Every finding on record at Millcreek Manor

Based on review of clinical records, resident and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of one residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 5/19/25, with diagnoses that included bladder cancer, diabetes, pain, high blood pressure and muscle wasting. Resident R1's clinical record revealed physician's orders, dated 1/26/26, that the resident was scheduled for a colonoscopy on 3/18/26, and directed that the resident's Aspirin be held for five days prior to the procedure. During an interview on 3/28/26, from approximately 10:00 a.m., through 11:30 a.m. Resident R1 revealed that the colonoscopy procedure scheduled to be done on 3/18/26, had to be canceled because the facility nursing staff failed to hold the daily Aspirin and continued to administer the medication daily up to the day of the scheduled procedure. During interview on 3/28/26, at approximately 12:15 a.m., the Nursing Home Administrator confirmed that the physician's orders were not followed and nursing staff did not hold Resident R1's Aspirin prior to the scheduled colonoscopy procedure and as a result the procedure had to be canceled 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 201.18(b)(2) Management

Based on review of facility policy and staff and resident interviews, it was determined that the facility failed to ensure resident's privacy rights by opening residents' mail/delivered packages without resident consent for one of one residents reviewed (Resident R1). Findings include: A facility policy entitled Mail/Package Screening revealed that delivered items would be opened by the facility upon written consent from the resident. The policy also made reference to residents' right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the resident, including those delivered through a means other than a postal service. During an interview on March 28, 2026, from approximately 10:00 am through 11:30 a.m. Resident R1 revealed that facility staff, at the direction of a previous administrative staff person, were opening packages delivered to the resident without his/her consent, and that the previous staff person explained that since the packages were not always delivered by the U.S. Postal Service he/she did not have the right to receive deliveries unopened. During interview on March 28, 2026, at approximately 12:10 p.m., the Nursing Home Administrator confirmed that Resident R1's deliveries were opened previously without the resident's knowledge or permission. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of eight residents reviewed for hospitalization (Residents R1, R56, R58, and Closed Record Resident CR149). Findings include: Review of a facility policy entitled Transfer or Discharge, Facility - Initiated, dated January 2026, indicated that should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: basis for the transfer or discharge, contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other information necessary to meet the resident's needs. Resident R1's clinical record revealed an admission date of 2/18/25, with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), pneumonia (inflammation and fluid in your lungs caused by bacteria, viral, or fungal infection causing symptoms such as cough, chills, fever, and difficulty breathing), and high blood pressure. Resident R1's clinical record revealed a progress note dated 10/17/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R56's clinical record revealed an admission date of 5/10/18, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs), and dementia (loss of cognitive functioning affecting a person's memory and behaviors). Resident R56's clinical record revealed a progress note dated 12/4/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R58's clinical record revealed an admission date of 2/26/21, with diagnoses that included anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and blindness in right and left eye. Resident R58's clinical record revealed a progress note dated 10/7/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident CR149's clinical record revealed an admission date of 8/12/25, with diagnoses that included extradural and subdural abscess (serious infections that occur in the spaces surrounding the brain and spinal cord), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident CR149's clinical record revealed a physician order dated 8/18/25, indicating to send Resident CR149 to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. During an interview on 1/22/26, at 2:09 p.m. Director of Nursing confirmed that Residents R1, R56, R58, and CR149's clinical records lacked evidence that necessary clinical information was communicated to the receiving health care provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation for one of 28 residents reviewed (Closed Record Resident CR149). Findings include: Review of a facility policy entitled Charting and Documentation dated January 2026 indicated All services provided to the resident, progress toward the care plan goals, or any change sin the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy further sated The following information is to be documented in the resident medical record: Objective observations, Medication administration, Treatment or services performed, Changes in the resident's condition, Events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals or objectives. Resident CR149's clinical record revealed an admission date of 8/12/25, with diagnoses that included extradural and subdural Abscess (serious infections that occur in the spaces surrounding the brain and spinal cord), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident CR149's clinical record progress note dated 8/18/25, at 1:01 p.m. revealed Single lumen PICC [Peripherally Inserted Central Catheter - a long, flexible catheter inserted into a vein in the upper arm, used for prolonged intravenous access to deliver medications, fluids, and nutrition] line #5 French noted to RUE [right upper extremity]. Receiving a continuous infusion. Old dressing removed. Line noted with good blood return. Flushes easily. Good blood return. Line measures 3 centimeters from insertion site. Old, dried blood in small amount at insertion site noted. Denies pain. Flushed with 10 ml [milliliters] ns [normal saline]. Insertion site with some pink noted. New dressing applied. Taped in place. Tol [tolerated] well. A physician's order dated 8/18/25, at 1:20 p.m. revealed Send to [local hospital emergency department] due to hypotensive episodes [sudden drop in blood pressure] and persistent hypokalemia [low potassium], patient agreeable. A progress note dated 8/25/25, at 6:46 p.m. and 6:47 p.m. revealed medication orders were entered. A progress note dated 8/26/25, at 12:58 p.m. from Resident CR149's physician revealed Patient was transferred to [local hospital] on 8/18/25, due to hypotension with lightheadedness and returned to [the facility] on 8/25/25. Resident CR149's clinical record progress notes lacked evidence of Resident CR149 experiencing a hypotensive episode including lightheadedness on 8/18/25, assessment of Resident CR149, notification of his/her physician and resident representative, Resident CR149 leaving the facility, and outcome of emergency room visit. During an interview on 1/23/26, at 9:56 a.m. Regional Director of Clinical Services and Director of Nursing confirmed that Resident CR149's clinical record progress notes should be present indicating Resident CR149 experienced an episode, assessment of that episode, physician and resident representative notification, leaving the facility, and outcome of the emergency room visit and that Resident CR149's clinical record progress notes lacked evidence of this information. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a resident was free from significant medication errors for one of seven residents reviewed (Resident R1). Findings include: Review of a current facility policy entitled Management of Hypoglycemia revealed that nursing staff must notify the physician if the resident has signs of hypoglycemia [low blood sugar] that are not resolved by following the facility protocol for hypoglycemia management. Resident R1's clinical record revealed an admission date of 12/07/21, with diagnoses that included diabetes (condition of improper blood sugar/insulin levels), pancreatectomy (removal of the pancreas), and Hodgkin's lymphoma (cancer of the immune system). Resident R1's clinical record revealed a physician's order dated 8/22/25, for Lispro (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) three times daily (9:00 a.m. 1:00 p.m. and 6:00 p.m.) for diabetes. Hold if BS (blood sugar) is below 270 [milligrams/deciliter (mg/dL)]. Resident R1's October 2025, Medication Administration Record (MAR) revealed that Resident R1 had a BS of 257 mg/dL on 10/6/25 at 1:00 p.m. and BS of 157 mg/dl on 10/6/25 at 6:00 p.m. and staff administered the Lispro 3 units, which should have been held according to physician's orders. Lispro insulin was administered and not in accordance with physician's orders when Resident R1 was administered 3 units of Lispro when his/her BS was below 270 mg/dL on the above date and times and should have been held. During an interview on 10/13/25, at approximately 11:55 a.m. the Director of Nursing confirmed that Resident R1's Lispro insulin was administered on 10/6/25 at 1:00 p.m. and on 10/6/25 at 6:00 p.m. when it was ordered to be held. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to follow physician's orders regarding the administration of insulin for one of five residents reviewed (Resident R1). Findings include: A facility policy entitled Administering Medications dated 11/12/24, indicated that medications are administered in accordance with prescriber orders. Resident R1's clinical record revealed an admission date of 5/19/21, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), Hodgkin lymphoma (cancer of the immune system) and Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R1's clinical record revealed a physician's order dated 3/8/25, for Insulin Lispro (a hormone that works by lowering level of glucose [sugar] in the blood) inject 3 units subcutaneously (sq - between the skin and muscle) after meals. Hold for BG (blood glucose) below 270. Resident R1's June 2025 Medication Administration Record (MAR) revealed that on 7/14/25, at 6:00 p.m. Resident R1's BG results were 212 mg/dL [milligrams/deciliter] and he/she received Insulin Lispro injection into his/her right arm when the Insulin Lispro was to be held per physician orders. During an interview on 7/29/25, at 3:12 p.m. Corporate Registered Nurse (RN) confirmed the clinical record indicated Resident R1 received his/her Insulin Lispro on 7/14/25, at 6:00 p.m. with a BG of 212 and per physician orders it was not to be given. Resident R1's clinical record revealed a physician's order dated 3/15/25, and 7/4/25, for Free Style Libre (a small sensor placed in the back of your arm so the device can continuously monitor your blood sugars) every 3 hours. A physician's order dated 5/5/25, and again 7/4/25, for Insulin Lispro inject 1 unit sq as needed for hyperglycemia (unusually high amounts of glucose are in the blood) if blood sugar (BS) is greater than 400 mg/dL and Insulin Lispro inject 2 units sq as needed for hyperglycemia if blood sugar is greater than 500 mg/dL. Resident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 12:00 a.m. with no evidence of insulin administration per physician's orders:6/13/25 413 mg/dL6/17/25 465 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 3:00 a.m. with no evidence of insulin administration per physician's orders:6/17/25 435 mg/dL7/18/25 469 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 6:00 a.m. with no evidence of insulin administration per physician's orders:6/17/25 500 mg/dL6/28/25 435 mg/dL7/19/25 406 mg/dL7/27/25 No resultsResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 9:00 a.m. with no evidence of insulin administration per physician's orders:7/05/25 473 mg/dL7/06/25 436 mg/dL7/07/25 523 mg/dL7/10/25 487 mg/dL7/18/25 498 mg/dL7/19/25 444 mg/dL7/26/25 474 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 12:00 p.m. with no evidence of insulin administration per physician's orders:7/07/25 416 mg/dL7/23/25 427 mg/dL7/26/25 490 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 1:00 p.m. with no evidence of insulin administration per physician's orders:7/07/25 460 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 6:00 p.m. with no evidence of insulin administration per physician's orders:7/06/25 469 mg/dL7/07/25 460 mg/dL7/09/25 404 mg/dL7/19/25 460 mg/dL7/20/25 418 mg/dL7/22/25 421 mg/dLResident R1's MAR revealed the following BS results for 6/13/25, through 7/29/25, at 9:00 p.m. with no evidence of insulin administration per physician's orders:7/05/25 479 mg/dL7/12/25 420 mg/dL7/15/25 459 mg/dLDuring an interview on 7/29/25, at 3:32 p.m. Corporate Registered Nurse (RN) confirmed the clinical record lacked evidence of as needed physician's order for blood sugars above 400 mg/dL and 500 mg/dL being followed stating the order may be confusing to some nurses, which may be the reason and clarification should be obtained. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to physician notification for one of five residents reviewed (Resident R17).Findings include: Review of facility policy entitled Charting and Documentation dated 11/12/24, indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's conditions and response to care. The policy further stated that documentation of procedures and treatments will include care-specific details, including notification of family, physician, or other staff, if indicated. Resident R17's clinical record revealed an admission date of 10/9/24 with diagnoses that included Alzheimer's disease (a brain disorder that destroys memory and thinking skills), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R17's clinical record revealed a physician's order dated 11/20/24, for Insulin Lispro sliding scale before meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m., and bedtime at 9:00 p.m. Physician's order further indicated that if BS [blood sugar] results are 401+ [and greater] to administer 12 units of insulin and call MD (physician). Resident R17's July 2025 Medication Administration Record (MAR) revealed Resident R17's BS at 11:30 a.m. on 7/18/25, was 486 mg/dL, at 4:30 p.m. on 7/4/25, was 430 mg/dL, and at 9:00 p.m. on 7/25/25, was 422 mg/dL and on 7/28/25, was 538 mg/dL. Further review of Resident R17's clinical record lacked evidence of physician notification in accordance with physician orders. During a telephone interview on 7/30/25, at 2:50 p.m. the Nursing Home Administrator (NHA) stated the facility often will text a physician per their preferences on the supervisor's phone. NHA confirmed the supervisors phone containing text messages to the physicians are not part of the resident's permanent clinical record and the clinical record for Resident R17 lacked evidence that the physician was notified in accordance with physician's orders. 28 Pa. Code 211.5(f)(ii)(iii) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a resident was free from significant medication errors for one of ten residents reviewed (Resident R1). Findings include: Review of a current facility policy entitled Management of Hypoglycemia revealed that nursing staff must notify the physician if the resident has signs of hypoglycemia [low blood sugar] that are not resolved by following the facility protocol for hypoglycemia management. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (condition of improper blood sugar/insulin levels), pancreatectomy (removal of the pancreas), and Hodgkin's lymphoma (cancer of the immune system). Resident R1's clinical record revealed a physician's order dated 2/27/25, for Lispro (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the morning (9:00 a.m.) for diabetes. Hold if BS (blood sugar) is below 270 [milligrams/deciliter (mg/dL)]. Resident R1's February 2025, Medication Administration Record (MAR) revealed that Resident R1 had a BS of 267 mg/dL on 2/13/25, and staff administered the Lispro 3 units, which should not have been given according to physician's orders. Lispro insulin was administered and not in accordance with physician's orders and Resident R1 was administered 3 units of Lispro when his/her BS was below 270 mg/dL on the above date and times and should have been held. Resident R1's clinical record revealed a physician's order dated 2/27/25, for Glucagon (type of sugar) intramuscular injection (IM) to be given if blood sugar is less than 90 mg/dl. Resident R1's February 2025 MAR revealed that Resident R1 had a BS of 100 mg/dL on 3/15/25 at 12:03 p.m., and staff gave the injection of Glucagon when the medication was ordered to be held. There was no documentation in the Resident R1's clinical record to indicate that they were experiencing symptoms related to hypoglycemia, such as reporting that they were feeling cold, clammy, or experiencing light headedness and no recorded communication with the physician. Glucagon IM was administered and not in accordance with physician's orders and Resident R1 was administered Glucagon IM when BS was above 90 mg/dl when it should not have been given. During an interview on 3/25/25, at approximately 12:55 p.m. the Regional Director of Nursing confirmed that Resident R1's Lispro insulin was administered on 2/13/25 at 9:00 a.m. when it was ordered to be held and on and Glucagon IM was administered on 2/13/25 at 12:03 p.m. when it was ordered to not be administered. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 26 residents reviewed (Resident R121). Findings include: A facility policy entitled Advance Directives dated [DATE], indicated The Director of Nursing services . of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care. and The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Resident R121's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and hypertension (high blood pressure). Review of Resident R121's clinical recorded revealed a POLST dated [DATE], signed by the physician for Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest)- Full Code. Review of physician's orders revealed an order dated [DATE], for Do Not Attempt Resuscitation (DNR- allow natural death). Review of Resident R121's care plans revealed a care plan with a focus of Advanced Directives Full code with Interventions to initiate CPR. During an interview with the Director of Nursing on [DATE], at 2:45 p.m. he/she confirmed Resident R121's physician's orders, POLST, and care plan were not consistent with each other. He/she also confirmed that Resident R121's physician's orders, POLST and care plan should reflect Resident R121's Advance Directive wishes and be consistent with each other. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R58). Findings include: Review of facility policy entitled Antipsychotic Medication Use dated 11/12/24, revealed Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Review of Resident R58's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, major depressive disorder, and cognitive communication deficit. The clinical record revealed that on 8/28/24, Resident R58's physician ordered Hydroxyzine (a medication ordered to treat anxiety) 10 milligrams (mg) every 24 hours PRN for anxiety. Review of Resident R58's December 2024 and January 2025 Medication Administration Record revealed that the PRN Hydroxyzine was used on 12/03/24, 12/09/24, 12/11/24, 12/17/24, 12/21/24, 12/30/24, 1/02/25, 1/06/25, 1/08/25, 1/14/25, 1/18/25, 1/19/25, and 1/20/25. Resident R58's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Hydroxyzine for the six administrations in December 2024 and for the seven administrations in January 2025. During an interview on 1/23/25, at 2:45 p.m. the Director of Nursing confirmed that Resident R58's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store schedule II-V medications in a separately locked, permanently affixed compartment in one of four medication rooms reviewed (3 West) and the facility failed to appropriately discard outdated medications for one of four medication rooms reviewed (2 West). Findings include: Review of facility policy entitled Medication Labeling and Storage dated [DATE], indicated Controlled substances . and other drugs subject to abuse are separately locked in permanently affixed compartments . and Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days . Review of manufacturer's guidelines revealed that an open vial of Lispro Insulin (medication to treat diabetes and control blood sugar) must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on [DATE], at 1:15 p.m. of the 3 [NAME] medication room revealed a bottle of liquid Lorazepam (a controlled antianxiety medication) lying on the top shelf of the refrigerator. The Lorazepam was not in a separate locked permanently affixed container in the refrigerator allowing the Lorazepam to be removed from the refrigerator. During an interview with Licensed Practical Nurse (LPN) Employee E1 on [DATE], at the time of observation, he/she confirmed the bottle of Lorazepam was lying on the top shelf in the refrigerator and was not in a separate locked permanently affixed container. He/she also confirmed that the Lorazepam should be in a separate locked permanently affixed container. Observation of drug storage on [DATE], at 1:30 p.m. of the 2 [NAME] medication room revealed an open vial of Lispro Insulin in the refrigerator with an expiration date of [DATE]. During an interview with LPN Employee E2 on [DATE], at the time of observation, he/she confirmed that the open vial of Lispro Insulin had an expiration date of [DATE]. He/she also confirmed that the open expired vial of Lispro Insulin should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that it was free from significant medication errors for one of five residents reviewed (Resident R1). Findings include: Review of a facility policy entitled Person Centered Medication Administration dated 3/1/24, revealed that nursing staff must comply with person centered medication pass time ranges and Medication Administration Record (MAR) directions. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, pancreatectomy (removal of the pancreas), and Hodgkin lymphoma (cancer of the immune system). Resident R1's clinical record revealed physician's order dated 4/4/24, for Lantus (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the evening (6:00 p.m.) for diabetes. Hold if BS (blood sugar) is below 150 [milligrams/deciliter (mg/dL)]. Resident R1's August 2024 MAR revealed that Resident R1 had a BS of 226 mg/dL on 8/17/24, and staff failed to administer the Lantus 3 units as ordered. Resident R1's clinical record revealed physician's order dated 4/04/24, for Novolog (type of insulin) 100 Units/ml inject 3 units sq in the morning (9:00 a.m.) for diabetes. Hold if BS is below 280 mg/dL. Resident R1's August 2024 MAR revealed that Resident R1 had a BS of 215 mg/dL on 8/18/24, and staff failed to hold the Novolog 3 units as ordered. Resident R1's clinical record revealed physician's order dated 4/04/24, for Novolog inject 3 units sq in the afternoon (1:00 p.m.) for diabetes. Hold if BS is below 280 mg/dL. Resident R1's MAR revealed that Resident R1 had a BS of 247 mg/dL on 8/18/24, and staff failed to hold the Novolog 3 units as ordered. During an interview on 9/4/24, at approximately 12:55 p.m. the Regional Director of Nursing confirmed that Resident R1's Lantus insulin was not administered in accordance with physician's orders and that Resident R1 was administered 3 units of Novolog when his/her BS was below 280 mg/dL on the above date and times and should have been held. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to implement their established procedures for investigation and protection of residents in response to potential abuse for one of two residents reviewed (Resident R1). Findings include: Facility policy, Abuse and Neglect dated 1/10/24, revealed It is the policy to have zero tolerance for incidents of abuse and/or neglect. The purpose of the policy is to show that all allegations of abuse/neglect will be thoroughly investigated and reported to the appropriate County, State and Federal agencies pursuant to Federal regulations to include: screening, training, prevention, identification, investigation, protection, and reporting. Procedure: Identifying/Reporting/Investigating/Protection: Staff witnessing any incident of alleged abuse or neglect of Residents are required to report the incident to the supervisor immediately. The nursing supervisor will have the staff witnessing write a detailed account of the event, then sign and date. The supervisor will notify the Director of Nursing, who will notify the Administrator. The employee who has been accused will be informed of the allegation, asked to give a written statement (including signature, date, and time) and will be suspended pending investigation. If the allegations are found to be substantiated, the employee will be terminated and reported to the appropriate agency for disposition. If the allegations are not substantiated, the employee may resume their normal duties. Training/Prevention: All staff will be proficient in the reporting of abuse and neglect. Resident R1's clinical record revealed an admitted [DATE], with diagnoses of diabetes mellitus with hyperglycemia (condition where glucose [blood sugar] tends to build up in the bloodstream), colostomy (opening in the large intestine, or surgical procedure that creates one), intestinal obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel), and hemorrhage of anus and rectum (blood passes from rectum or anus). Upon request of an abuse investigation for Resident R1, regarding an incident that occurred on 7/04/24, the facility provided information that the investigation was initiated on 7/08/24. A description of the incident revealed that on July 8, 2024, the Assistant Director of Nursing (ADON) was notified by Resident R1's family member regarding alleged abuse by a staff member toward Resident R1. The incident alleged that Registered Nurse (RN) Employee E1 had grabbed his/her wrist attempting to obtain blood sugar level and the resident felt like RN Employee E1 was trying to break their arm. Review of Nurse Aide Employee E2's witness statement for the incident that occurred on 7/04/24, revealed that RN Employee E1 was attempting to obtain Resident R1's blood sugar and the resident was moving her hand back and forth so the nurse grabbed her arm and told her she had to get it. Resident R1 started struggling with the RN and she was holding down her arm. NA Employee E2 had stated I told her to stop, what is wrong with you-you should leave the room and call the supervisor. The statement further indicated that NA Employee E2 had to remove RN Employee E1's hand off Resident R1's arm and the RN was upset and said f*** this job, I don't need it and threw the blood glucose testing machine that hit the table in the resident's room, called the supervisor and reported it to him/her (RN). Review of facility records of RN Employee E1's statement of the incident that occurred on 7/04/24, revealed - Resident's blood sugar reading Hi per Libre glucose monitor. Reported to his/her family member who requested a fingerstick confirmation. Upon entering the room to perform the fingerstick, resident became agitated and began hitting and kicking at staff. Resident swinging arm rapidly down towards overbed table and I caught his/her arm near the wrist to prevent him/her hurting himself/herself. Review of Resident R1's progress notes lacked evidence of an assessment of Resident's arm, physician notification, and/or any investigation of incident on 7/04/24, with RN Employee E1. The facility lacked evidence that a thorough investigation was immediately initiated on 7/04/24, to ensure Resident R1 and all residents were protected against potential abuse from RN Employee E1. During an interview on 7/24/24, at 2:35 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility was unable to provide evidence that a thorough investigation was initiated on 7/04/24, when the incident with Resident R1 and RN Employee E1 occurred, and the investigation was only initiated on 7/08/24, when Resident R1's family member notified the ADON. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, clinical and hospital records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide attempt by overdose, from appropriating a significant number of prescription medications that resulted in an overdose of the prescription medications that were provided during medication administration by the facility for one (Resident R234) of three residents reviewed with a history of suicide attempts, and resulted in an Immediate Jeopardy situation. Findings include: Review of a facility policy entitled Medication Administration dated 10/30/23, indicated that staff will remain at bedside with the resident until all medications are taken. Resident R234's clinical record revealed an admitted [DATE], with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy. Resident R234's clinical record lacked evidence of a care plan addressing safety interventions to prevent suicide attempts and to include safety measures to prevent an overdose of medications. Review of Resident R234's physician orders revealed an order dated 10/11/23, to administer Tizanidine HCL (medication to reduce muscle spasms often used with spinal cord injuries) four milligram tablet four times per day for pain. Further review of Resident R234's clinical record revealed: A physician's progress note dated 10/10/23, that identified that Resident R234 had attempted to overdose on medication in August 2023. A departmental progress note dated 10/10/23, revealed that the results of Resident R234's Basic Interview of Mental Status (BIMS)- scored 15 (intact cognition). A physician's order dated 10/11/23, to administer Tizanidine for pain four times per day. A practitioner progress note dated 10/18/23, revealed facility knowledge of two previous attempted over-doses. A practitioner progress note dated 10/25/23, revealed Resident R234 expressed increased pain and feeling miserable since admission. A departmental progress note dated 12/31/23, revealed Resident R234 reported to staff that he/she was extremely depressed. A Social Services progress note dated 1/06/24, indicated that psychological/psychiatric services were not indicated. A practitioner progress note dated 1/11/24, indicated that Resident R234 had not seen psychiatry services since 10/26/23. A Social Services progress note dated 1/15/24, indicated that Resident R234's BIMS remained a 15. A departmental progress note dated 1/30/24, indicated staff found a box of approximately 100 Tizanidine tablets in a box in Resident R234's room. Review of hospital records revealed: An Intensive Care Unit (ICU) Inpatient Record and Progress Note dated 1/30/24, listed Resident R234's admitting diagnosis as Tizanidine overdose, and that the hospital contacted the Poison Control Center for recommended management. Review of a History and Physical Admission Exam dated 1/30/24, revealed that Resident R234 was found to be completely unresponsive, and that facility staff had found a stash of his/her muscle relaxers (Tizanidine). Resident R234 was treated in the Emergency Department and admitted to ICU for evaluation and management of Tizanidine overdose. A Behavioral Health Evaluation dated 2/01/24, revealed that Resident R234 had been hoarding Tizanidine while at the Senior Living Center; then took a large amount of the medication with the intention of killing herself; that he/she planned out how to save his/her medication; took them with the intention of killing herself; had a prior psychiatric history of three suicide attempts ([AGE] years ago- overdose of Aspirin, 8/23/23-overdose of Oxycodone, 1/30/24-overdose of Tizanidine). During an interview on 2/20/24, at 3:03 p.m. resident stated: He/she was able to hoard his/her muscle relaxer (Tizanidine) over time and get enough to attempt to commit suicide on 1/30/24; he/she stated that is wasn't hard, as many nurse's didn't stay in the room while he/she took her pills and he/she easily slipped them into the sheets, and there were certain nurses who stayed in the room so he/she came up with a way to have his/her pills delivered in separate cups. While they weren't paying attention he/she was able to stack an empty cup into the cup with his/her Tizanidine to hide it, once he/she stacked all of the cups, the nurse's would throw the whole stack in the trash, once the nurse left the room, then he/she would retrieve the medication out of the trash and put it in his/her drawer. Resident R234 also stated that he/she kept asking to see a VA (Veteran's Administration) doctor and a counselor. When he/she was admitted , the Social Worker told him/her to call anytime, and that in the afternoon on 1/30/24, he/she left a message and didn't hear back, later that day he/she took the pills. Resident R234 disclosed that if the nurse's had been more diligent with watching him/her take his/her meds, he/she would not have been able to attempt suicide. The facility knew on admission that he/she was a risk for this and did nothing. During an interview on 2/20/24, at 4:30 p.m. the Director of Nursing (DON) confirmed that staff have not completed competencies on medication administration pass since last summer. During an interview on 2/20/24, at 4:57 p.m. the current Nursing Home Administrator (NHA) confirmed that there were no staff competencies for medication administration. The facility failed to implement sufficient safety measures to prevent appropriating prescription medications, putting three residents with a history of suicide attempts at risk and causing an Immediate Jeopardy situation. The NHA and DON were notified of the Immediate Jeopardy (IJ) situation on February 20, 2024, at 5:35 p.m. An Immediate Plan of Correction was requested and the IJ Template was provided. The Immediate Action Plan was provided by the NHA and DON on February 20, 2024, at 7:08 p.m. which was accepted at 7:26 p.m. The plan included: 1. Resident R234's care plan was updated to include; crushing medications, observe resident taking medications and ensuring it is swallowed; every 15 minutes checks; psych services as needed; diversion activities; involve family; behavioral tracking and addressing feelings of loss/suicidal ideations; involve physician, psych services and family with indications of suicidal ideations; and contact and facilitate mental health inpatient stay as needed. 2. All other residents with suicidal ideations will have psych services in place. 3. Staff will observe and ensure medication are taken and swallowed before exiting the room. 4. Facility will offer Mental Health inpatient services. 5. Preventative and safety precautions will be implemented as needed. 6. Each resident's needs will be addressed individually specific to their psychological needs. 7. Care plans will be updated to reflect the present plan of care. 8. Effective immediately, all nurses will be trained on proper medication administration. 9. Training will be completed by 2/24/24. 10. Training will be completed before each nurse works on the units. 11. The above plan will be reviewed at the Quality Assurance Performance Improvement Meeting. Review of facility documentation 100% of nurses working on the units between 2/20/24, at 7:26 p.m. and 2/21/24, at 11:00 a.m. received the medication administration training. Interviews on 2/21/24, between 8:30 a.m. and 10:40 a.m. revealed six licensed nursing staff confirmed that they received medication administration training prior to starting their shifts. On February 21, 2024, at 11:36 a.m. the Immediate Jeopardy was lifted after ensuring the Immediate Action Plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to medication administration for one of 25 residents reviewed (Resident R102). Findings include: Review of facility policy entitled Resident Self-Administration of Medication dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility. Resident R102's clinical record revealed an admitted [DATE], with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression. Observation of medication administration on 2/21/24, at approximately 8:30 a.m. revealed Resident R102 with a bottle of Ipratropium Bromide Nasal spray (medication to treat runny nose caused by colds or allergies) on the bedside tray table. At the time of the observation Resident R102 stated, I always have my nasal spray on my bedside tray table. Resident R102's clinical record revealed a physician's order dated 3/01/23, for Ipratropium Bromide Nasal Solution 0.03% two sprays in each nostril as needed for runny nose four times daily. Resident R102's clinical record lacked a self administration of medication assessment or an order to keep the nasal spray at the bedside. Resident R102's Medication Administration Record (MAR) revealed from the original order date of 3/01/23, to 2/20/204, a period of 11 months and 20 days that Resident R102 was administered the nasal spray on 3/05/23, 3/24/23, 7/22/23, and 7/23/23, a total of four times. A order audit report from the pharmacy for Resident R102 revealed that the nasal spray was ordered on 3/01/23, and re-ordered on 4/10/23, 7/22/23, 9/18/23 and 12/27/23, for a total of 5 bottles that were dispensed from 3/01/23, to 2/20/24. During an interview on 2/22/2024, at approximately 8:30 a.m. the Nursing Home Administrator confirmed that Resident R102's clinical record lacked documentation regarding the nasal spray administration. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 25 residents reviewed (Resident R102). Findings include: Review of facility policy entitled Resident Self-Administration of Medication dated 10/03/23, indicated that the interdisciplinary team will determine if it is safe for the resident to self-administer drugs before the resident may exercise that right. It also indicated that the interdisciplinary team must determine who will be responsible for the storage and documentation of the administration of drugs and that self-administration of medication will be permitted with the orders of a licensed physician and is monitored by the facility. Resident R102's clinical record revealed an admitted [DATE], with diagnoses that included schizoaffective disorder (condition with symptoms of schizophrenia and affective disorder at the same time), bipolar disorder, anxiety, and depression. Observation of medication administration on 2/21/24, at approximately 8:30 a.m. revealed Resident R102 with a bottle of Ipratropium Bromide Nasal spray (medication to treat runny nose caused by colds or allergies) on the bedside tray table. At the time of the observation Resident R102 stated, I always have my nasal spray on my bedside tray table. Resident R102's clinical record revealed a physician's order dated 3/01/23, for Ipratropium Bromide Nasal Solution 0.03% two sprays in each nostril as needed for runny nose four times daily. Resident R102's clinical record lacked a self administration of medication assessment or an order to keep the nasal spray at the bedside. Resident R102's Medication Administration Record (MAR) revealed from the original order date of 3/01/23, to 2/20/204, a period of 11 months and 20 days that Resident R102 was administered the nasal spray on 3/05/23, 3/24/23, 7/22/23, and 7/23/23, a total of four times. An order audit report from the pharmacy for Resident R102 revealed that the nasal spray was ordered on 3/01/23, and re-ordered on 4/10/23, 7/22/23, 9/18/23 and 12/27/23, for a total of 5 bottles that were dispensed from 3/01/23, to 2/20/24. During an interview on 2/21/2024, at approximately 10:00 a.m. the Nursing Home Administrator confirmed that Resident R102's clinical record lacked a self-administration assessment of medication for Resident R102 for the nasal spray that was at the bedside. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 25 residents reviewed (Residents R10, R79, R124, and R117). Findings include: A facility policy entitled, Care Plans dated 10/30/2023, revealed that A copy of the care plan will be provided to the resident and/or family/responsible party. Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood-pressure), hyperlipidemia (high cholesterol), and a femur fracture. R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative. Resident R79's clinical record revealed an admitted [DATE], with diagnoses that included hypertension, muscle weakness, and a femur fracture. R79's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R79 and/or his/her representative. Resident R124's clinical record revealed an admitted [DATE], with diagnoses that included hypertension anxiety, and Parkinson's disease (a progressive disorder that affects the nervous system and can cause tremors, stiffness, and poor balance). R124's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R124 and/or his/her representative. Resident R117's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (condition of improper blood sugar control), hypertension (high blood pressure), and osteomyelitis of vertebra (infection in the bone of the vertebra). R117's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R117 and/or his/her representative. During an interview on 2/22/2024, at 3:45 p.m. the Director of Nursing confirmed that the clinical records for the residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 25 residents reviewed (Resident R67). Findings include: Resident R67's admission record revealed an admitted [DATE], with diagnoses that included dementia, depression, and pain. Resident R67's clinical record revealed that Hospice (end-life services) was ordered on 1/30/2023 and has continued throughout R67's stay at the facility. The Annual MDS dated [DATE], Section O110. Special Treatments, Procedures, and Programs category K1. Hospice was marked No indicating Resident R67 was not receiving Hospice services. During an interview on 2/22/2024, at 12:58 p.m. Licensed Nurse Assessment Coordinator Employee E2 confirmed that Section O110. Special Treatments, Procedures, and Programs category K1. Hospice for the Quarterly MDS dated [DATE], was incorrectly coded for Resident R67 regarding Hospice care services. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R89). Findings include: Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Resident R89's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), muscle wasting, neurogenic bowel (the loss of normal bowel function), and cognitive communication deficit (difficulty with thinking and how someone uses language). The clinical record revealed a physician's order dated 10/26/23, to admit Resident R89 to Hospice services. Review of Resident 89's MDS's lacked evidence that a significant change MDS with an ARD completed within 14-days from when Resident R897 was admitted to hospice care was completed. During an interview on 2/22/24, at 1:00 p.m. the Licensed Practical Nurse Assessment Coordinator Employee E2 confirmed that the significant change MDS was not completed within 14-days of Resident R89 entering Hospice services. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records, it was determined that the facility failed to implement a person-centered care plan that included safety precautions for a resident with a history of suicide attempt by overdose, for one of 25 residents reviewed (Resident R234). Findings include: A facility policy entitled, Care Plans (Plans of Service) dated 10/30/23, indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs within 10 days of admission. Resident R234's clinical record revealed an admitted [DATE], with diagnoses that included major depressive disorder, anxiety, long-term pain, spinal stenosis (inflammation of the vertebrae causing compression of the spinal cord) of the neck, and epilepsy. Resident R234's clinical record revealed a care plan related to major depressive disorder which lacked interventions to ensure resident safety related to previous suicide attempts with an overdose. Further review of Resident R234's clinical record revealed: A physician's progress note dated 10/10/23, that identified that Resident R234 had attempted to overdose on medication in August 2023. A departmental progress note dated 10/10/23, revealed that the results of Resident R234's Basic Interview of Mental Status (BIMS)- scored 15 (intact cognition). A practitioner progress note dated 10/18/23, revealed facility knowledge of two previous attempted over-doses. A practitioner progress note dated 10/25/23, revealed Resident R234 expressed increased pain and feeling miserable since admission. A departmental progress note dated 12/31/23, revealed Resident R234 reported to staff that he/she was extremely depressed. A practitioner progress note dated 1/11/24, indicated that Resident R234 had not seen psychiatry services since 10/26/23. The facility was aware of Resident R234's history of suicide attempt previously and did not develop a comprehensive person-centered care plan with adequate safety precautions to address that concern. Refer to F689 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, facility policies, and staff interviews, it was determined that the facility failed to follow professional standards regarding pressure ulcer prevention measures, that resulted in actual harm of a Stage III (full-thickness loss of skin) pressure ulcer for one of ten residents reviewed (Resident R83) and failed to make certain weekly skin assessments were being performed for two of ten residents reviewed (Residents R83 and R164). Findings include: Review of the facility policy entitled, Pressure Ulcer Prevention and Wound Treatment dated 4/8/22, stated that the weekly skilled documentation should include at a minimum: the location of the wound, wound type, stage, size, odor, drainage, description, treatment, pain, and overall healing progress. Review of the facility policy entitiled, Skin Care Protocol - Preventative dated 4/8/22, revealed that skin will be checked during care and on weekly skin assessments. Review of Resident R83's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R83's quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 2/23/22, revealed that his/her toilet use required extensive assist (resident involved in activity and staff provide weight-bearing support) and one person physical assist. In addition, both bladder and bowel continence revealed always incontinent and that he/she was not on a toileting program. Resident R83's Mini Nutritional Assessment score from 3/13/22, was 5.0 which was considered malnourished. The Braden Scale for Predicting Pressure Ulcer Risk score on 1/2/22, for Resident R83 was 14 which is considered a moderate risk. The Brief Interview for Mental Status score on 1/13/22, for Resident R83 was assessed by staff and considered severely impaired. A progress noted dated 3/20/22, revealed that a nursing assistant discovered the wound while putting Resident R83 to bed. In addition, the note revealed Skin Issue Location: Right buttocks, Pressure Ulcer/Injury, Stage: Stage III - Full thickness skin loss. Length: 2.5, Width (cm): 3, Wound Bed: Slough. Wound Exudate: Purulent. Wound odor noted. No tunneling. No undermining. Tissue: Mushy. Resident R83's clinical record revealed a care plan not initiated until 5/9/22, with a target date of 5/20/22, for being at risk for impaired skin integrity resulting from decreased mobility and incontinence. Care plan interventions included to monitor skin for redness and moisture, apply a barrier product to the skin as needed, position resident to reduce causes of friction, and to provide skin care according to facility guidelines and as needed. According to the assessments in Resident R83's electronic record, the last weekly Skin Observation Tools documentation completed before the Stage III pressure ulcer was discovered on 3/20/22, were from 9/20/21 and 2/4/22, that did not identify there were skin concerns at that time. Since the discovery of Resident R83's pressure ulcer to his/her buttock on 3/20/22, weekly skin assessments were not completed for 3/28/22, 4/14/22, and 4/28/22. During an interview on 5/05/22, at 2:45 p.m. the Director of Skilled Nursing Services stated that all residents should have their skin checked weekly and documented in the Skin Observation Tools. The facility failed to ensure Resident R83 who was at a moderate risk for pressure ulcer development was monitored with weekly skin assessments and measures implemented that resulted in actual harm of a Stage III pressure ulcer. Review of Resident R164's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R164's pressure ulcers to his/her left heel and left great toe were discovered on 3/1/22 according to the Wound Nurse on 5/6/22, at 2:30 p.m. Weekly skin assessments missing since 3/1/22 included from 3/3/22, 3/10/22, 3/17/22, 3/24/22, 4/7/22, and 4/28/22. Review of Resident R72's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R72's clinical record identified a coccyx pressure ulcer was discovered on 8/6/20. The clinical record lacked documentation consistency with wound skin assessments since September 2021 when the facility switched to using another computer system for medical documentation. The missing weekly wound skin assessments included 9/1/21, 9/15,21, 9/22/22, 10/27/22, 11/10/22, 1/6/22, 3/8/22, and 4/28/22. During an interview on 5/6/22, at 2:45 p.m. the Director of Skilled Nursing Services stated that there should be completed weekly skin assessments as part of the weekly rounds by the wound team in addition to weekly progress notes for any resident that has a pressure ulcer and those tasks were not completed consistently for Residents R83, R164, and R72. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services