowel movement. The resident stated that about a week ago he was so distraught about not being able to have a bowel movement, that he became angry and began yelling in the hallway of the facility for someone to help him. The resident stated that now he is afraid to leave his room because he feels that he is leaking stool. The resident stated that he was unaware that the pain medication he was taking could potentially cause constipation. A review of the resident's clinical record revealed that the resident is cognitively intact. The resident had a BIMS score of 15 (BIMS-brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) recorded on an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 12, 2014. The nursing documentation dated August 16, 2014, indicated that Employee 2, LPN (Licensed Practical Nurse), was informed at 1:45 PM, on that date, that the resident was having trouble moving his bowels. The resident had stated, "I've been like this for three days and it won't come out." The resident asked for a suppository, which was given on August 16, 2014, at 2:00 PM. The nursing documentation further noted that the resident was heard yelling down the hallway stating, "I need something else this doesn't work." On August 16, 2014, at 2:50 PM, the resident was sitting on the toilet and nursing conducted an assessment and the nurse told the resident to "push." However, the resident replied that he was not going to push and wanted an enema. Nursing noted that the resident proceeded to stand and he was, "given a disimpaction" (removal of stool from the rectum by hand). The resident continued to yell, that he needed help and was in pain. The physician was called and orders for an enema (fluid entered into the rectum to clean out stool) were obtained and administered at 3:00 PM. The physician also ordered [MEDICATION NAME] (fiber laxative) 1 teaspoon with 8 ounces of water twice daily and [MEDICATION NAME] 10mg (stool softener) by mouth twice daily as needed for constipation and to discontinue the [MEDICATION NAME] 5/325 mg. A review of the facility's Bowel/Laxative Protocol dated as reviewed by the facility May 2014, indicated that MOM (Milk of Magnesia-used as a laxative (laxative-medication used to promote bowel movement) to relieve occasional constipation) 30 cc (cubic centimeters= one ounce) daily as needed if no bowel activity after 48 hours; [MEDICATION NAME] 10 mg (milligram) a stimulant laxative suppository (rectally) every fourth day early in the morning if MOM remains ineffective; Fleet enema (lubricant laxative) every fourth day, after suppository ineffective. If the protocol is ineffective for bowel activity, the staff are to inform the physician for further orders. The licensed staff on the 3:00 PM to 11:00 PM tour of duty will check each record daily for resident bowel activity and the need to initiate the bowel protocol. A review of the resident's bowel movement reports revealed that the resident did not have a bowel movement from 10:10 PM, on July 5, 2014 until 12:00 AM, on July 10, 2014. No bowel movement from 10:11 PM, on July 14, 2014 until 4:28 PM, on July 19, 2014. No bowel movement from 12:51 PM, on July 24, 2014 until 1:54 PM, on August 3, 2014. No bowel movement from 8:18 PM, on August 12, 2014 until August 16, 2014, at 3:00 PM, after the enema was administered. A review of the resident's August 2014, MAR indicated [REDACTED]. The bowel protocol was not implemented after the resident had no BM for periods of five days or more. Interview with the Assistant Director of Nursing (ADON) on August 20, 2014, at approximately 11:30 AM, failed to provide evidence that the facility implemented its established bowel protocol for this resident. The facility failed to monitor this resident's bowel activity until the resident complained of significant pain and distress requiring the manual removal of stool from the resident's rectum. 483.25 Quality of Care Previously cited 7/18/13, 2/4/14, 5/1/14 28 Pa. Code 211.10(a)(c)(d) Resident care policies. Previously cited 7/18/13, 2/4/14, 5/1/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 7/18/13, 2/4/14, 4/3/14, 5/1/14

Based on a review of clinical records, facility event reports (incident/accident reports) and an Event Report submitted to the State Survey Agency, observation and staff and resident interview, it was determined that the facility failed to implement planned interventions to prevent an accident with injury for one of 15 residents sampled (Resident 2). Findings include: Resident 2's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance of one person with most activities of daily living and was totally dependent on two person physical assistance for bed mobility. A review of a facility event report (incident/accident report) dated March 31, 2013, indicated that Resident 2 was found "half in and half out of the bed." Documentation on the event report indicated that the resident stated he "rolled out of bed." The facility's corrective action planned in response to this incident was a therapy evaluation and bilateral floor mats. A review of Section J (fall management) of the resident's Care Plan with dates of review noted as January 16, 2013, January 26, 2013, and April 29, 2013 indicated that the resident was to have bilateral safety mats. The resident's plan of care for fall risk did not include the placement of the resident's bed in the low position. A review of the nursing notes in the resident's record, dated April 28, 2013, revealed that at 12:45 a.m. the resident was found on his right side, on the floor, next to the resident's bed. An addendum in the resident's clinical record, dated April 28, 2013, indicated that the resident's right wrist and hand were swollen and purple and that the resident was transferred to the emergency room for evaluation. He was diagnosed at the emergency room with a right wrist fracture. He was treated and sent back to the facility with a soft cast in place. A review of the facility event report dated April 28, 2013, indicated that Resident 2 was found lying on his right side, next to the left side of the bed. The event report further indicated that the resident had a history of [REDACTED]. During an interview with Resident 2 on July 18, 2013, at 10:40 a.m., the resident stated that on April 28, 2013, at the time that the resident fell from bed and fractured his wrist, the floor mats were not in place. An observation was made on July 18, 2013 at 9:30 a.m. of Resident 2 while he was in bed in his room. The resident was observed sitting up in bed, the entire bed was observed to raised off the floor to waist level (not low position). There were no fall mats observed on either side of the resident's bed nor were there any fall mats located in the resident's room. An interview with the Director of Nursing (DON) on July 18, 2013 at approximately 9:32 a.m. confirmed that the resident was to have fall mats on the floor when he was in bed. The DON confirmed that the fall mats were not in place on July 18, 2013 and that the resident's bed was in an elevated position, increasing his risk for injury in the event of a fall from bed. The DON stated that after breakfast the resident's bed should have been placed in a low position. The director of nursing further stated that she failed to notice on the event report dated April 28, 2013, that the resident's fall mats were not in place when the resident fell and sustained a fractured wrist and did not investigate why the planned intervention was not in place. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services Previously cited 8/10/12

Based on a review of clinical records, facility policy and procedures and staff interview, it was determined that the facility failed to effectively monitor and assess the adequacy of fluid intake and implement timely and adequate measures to maintain sufficient fluid intake and prevent dehydration for one of 10 residents reviewed (Resident 52). Findings include: A review of the facility's Intake and Output Protocol reviewed/revised June 6, 2011, revealed that residents who would be at risk for dehydration (condition that occurs when you lose more fluid than you take in, and your body does not have enough water and other fluids to carry out its normal functions) are those with: -impaired decision making ability, [MEDICAL CONDITION] (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), cognitive deficits (also known as cognitive impairment describes any characteristic that acts as a barrier to mental processing performance), dementia (symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning); functional impairments that make it difficult to drink; difficulty reaching for fluids; difficulty communicating fluid needs; those requiring assistance with eating, drinking, transfers or ambulation; those with balance or gait concerns; limited range of motion or loss of movement, hand dexterity limitations or difficulty grasping a cup; those with oral/nutritional risks to include being unaware of the need to intake sufficient fluids, refusing fluids; health conditions, which include internal bleeding; medications/treatments including laxatives (products used to increase bowel activity), enemas (procedure which introduces liquids into the rectum and colon via the anus to promote a bowel movement), antipsychotics (class of medicines to treat [MEDICAL CONDITION] and other mental and emotional conditions), hypnotics and sedatives (tranquilizers and sleeping pills). The protocol noted that residents' risk factors for dehydration are identified during the assessment process and ongoing, and will be documented in the clinical record and outlined on the resident's care plan. The care plan will outline the risk factors for dehydration and preventative measures. According to the protocol the resident's fluid requirements/needs are to be calculated/assessed by the Dietitian during the admission assessment, quarterly and with any significant change in status. The facility will monitor intake/output as indicated for the following: - residents who present with recent onset of decreased by mouth intake; acute conditions; exacerbation of health condition or decline in status, which placed the resident in a high risk category for dehydration as deemed necessary by nursing or dietary professionals. Clinical record review revealed that Resident 52 was admitted to the facility on [DATE], and had multiple [DIAGNOSES REDACTED]. According to an admission MDS (Minimum Data Set Assessment is a periodic assessment of the resident's status and care needs) assessment dated [DATE], the resident is rarely/never understood, sometimes understands others, has short/long term memory problems, has signs/symptoms of [MEDICAL CONDITION], to include inattention and disorganized thinking, has physical and behavioral symptoms directed toward others, requires extensive to total assistance for activities of daily living (i.e., bathing, dressing, grooming, eating, toileting), has balance problems, is on a mechanically altered (texture and consistency of foods prepared in a manner to allow minimal chewing and ease of swallowing) and therapeutic (prescribed to treat a medical disease or symptom) diet. A review of laboratory values obtained on August 11, 2011, revealed the following lab values utilized to assess hydration status and/or kidney function were: Sodium 144 (normal-136-144 mmol/L), Chloride 113 (normal- 101-111 mmol/L), BUN (blood urea nitrogen)18 (normal-8-26 mg/dl), and Creatinine 0.7 (normal-0.6-1.2 mg/dl). A review of a "Nutritional Assessment" dated August 12, 2011, revealed that the resident's fluid requirements were 1591-1937 cubic centimeters /24 hours and that his oral intake of food was 26%-75%. His intake of fluids was noted as "accepted." According to a "Nutrition Progress Assessment" dated August 30, 2011, it was revealed that the resident was averaging 50-100% meal completion and the resident's average fluid intake was noted as "accepted." The next documented nutritional progress note was not until October 25, 2011. A review of a "Nutritional Progress Note" dated October 25, 2011, revealed that nursing requested Resource 2.0 (nutritional supplement) three times daily as a supplement due to the resident's decreased meal intakes. There was no documented evidence that the Dietitian had consistently monitored the resident's fluid intake or evaluated the adequacy of the resident's intake in meeting his hydration needs as a result of nursing's request for nutritional support. A review of his meal intake records for the month of October 2011, revealed that he was consuming 100 percent of his meals, however, there was missing documentation for meal consumption, once on October 15, 16, and 22, 2011, and twice on October 4 and 17, 2011. An interview with the Acting Director of Nursing on November 9, 2011, at 2 PM, revealed that the facility was unable to provide clarification regarding the discrepancy between the documented meal intake records and the reason noted in the Nutritional Progress Note of October 25, 2011, for the initiation of the Resource (poor meal intakes). A review of the resident's Resource 2.0 consumption records from October 26 until October 31, 2011, revealed that the resident was consuming 50-100%. There was missing documentation for the percentage of consumption of this supplement for the entire day on October 29, 2011, and once on October 31, 2011. According to nursing documentation dated October 24, 2011, at 3:00 PM, and October 25, 2011, at 2:45 PM, the resident's meal intakes were poor. There was no documented evidence that his fluid intake was consistently monitored upon nursing's identification of poor meal intake. Nursing documentation dated October 31, 2011, at 5:20 PM, revealed that when the resident's spouse attempted to feed the resident he could not be aroused, despite several attempts made by the spouse and the nurse. The Registered Nurse Supervisor assessed the resident. The resident's physician was called and ordered that the resident be sent to the Emergency Department. The resident was subsequently admitted to the hospital. A review of the resident's history and physical from this hospital admission revealed that the resident was transferred from the nursing care facility to the hospital due to his lethargy. He was not responding well to verbal commands. He had been drowsy for the last two days. Per the resident's spouse, he was not eating or drinking well for the last two to three days and for the last couple of days he had not been walking around and had been lying in bed most of the time sleeping, he was hard to arouse and very drowsy. According to this hospital report the resident had the following laboratory values: Sodium 161(normal-136-144 mmol/L), Potassium 4.5 (normal-3.5 - 5.1 mmol/L), Chloride more than 130 (normal-101-111 mmol/L), BUN 125 (normal 8-26 mg/dl), Creatinine, 3.4 (normal-0.6-1.2 mg/dl). (These abnormal laboratory values are indicative of dehydration and the sodium, chloride and BUN were noted at critical levels). The report also noted that he would be admitted to the telemetry (connecting the patient to machines that measure heart rate, blood pressure, breathing rate, blood-oxygen level and electrocardiogram information) unit with the [DIAGNOSES REDACTED]. A review of the hospital discharge summary indicated that the resident was found at the facility to be not responding well and lethargic. By the time the resident was brought into the emergency department he was in acute [MEDICAL CONDITION] and had critical levels (laboratory values). He was admitted to telemetry and given IV (intravenous) hydration. The discharge plan was noted that he will receive a pureed diet (foods are blended until smooth) with nectar thick liquids (liquids are thickened to a nectar like consistency to facilitate safe swallowing) and that he should be offered frequent liquids to prevent dehydration. A review of subsequent laboratory values determined from blood that was drawn on November 9, 2011, following IV hydration at the hospital, revealed the following: Sodium 145(normal-136-144 mmol/L), Chloride 114 (normal-101-111 mmol/L), BUN 8 (normal 8-26 mg/dl), and Creatinine 0.7 (normal-0.6-1.2 mg/dl). The resident had several of the criteria identified in the facility policy that placed the resident at risk for dehydration, (dementia, impaired decision making, cognitive deficits, decreased meal intake and feeding assistance) but the facility failed to provide evidence that the resident's risk for dehydration was accurately identified and sufficient measures developed and implemented to maintain adequate hydration. review of the resident's medical record revealed [REDACTED]. to the facility on [DATE], following hospitalization and treatment for [REDACTED]. 28 Pa Code 211.5(f)(g)Clinical records. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan Previously cited: 9/9/11. 28 Pa. Code 211.6(d) Dietary services 28 Pa Code 211.12 (c)(d)(3)(5)Nursing services. Previously cited: 9/9/11, 10/18/11.