Every finding on record at Mountain Laurel Healthcare and Rehabilitation CTR

Based on review of facility policy, Resident Council meeting minutes, as well as resident, staff interviews and observations, it was determined that the facility failed to make ongoing efforts to resolve grievances presented by the Resident Council.Findings include: A facility policy regarding resident and family grievances dated April 10, 2026, indicated that grievances may be voiced verbally during resident or family council meetings. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form. The Grievance Official would take steps to resolve the grievance. Resident Council meeting minutes, dated June 15, 2026, revealed that residents voiced concern about call bell response time being longer than ten minutes causing residents to have accidents. A review of the grievance logs for June and July 2026 revealed no documented evidence that a grievance form was created or investigated regarding the group's concern about untimely call bell response. Interview with a group of Residents on July 21, 2026, at 2:30 p.m. revealed that some of their concerns get a response back, while other do not. Staffing continues to be a problem, and the agency staff sit and play on their phones instead of providing care and answering call bells. Interview with the Nursing Home Administrator on July 22, 2026, at 11:37 a.m. confirmed that the residents voiced concerns about call bell wait times being too long at the Resident Council meeting on June 2026, and that as of July 22, 2026, the concern from Resident Council had not been investigated. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on observations and staff interviews, it was determined that the facility failed to provide a homelike environment for the residents in the facility's second floor dining room. Findings include: The facility's policy regarding homelike environment, dated April 10, 2026, revealed the facility will provide a safe, clean, comfortable, and homelike environment. Observations of the second floor dining room during lunch on July 23, 2026, at 12:27 p.m. revealed four empty wheelchairs stored along the walls of the dining room during lunch hour. Interview with Nurse Aide 6, on July 23, 2026, at 12:30 p.m. confirmed that the wheelchairs should be stored in the closet adjacent to the dining room, and she proceeded to relocate the empty wheelchairs into the storage closet. Interview with the Nursing Home Administrator on July 23, 2026, at 12:45 p.m. confirmed that empty wheelchairs should not be stored in the dining room. Observations on July 23, 2026, at 9:14 a.m. revealed that the wallpaper in the second-floor dining room was peeling off the wall below the windows. Interview with the Director of Maintenance on July 23, 2026 at 9:30, revealed that the wall in the second-floor dining room was on the list of repairs and he was aware that it was a problem. Interview with the Director of Nursing on July 23, 2026, at 9:35 a.m. confirmed that the wall in the dining room needed repaired. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications for one of 87 residents reviewed (Resident 59). Findings included: The facility's policy regarding medication administration, dated April 10, 2026, indicated that medications were to be administered by licensed nurses or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated May 11, 2026, revealed that the resident was cognitively impaired, had behaviors of rejecting care and wandering, received antidepressant and antipsychotic medications, and had medical diagnoses that included anxiety, depression, and dementia. Physician's orders for Resident 59, dated June 26, 2026, included an order for the resident to receive 10 mg of Olanzapine (antipsychotic medication) two times a day, and an order, dated June 28, 2026, included orders for the resident to receive 2 milligrams (mg) of Haldol (antipsychotic medication) two times a day. A nursing note, dated July 2, 2026, revealed that a verbal order was received from the psychiatry provider to increase the resident's Haldol to three times a day and make Olanzapine taper to a bedtime dose ending on July 6th. Physician's orders, dated July 2, 2026, included orders for the resident to receive 2mg of Haldol three times a day, and 10 mg of Olanzapine twice a day for seven days and then give 10 mg of Olanzapine at bedtime. A psychiatry note for Resident 59, dated July 7, 2026, revealed that on July 2, 2026 verbal orders were given for Haldol dosing and Olanzapine taper parameters. A review of the Medication Administration Record (MAR) revealed that the transcription of the orders resulted in doses that differed from the intentions. The Olanzapine taper parameters had been entered in a manner that resulted in higher doses being administered than the 10 mg bedtime dose intended at the stage of the taper. A review of Resident 59's Medication Administration Record (MAR) for July 2026 revealed that the resident received 2mg of Haldol three times a day from July 2 through 7, 2026, and received 10 mg of Olanzapine twice a day from July 2 through 7, 2026 and 10 mg of Olanzapine at bedtime from July 3 through 5, 2026. An interview with the Assistant Director of Nursing on July 23, 2026, at 2:38 p.m. confirmed that Resident 59 did not receive the taper of Olanzapine as ordered by the physician, which resulted in a medication error of receiving more Olanzapine than intended. Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare &; Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 16 of 87 residents reviewed (Residents 9, 57, 83, 97, 98, 129, 152, 153, 157, 159, 162, 163, 165, 170, 171, 172). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that for admission MDS assessments, the assessment completion date, and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days. A comprehensive MDS assessment for Resident 9 revealed that the ARD was June 28, 2026. The MDS assessment was dated as completed on July 13, 2026, which was one day late. A comprehensive MDS assessment for Resident 57 revealed that the ARD was June 27, 2026. The MDS assessment was dated as completed on July 13, 2026, which was three days late. A comprehensive MDS assessment for Resident 83 revealed that the ARD was July 7, 2026. The MDS assessment was dated as completed on July 14, 2026, which was one day late. A comprehensive MDS assessment for Resident 97 revealed that the ARD was June 1, 2026. The MDS assessment was dated as completed on June 15, 2026, which was one day late. A comprehensive MDS assessment for Resident 98 revealed that the ARD was June 23, 2026. The MDS assessment was dated as completed on July 9, 2026, which was six days late. A comprehensive MDS assessment for Resident 129 revealed that the ARD was June 8, 2026. The MDS assessment was dated as completed on June 15, 2026, which was one day late. A comprehensive MDS assessment for Resident 152 revealed that the ARD was May 5, 2026. The MDS assessment was dated as completed on May 19, 2026, which was one day late. A comprehensive MDS assessment for Resident 153 revealed that the ARD was May 8, 2026. The MDS assessment was dated as completed on May 26, 2026, which was five days late. A comprehensive MDS assessment for Resident 157 revealed that the ARD was May 1, 2026. The MDS assessment was dated as completed on May 15, 2026, which was one day late. A comprehensive MDS assessment for Resident 159 revealed that the ARD was May 14, 2026, 2026. The MDS assessment was dated as completed on May 28, 2026, which was one day late. A comprehensive MDS assessment for Resident 162 revealed that the ARD was May 13, 2026. The MDS assessment was dated as completed on May 28, 2026, which was two days late. A comprehensive MDS assessment for Resident 163 revealed that the ARD was May 13, 2026. The MDS assessment was dated as completed on May 28, 2026, which was two days late. A comprehensive MDS assessment for Resident 165 revealed that the ARD was May 26, 2026. The MDS assessment was dated as completed on June 9, 2026, which was one day late. A comprehensive MDS assessment for Resident 170 revealed that the ARD was May 5, 2026. The MDS assessment was dated as completed on May 19, 2026, which was one day late. A comprehensive MDS assessment for Resident 171 revealed that the ARD was May 4, 2026. The MDS assessment was dated as completed on May 19, 2026, which was two days late. A comprehensive MDS assessment for Resident 172 revealed that the ARD was May 2, 2026. The MDS assessment was dated as completed on May 19, 2026, which was four days late. Interview with the Nursing Home Administrator on July 23, 2026 at 11:15 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for dental needs for eight of 87 residents reviewed (Residents 4, 25, 56, 59, 129, 135, 162, 171). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 24, 2026, indicated that the resident was cognitively intact, required assistance for daily care, and was a diabetic. A physician's order for Resident 4, dated June 17, 2026, revealed that the resident was medicated with Insulin Glargine (long-acting insulin, and an order dated June 18, 2026, revealed that the resident was ordered Jardiance (anti diabetic medication). There was no documented evidence that a care plan was developed to address Resident 4's care needs related to her diabetes. A comprehensive MDS assessment for Resident 25, dated June 7, 2026, indicated that the resident was slightly cognitively impaired, required assistance for daily care, and medicated with an antipsychotic medication, antidepressant medication, and an anticonvulsant medication. There was no documented evidence that a care plan was developed to address Resident 25's care needs related to her psychosis, antiseizures, and depression. A quarterly MDS assessment for Resident 56, dated May 26, 2026, revealed that the resident was cognitively intact, and received an anti-depressant and an anti-psychotic medication. Physician's orders for Resident 56, dated May 9, 2026, included an order for the resident to receive 30 milligrams (mg) of Mirtazapine (anti-depressant) at bedtime, and an order, dated June 24, 2026, included an order for the resident to receive 20 mg of Olanzapine (anti-psychotic) at bedtime. The resident's Medication Administration Record (MAR) for July 2026 revealed the resident was currently receiving Mirtazapine and Olanzapine. There was no documented evidence that a care plan was developed to address Resident 56's care needs related to the use of anti-depressant or anti-psychotic medications. An admission MDS assessment for Resident 59, dated May 11, 2026, revealed that the resident was cognitively impaired, and received an anti-depressant and an anti-psychotic medication. Physician's orders for Resident 59, dated June 17, 2026, included an order for the resident to receive 20 mg of Citalopram (anti-depressant) one time a day, and an order, dated July 7, 2026, included an order for the resident to receive 2 mg of Haldol (anti-psychotic) twice a day. The resident's MAR for July 2026 revealed the resident was currently receiving Citalopram and Haldol. There was no documented evidence that a care plan was developed to address Resident 59's care needs related to the use of anti-depressant or anti-psychotic medications. A comprehensive MDS assessment for Resident 129, dated June 8, 2026, indicated that the resident was cognitively intact, required assistance for daily care, and was a diabetic. A physician's order for Resident 129, dated June 1, 2026, included an order for the resident to receive 15 milligrams (mg) Buspirone (anti-anxiety medication) two times daily. Physician's order, dated June 15, 2026, included an order for the resident to receive 50 mg Seroquel (anti-psychotic medication). There was no documented evidence that a care plan was developed to address Resident 129's care needs related to her anxiety or psychosis. A comprehensive MDS assessment for Resident 129, dated June 8, 2026, indicated that the resident was cognitively intact, required assistance for daily care, and was a diabetic. A physician's order for Resident 129, dated June 1, 2026, included an order for the resident to receive 15 milligrams (mg) Buspirone (anti-anxiety medication) two times daily. Physician's order, dated June 15, 2026, included an order for the resident to receive 50 mg Seroquel (anti-psychotic medication). There was no documented evidence that a care plan was developed to address Resident 129's care needs related to her anxiety or psychosis. An interview with the Nursing Home Administrator on July 23, 2026, at 9:39 a.m. revealed that there was no care plan in place regarding Residents 4, 29, 125's individualized needs and there should have been. A quarterly MDS assessment for Resident 135, dated June 30, 2026, revealed that the resident was cognitively impaired, and received an anti-depressant and an anti-psychotic medication. Physician's orders for Resident 135, dated November 12, 2025, included an order for the resident to receive 100 mg of Sertraline (anti-depressant) at bedtime, and an order dated June 27, 2026, included an order for the resident to receive 25 mg of Seroquel (anti-psychotic) twice a day. The resident's MAR for July 2026 revealed the resident was currently receiving Sertraline and Seroquel. There was no documented evidence that a care plan was developed to address Resident 135's care needs related to the use of anti-depressant or anti-psychotic medications.An admission MDS assessment for Resident 162, dated May 20, 2026, revealed that the resident was cognitively impaired, had diagnoses that included dementia, and did not receive an anti-depressant or an anti-psychotic medication. Physician's orders for Resident 162, dated June 23, 2026, included an order for the resident to receive 50 mg of Zoloft (anti-depressant) one time a day, and an order dated July 15, 2026, included an order for the resident to receive 0.5 mg of Haldol (anti-psychotic) three times a day. The resident's MAR for July 2026 revealed the resident was currently receiving Zoloft and Haldol. There was no documented evidence that a care plan was developed to address Resident 162's care needs related to the use of anti-depressant or anti-psychotic medications. An admission MDS assessment for Resident 171, dated May 19, 2026, revealed that the resident was cognitively impaired and received an anti-convulsant medication. Physician's orders for Resident 171, dated May 5, 2026, included an order for the resident to receive 100 mg of Neurontin (anti-convulsant) twice a day for neuropathy (nerve pain). The resident's MAR for July 2026 revealed the resident was currently receiving Neurontin. There was no documented evidence that a care plan was developed to address Resident 171's care needs related to the use of anti-convulsant medications. Interview with Nursing Home Administrator on July 23, 2026, at 9:56 a.m. confirmed that the care plans for Residents 56, 59, 135, 162, and 171 did not have a care plan to address their use of anti-depressant, anti-psychotic, or anti-convulsant medications and should have. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policies and clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for three of 87 residents reviewed (Resident 7, 25, and 129).Findings include: The facility's policy regarding Trauma Informed Care, dated April 10, 2026, revealed that the facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/ or re-traumatization. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 16, 2026, revealed that the resident was understood, could understand, was moderately cognitively impaired, required assistance from staff for daily care needs, was taking antipsychotic, antianxiety, and antidepressant medication, and had a diagnosis that included PTSD. A care plan for Resident 7 dated September 24, 2024, indicated that he was a survivor of trauma. He was a veteran of Vietnam War, lost his wife to suicide, and had a history of physical and verbal abuse from his father. An interview with Resident 7 on July 21, 2026, at 8:36 a.m. revealed that he had anxiety due to his service in Vietnam, he lost his best friend, and he mostly has problems at night with his PTSD. A PTSD trauma assessment dated [DATE], indicated that he has intrusive memories and flashbacks as well as upsetting dreams and nightmares. There was no documented evidence that the facility identified Resident 7s specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring,. Interview with the interim Director of Nursing and Regional Consultant on July 22, 2026, at 1:30 p.m. revealed that she believed Resident 7 current care plan does not address triggers or his nightmares and flashbacks. A comprehensive MDS assessment for Resident 25, dated June 7, 2026, indicated that the resident was cognitively impaired, required assistance for daily care, and had diagnoses that included anxiety, depression, schizophrenia, and PTSD. Resident 25's care plan, dated May 31, 2026, indicated that the resident had PTSD, however, there was no documented evidence that the facility identified Resident 25's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring, and there was not documented evidence of a care plan for her PTSD. A comprehensive MDS assessment for Resident 129, dated June 8, 2026, indicated that the resident was cognitively intact and required assistance for daily care. Nursing note for Resident 129, dated June 7, 2026, revealed that the resident was upset that a nurse aide had grabbed her arm and yanked on it, and that she was crying in pain. Nursing note for Resident 129, dated June 8, 2026, revealed that the resident was experiencing occasional flashbacks related to a past sexual abuse incident. There was no documented evidence that the facility identified Resident 129's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring, and there was not documented evidence of a care plan for her PTSD. Interview with the Nursing Home Administrator on July 23, 2026 at 9:56 a.m. revealed that she Residents 25 and 129 did not have PTSD trauma assessments or care plans and that they should have. 28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed (Nurse Aide 1, Nurse Aide 2, Nurse Aide 3, Nurse Aide 4, and Nurse Aide 5). Findings include: Review of Nurse Aide 1's personnel file revealed that she was hired October 29, 2015. There was no evidence that Nurse Aide 1 had a performance evaluation completed since 2021. Review of Nurse Aide 2's personnel file revealed that she was hired March 20, 2014. There was no evidence that Nurse Aide 2 had a performance evaluation completed since 2021. Review of Nurse Aide 3's personnel file revealed that she was hired August 18, 2021. There was no evidence that Nurse Aide 3 had a performance evaluation completed since 2021. Review of Nurse Aide 4's personnel file revealed that she was hired October 16, 2012. There was no evidence that Nurse Aide 4 had a performance evaluation completed since 2021. Review of Nurse Aide 5's personnel file revealed that she was hired November 15, 2011. There was no evidence that Nurse Aide 5 had a performance evaluation completed since 2021. Interview with the Nursing Home Administrator on July 22, 2026 at 10:58 a.m. revealed that there have been no annual performance evaluations since 2021. Interview with the Director of Human Resources on July 22, 2026 at 12:08 p.m. revealed that there have been no annual performance evaluations since 2021. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on observations, and a test tray, as well as resident and staff interviews, it was determined that the facility failed to serve food that was palatable.Findings include: Review of the posted menus for the lunch meal on Wednesday, July 22, 2026, revealed that residents were to receive a ham steak, mashed potatoes with gravy, green beans, ice cream, and a beverage. A test tray for the lunch meal on B wing on July 22, 2026, revealed that the cart left the kitchen at 12:38 p.m. arrived on the nursing unit at 12:40 p.m., and the last resident was served at 12:47 p.m. The test tray was tasted at 12:47 p.m., and the mashed potatoes were bland, thin in texture, and not palatable. Interview with Resident 44 on July 20, 2026, at 7:30 p.m. revealed that she does not like the taste of the food and feels as though the selection is limited. Interview with Resident 53 on July 20, 2026, at 8:00 p.m. revealed that she does not like the taste of the food. Interview with Resident 113 on July 20, 2026 at 7:42 p.m. revealed that he disliked some the food and that it was rarely cooked properly. Interview with Resident 129 on July 20, 2026 at 8:32 p.m. revealed that she disliked the food, that her chicken was raw., her vegetables are either mushy or raw, and no one in the kitchen listens to her complaints. Interview with Resident 155 on July 20, 2026 at 7:58 p.m. revealed that she disliked the food, it was rarely cooked properly, the meats were either over cooked and tough or undercooked and raw, and that sometimes its cold when it arrives to her room. Interview with the Dietary Manager on July 22, 2026, at 12:48 p.m. confirmed that the mashed potatoes were bland, thin in texture, and not palatable. 28 Pa. Code 211.6(b) Dietary services.

Based on review of manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that the dishwashing temperatures were at proper temperatures to ensure sanitary dishwashing conditions.Findings include: Manufacturer's instructions for the main kitchen high-temperature dishwasher, a CMA Dish Machine EST-44H, recommended the wash cycle temperature range between 150 to 160 degrees Fahrenheit. Also in accordance with the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code for High Temperature Dishwasher heat sanitization of 150-165 degrees Fahrenheit for wash cycle temperature.Observations in the main kitchen on July 23, 2026, at 10 a.m. revealed that the wash cycle temperature was only 132 degrees Fahrenheit. On July 23, 2026, at 10 a.m., Dietary Manager confirmed that this temperature was not the correct temperature for a high-temperature wash cycle.Interview with the Dietary Manager on July 23, 2026, at 10 a.m. confirmed that the dishwashing cycle was only registering as 132 degrees Fahrenheit. She confirmed that it should register at least 150 degrees Fahrenheit. Dietary Manager confirmed that the thermostat was not set correctly, and this was adjusted. 28 Pa. Code 201.18(e) (2.1) Management.28 Pa. Code 211.6(f) Dietary Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for three of three residents reviewed (Residents 10, 14, 46) who remained in the facility for long-term care. Findings include: An quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 10, dated June 1, 2026, indicated that the resident was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances or chemical imbalances). A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility, revealed that Medicare coverage for Resident 10 started on March 18, 2026, and that his last covered day was June 1, 2026. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. Resident 10 signed the Beneficiary Protection Notification himself, however he is severely cognitively impaired and could not understand the form. Resident 10 remained the facility for long-term care. There was no documented evidence that Residents 10 was provided with an Advance Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case). A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility, revealed that Medicare coverage for Resident 14 started on January 27, 2026, and that his last covered day was March 5, 2026. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. Resident 14 remained the facility for long term care. There was no documented evidence that Residents 14 was provided with an ABN of Non-coverage. An quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 46, dated May 20, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included dementia (syndrome characterized by a decline in cognitive function. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility, revealed that Medicare coverage for Resident 46 started on February 14, 2026, and that her last covered day was March 4, 2026. The form indicated that the facility-initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documentation that Resident 46 was aware of the Beneficiary Protection Notification form, or that her Power of Attorney was aware. Resident 46 remained the facility for long term care, and was unaware that she was now private pay. There was no documented evidence that Residents 47 was provided with an ABN of Non-coverage. Interview with the Nursing Home Administrator on July 22, 2026, at 10:45 a.m. confirmed that an ABN notice was not provided to Residents 10, 14, or 46 as required and no Beneficiary Protection Notification Review form was not provided to Residents 10 or 46. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for seven of 87 residents reviewed (Residents 56, 74, 85, 96, 119, 130, 141). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 56 had an ARD of May 26, 2026, but it was not completed (Section Z0500B) until June 10, 2026, which was two days late. A quarterly MDS assessment for Resident 74 had an ARD of June 24, 2026, but it was not completed (Section Z0500B) until July 9, 2026, which was two days late. A quarterly MDS assessment for Resident 85 had an ARD of June 28, 2026, but it was not completed (Section Z0500B) until July 13, 2026, which was two days late. A quarterly MDS assessment for Resident 96 had an ARD of June 24, 2026, but it was not completed (Section Z0500B) until July 9, 2026, which was two days late. A quarterly MDS assessment for Resident 119 had an ARD of June 24, 2026, but it was not completed (Section Z0500B) until July 9, 2026, which was two days late. A quarterly MDS assessment for Resident 130 had an ARD of June 3, 2026, but it was not completed (Section Z0500B) until June 18, 2026, which was two days late. A quarterly MDS assessment for Resident 141 had an ARD of June 24, 2026, but it was not completed (Section Z0500B) until July 9, 2026, which was two days late. Interview with the Nursing Home Administrator on July 23, 2026 at 11:15 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 87 residents reviewed (Residents 155). Findings include: Resident 155's physician orders, dated July 15, 2026, revealed that the resident had a urostomy (a surgical procedure that creates a new path for urine to leave the body when the bladder is removed), and that she medicated with Diltiazem (high blood pressure medication), Lasix (water pill), Apixaban (blood thinner), glipizide (anti-diabetic medication), Sertraline (anti-depressant medication), and Clonazepam (anti-anxiety medication). An admission note for Resident 155 dated July 15, 2026 at 5:00 p.m. revealed that the resident arrived at the facility at 5:00 p.m., was alert and oriented, had anxiety and depression and was crying, bladder cancer with bladder removal and urostomy in place, atrial fibrillation (irregular heart beat treated with a blood thinner), high blood pressure, and diabetes, There was no documented evidence that a baseline care plan was developed or individualized for Resident 155's care and treatment needs related to her urostomy, irregular heartbeat, water pill, blood thinner, diabetes, depression or anxiety. Interview with the Assistant Director of Nursing on July 23, 2026 at 1:16 p.m. confirmed that the resident's baseline care plan did not include care and treatment needs required for her urostomy, irregular heartbeat, water pill, blood thinner, diabetes, depression or anxiety. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 80 residents reviewed (Resident 136).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and 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. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 136, dated May 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included Type II diabetes mellitus (condition defined by persistently high levels of sugar (glucose) in the blood). Physician's orders for Resident 136, dated June 22, 2026, included an order for the resident to receive Humulin R U-500 (a type of insulin) to be injected per sliding scale: if blood sugar 0-300 give 0 units; 301-450 give 40 unites; 451 or more call the provider; 0-300 give 0 units; 301-450 give 5 units; 451 give 7 unites and call the provider. The facility failed to clarify which sliding scale should be followed for administration. Interview with the Director of Nursing on July 22, 2026, at 12:32 p.m. confirmed that Resident's 136 medication order should have been clarified with the physician prior to administering the medication, and it was not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 80 residents reviewed (Resident 9). Findings include: A wound management policy, dated April 10, 2026, indicated that clinical staff will follow medical physician's orders for the treatment plan. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated June 28, 2026, revealed that the resident was cognitively intact, required extensive assistance with daily care tasks, was at risk for pressure ulcer (skin impairment caused by pressure) development, a stage IIV (a deep, severe skin wound featuring full-thickness skin loss where subcutaneous fat is visible, but muscle, tendon, and bone are not exposed) pressure ulcer and had one stage IV (most severe form of pressure injury, involving full-thickness tissue loss with exposed muscle, tendon, or bone) pressure ulcer. A physician's order for Resident 9, dated July 15, 2026, included an order to cleanse area with soap and water, pat dry. Apply skin prep to wound. Cut black foam too size and loosely pack tunnel of right buttocks at 2 o'clock (approximate location of area that needs packed) and cover wound bed, cover with transparent dressing, set to 125 millimeters of mercury (mmHG) continuous vacuuming suction. Bridge wounds together above the anus to maintain good seal. Observations of wound care for Resident 9 on July 21, 2026, at 11:01 a.m. revealed that Licensed Practical Nurse 7 bridged the wound together above and below the anus, however the wound care order specifically stated to bridge above and not below. An interview with Licensed Practical Nurse 7 immediately following the completion of the treatment revealed that she thought that it was necessary to bridge above and below the anus. An interview with the Certified Wound Care Registered Nurse 8 from the wound care center where Resident 9 receives specialized wound care weekly on July 21, 2026, at 2:30 p.m. revealed that the staff should have only bridged the wound above the anus. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for three of 87 residents reviewed (Residents 133, 169, and 171).Findings include: A facility policy regarding resident falls dated April 10, 2026, indicated that residents who had a fall were to be assessed by nursing staff. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 133, dated June 19, 2026, revealed that the resident was severely cognitively impaired, had wandering behaviors, required assistance for daily care needs, and had a diagnosis of dementia. The resident's care plan, dated March 15, 2026, revealed that the resident had a potential for falls due to impaired mobility and balance. Observations of Resident 133 on July 20, 2026, at 7:27 p.m. revealed him to be laying on the floor on his right side, head near the top of the bed, knees bent fetal. Nurse Aide 10 confirmed that Resident 133 was on the floor, she entered the room and pulled him up to a sitting position and left the room. Nurse Aide 10 came back with Nurse Aide 12, and they physically assisted Resident 133 to stand. Nurse Aide 12 stated that she had provided incontinence care to Resident 133 approximately 45 minutes ago, and she lowered him to the floor because he wanted to be on the floor and that he was ambulatory. Interview with Licensed Practical Nurse 11 on July 20, 2026, at 7:39 p.m., revealed that she was not informed that Resident 133 was found on the floor, and did not assess him. Interview with Registered Nurse 13 on July 20, 2026, at 8:20 p.m., revealed that she was not informed that Resident 133 was found on the floor. She saw him downstairs with staff and informed the staff member that Resident 133 could not be downstairs. Registered Nurse 13 assessed Resident 133 and started neurological checks. Nurse Aide 12 reported that she had changed Resident 133 then lowered him to the floor. Nurse Aide 12 did not notify staff that she had lowered the resident to the floor. It was not until this surveyor found him on the floor and notified the staff. The registered nurse was not informed of the fall. A witness statement dated July 20, 2026, by Nurse Aide 10 indicated that she and Nurse Aide 12 assisted Resident 133 off the floor. Nurse Aide 10 indicated that Resident 133 did not fall and that he was lowered to the floor earlier by another staff member. A witness statement dated July 20, 2026, by Nurse Aide 12 indicated that she changed Resident 133 and was helping him into bed when he started sitting on the floor. I asked him if that's where he wanted to be and Resident 133 said yes. I told him I would come back and check on him then went into another room. An interview with the interim Director of Nursing on July 22, 2026, at 1:32 p.m. confirmed that Resident 133 was not assessed by a registered nurse after being found on the floor and that the resident should not have been assisted off the floor before being assessed. The witness statements were inconsistent. Nurse Aide 12 reported that she lowered the resident to the floor after providing care on July 20, 2026, at 6:45 p.m. However, the Licensed Practical Nurse or the Registered Nurse on duty were informed that Resident 133 was lowered to the floor. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 169, dated May 19, 2026, revealed that the resident was cognitively impaired, was dependent on staff for wheelchair use, and had diagnoses that included dementia. Observations of Resident 169 on July 22, 2026, at 8:49 a.m. revealed that the resident was sitting in her wheelchair in the hallway outside of her room and her left foot was off of the wheelchair footrest, positioned behind the footrest. Nurse Aide 14 began pushing the resident from the hallway outside of the resident's room to the end of the hallway near the elevator and dining room, with the resident's foot sliding on the floor. An interview with Nurse Aide 14 at that time revealed that she was not aware that the resident's left foot was positioned off of the left wheelchair footrest and was sliding on the floor. An interview with the Director of Nursing on July 23, 2026, at 10:43 a.m. confirmed that Nurse Aide 14 should not have pushed Resident 169 down the hallway while her left foot was positioned behind the wheelchair footrest and sliding on the floor. The facility's policy regarding resident falls, dated April 10, 2026, indicated that the unit manager/designee would notify the staff of the residents at risk for falls and any interventions that were put into place. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 171, dated May 19, 2026, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. A nursing note dated July 14, 2026, at 2:35 a.m. revealed that Resident 171 was found on the floor beside her bed. The bed was put in a low position and fall mats were placed on both sides of the bed. The resident's care plan was updated on July 14, 2026, to include fall mats on both sides of the bed. Observations on July 23, 2026, at 2:39 p.m. revealed that Resident 171 was in bed without fall mats on either side of her bed. Interview with Licensed Practical Nurse 15 on July 23, 2026, at 2:44 p.m. confirmed that Resident 171 was to have fall mats down on each side of her bed when she was in bed. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for two of 87 residents reviewed (Residents 7, 13) and failed to ensure that monthly pharmacy medication reviews were completed for one of 87 residents reviewed (Resident 56).Findings include: A facility policy regarding medication regime review dated April 10 2026, indicated that each resident was reviewed at least once a month by a licensed pharmacist and the facility staff shall act upon all recommendations according to procedures for assessing medication regimen review irregularities A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 16, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and was taking antipsychotic, antianxiety, and antidepressant medication. Pharmacy medication regimen review reports for Resident 7 dated February 25, 2026, provided to the facility, included recommendations for the physician to consider a gradual does reduction of Ziprasidone 20 milligrams (mg) (antipsychotic medication), Venlafaxine 112.5 mg (antidepressant medication), and Lorazepam 0.5 mg (antianxiety medication) ; however there was no documented evidence that they were addressed by the physician. A quarterly MDS assessment Resident 13 dated January 2, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for daily care needs, and was taking antipsychotic, antianxiety, and antidepressant medication. Pharmacy medication regimen review reports for Resident 7 dated March 30, 2026, provided to the facility, included recommendations for the physician to consider a gradual does reduction of Risperidone 1.5 mg (antipsychotic medication) and Citalopram mg (antidepressant medication); however there was no documented evidence that they were addressed by the physician. An interview with the interim Director of Nursing on July 23, 2026, at 9:55 a.m. confirmed that the above pharmacy consultant reports for Resident 7 and 13 were not addressed by the physician. A quarterly MDS for Resident 56, dated May 26, 2026, revealed that the resident was cognitively intact, and received antidepressant, anticoagulant, and antipsychotic medications. Review of Resident 56's clinical record revealed no documented evidence that the pharmacist performed a monthly review of medications in May 2026. Interview with the Assistant Director of Nursing on July 23, 2026, at 1:16 p.m. confirmed that a monthly pharmacy review for Resident 56 was not completed for the month of May and should have been. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending August 14, 2025, as well as complaint surveys ending March 19, 2026 and April 28, 2026, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 23, 2026, identified repeated deficiencies related to clean, homelike environment, pressure ulcer development/prevention, drug regime reviews, food store/prepare/serve safely, and infection control. The facility's plan of correction for a deficiency regarding clean/homelike environment, cited during the survey ending August 14, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the QAPI committee was ineffective in correcting deficient practices related to the clean/homelike environment. The facility's plan of correction for a deficiency regarding pressure ulcer development/prevention, cited during a complaint survey ending March 19, 2026, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the QAPI committee was ineffective in correcting deficient practices related to pressure ulcer development/prevention. The facility's plan of correction for a deficiency regarding drug regime reviews, cited during the survey ending August 14, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F756, revealed that the QAPI committee was ineffective in correcting deficient practices related to drug regime reviews. The facility's plan of correction for a deficiency regarding food store/prepare/serve safely, cited during the survey ending August 14, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to food store/prepare/serve safely. The facility's plan of correction for a deficiency regarding infection control, cited during a complaint survey ending April 28, 2026, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in correcting deficient practices related to infection control. Refer to F584, F686, F756, F812, F880 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for one of 80 residents reviewed (Resident 9).Findings include: The facility's policy regarding enhanced barrier precautions (EBP), dated April 10, 2026, revealed that EBP may be indicated for residents with wounds, and the health care worker must wear the appropriate personal protective equipment (PPE), including gown and gloves, when providing care. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated June 28, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, had limited range of motion to his lower extremity, and had a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Observations on July 21, 2026, at 11:01 a.m. revealed that Resident 9 had a sign outside his room indicating that he was on enhanced barrier precautions, however, there was no Personal Protective Equipment (PPE, gloves, gowns, face shields, etc.) visible outside or inside the residents room. Licensed Practical Nurse 9 and Licensed Practical Nurse 7 entered the resident's room to perform wound care. The licensed nurses proceeded to provide wound care for the resident by removing the old dressing, cleansing the wound, and dressing the clean wound. The licensed practical nurses did not wear gowns while performing wound care per the facility's EBP policy. Interview with Licensed Practical Nurse 9 on July 21, 2026, at 12:39 p.m. confirmed that she did not have on a gown while performing wound care, and that both LPNs should have worn gowns during care.Interview with the Director of Nursing on July 21, 2026, at 10:09 a.m. and 2:50 p.m. confirmed that LPN 9 and LPN 7 should have worn gowns when performing wound care. 28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza and/or the pneumococcal immunizations for four of 87 residents reviewed (Residents 1, 4, 113, 171).Findings include: The facility's influenza and pneumonia vaccination policies, dated April 10, 2026 revealed that all residents would be offered the influenza and pneumonia vaccines. A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 6, 2026, revealed that the resident was admitted to the facility on [DATE] and that her pneumonia vaccine was not up to date and that she was not offered the pneumonia vaccine. There was no documented evidence that the facility offered or administered the pneumonia vaccine to Resident 1. A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 24, 2026, revealed that the resident was admitted to the facility on [DATE] and that her pneumonia vaccine was not up to date and that she was not offered the pneumonia vaccine. There was no documented evidence that the facility offered or administered the pneumonia vaccine to Resident 4. A comprehensive MDS assessment for Resident 113, dated June 30, 2026, revealed that the resident was cognitively intact, was admitted to the facility on [DATE], that his pneumonia vaccine was not up to date, and that he was not offered the pneumonia vaccine. There was no documented evidence that Resident 113 was offered the pneumonia vaccine. An admission MDS assessments for Resident 171, dated May 19, 2026, revealed that the resident was admitted to the facility on [DATE], and that her pneumonia vaccine was not up to date and that she was not offered the pneumonia vaccine.There was no documented evidence that the facility offered or administered the pneumonia vaccine to Resident 171 Interview with the Nursing Home Administrator on July 23, 2026, at 9:42 a.m. revealed that Residents 1, 4, 113, and 171 were not offered the pneumonia vaccine and they should have been. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to monitor, assess and analyze, and attempt new interventions for a resident's increased verbal, physically-aggressive behaviors, and sexual behaviors for one of seven residents reviewed (Resident 1). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 11, 2026, indicated that the resident was moderately cognitively impaired and had diagnoses that included dementia. The resident's care plan, dated May 27, 2026, revealed that staff were to keep the resident away from other residents when she was restless or agitated. Nursing note for Resident 1, dated May 14, 2026, revealed that the resident was admitted to the facility for long term care because she had become increasingly aggressive at home. Nursing note for Resident 1, dated May 15, 2026, revealed that the resident had an altercation with another resident and that they had to be separated. Nursing note for Resident 1, dated May 17, 2026, revealed that she hit and pushed another resident down and was screaming at her. Nursing note for Resident 1, dated May 20, 2026, revealed that she was displaying confrontational behaviors towards other residents who were ambulating by her in the hallway. Nursing note for Resident 1, dated May 23, 2026, revealed that the resident has been verbally abusive towards her roommate and other residents. She would not allow her roommate into their room and was slamming her door. She continued to display increased behaviors, made rude comments and negative remarks to others. Nursing note for Resident 1, dated May 24, 2026, revealed that she continues to walk around the unit arguing with the other residents, swearing and calling them names. Refused all care and would not bathe or change her clothes. Nursing note for Resident 1, dated May 28, 2026, revealed that she had been in a physical altercation with the same resident she had an altercation with on May 15, 2026. Nursing note for Resident 1, dated May 30, 2026, revealed that the resident continued to engage in aggressive behavior towards other residents within the unit, and she is often non-compliant with care. Psychiatry note for Resident 1, dated June 4, 2026 indicated that the resident was refusing medications, had restless agitation and intrusive behaviors, was combative with care, and inappropriate with a male resident. Her behaviors had increased and she was inappropriately touching a male resident. She became very combative with the staff when they attempted to separate the two residents. She was swearing, combative and threatening staff and other residents. She was sent to the emergency room for psychiatric evaluation and admission. Nursing note for Resident 1, dated June 17, 2026, revealed that she was readmitted to the nursing facility and was screaming at the men on the unit. She refused all care and assessments. She was then found in another resident's room shouting and confrontational. She was making rude comments to a male resident that was wandering around the unit and she had placed her self in his path and lunged at him. She had the male resident agitated and the female resident remained agitated and required a staff member to stay with her for a one on one for a half hour. Nursing note for Resident 1, dated June 20, 2026, revealed that she was ambulating around the unit yelling at other residents who also wander aimlessly around the unit. Nursing note for Resident 1, dated June 21, 2026, revealed that the resident is increasingly verbally nasty to staff and other residents, yelling at other residents telling them they are fat or ugly, getting in front of them and then screaming at them to get out of her way and cannot be redirected. She swung at another resident and continues to walk the halls. Nursing note for Resident 1, dated June 27, 2026, revealed that she became agitated with another female resident and went up to the resident and scratched her arm. Resident 1 further used her hip to try to make the other resident fall to the floor. The resident received an intra-muscular injection of an anti-psychotic medication due to her increase in violent and aggressive behaviors towards other residents. Nursing note for Resident 1, dated July 1, 2026, revealed that the resident struck another resident in the face after that resident struck her first, and was verbally aggressive with other residents. Nursing note for Resident 1, dated July 2, 2026, revealed that her psychiatric medications were increased due to her increasing behaviors on the unit. Nursing note for Resident 1, dated July 4, 2026, revealed that she had struck another resident in the face and was becoming more agitated. She again required psychiatric medication to calm her behaviors. Observations of Resident 1 on July 9, 2026 at 5:00 p.m. through 5:48 p.m. revealed that she stood in the hallway and would watch all of the other residents that wandered around her in the hallway. She made comments about each of the residents as they walked or wheeled by her. There was no programming on the unit and no behavior plan in place to prevent her from becoming verbally or physically aggressive with the other residents who were all wandering around her. There was no documented evidence that Resident 1's behaviors were assessed to determine if there were any patterns and/or precipitating factors that caused them. There was also no documented evidence that staff monitored the resident's behaviors, and no documented evidence that the interventions on the resident's behavior care plan were revised or that new interventions were developed to address the resident's ongoing behaviors. Interview with the Nursing Home Administrator on July 9, 2026 at 5:28 p.m. revealed that there was no behavior policy, individualized behavior plan or interventions that were put into place to prevent Resident 1 from engaging in further altercations with other residents who wander freely on the secured unit. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 3 pressure ulcer for one of nine residents reviewed (Resident 4), resulting in a deterioration of the wound; and failed to follow physician's orders in a timely manner for one of nine residents reviewed (Resident 3), which resulted in a delay of treatment.Findings include: The facility's wound care policy, dated March 19, 2026, indicated that to promote healing of wounds, it was the policy of the facility to have a physician's order for the procedure. The following documentation was to be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and the title of the individual providing the wound care, any changes in the resident's condition, all assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound, how the resident tolerated the procedure, and if the resident refused the treatment and reason(s) why. The facility's skin assessment policy, dated March 19, 2026, indicated that a full body, or head to toe, skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment could also be performed after a change of condition or after any newly identified pressure injury. The facility's policy for negative pressure wound therapy (NPTW, also known as a wound vac), dated March 19, 2026, indicated that to promote healing of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Negative pressure wound therapy (an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure) would be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing changes. Negative pressure wound therapy was to be used only when the goal was wound healing, the wound bed had minimal necrotic tissue, and treatment was underway for any wound infection. The physician was to be notified of any complications associated with the use of NPTW. The manufacturer's instructions for the wound vac, dated April 15, 2024, revealed the machine should be frequently monitored to ensure the pump was on and delivering negative wound pressure, and that the wound dressings should not stay in place longer than 72 hours. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 26, 2025, indicated that the resident was cognitively intact, was dependent on staff for his care needs, was frequently incontinent of bowel, had limited range of motion of his lower extremities, had Stage 4 pressure ulcer (full thickness tissue loss with bone, tendon or muscle exposed), and had diagnoses that included paraplegia (paralysis that impairs the lower half of the body). A physician's order, dated December 25, 2025, included orders for the wound on the resident's right buttock / ischium (the lower and back part of the hip bone) to be cleansed with normal saline solution, a 6 x 8 centimeter (cm) piece of white foam put into the tunnel/shelf at the 2 o'clock position, a rope of white foam placed into the tunnel at the 10 o'clock position, for any undermining (occurs when tissue beneath the wound edges separates from the underlying tissue) and black foam to wound bed, wound vac over all pressure at 125 millimeters of mercury (mmHg), and was to be changed every Tuesday, Thursday, and Saturday, and as needed for slippage/soilage. A wound consultation for Resident 4, dated February 17, 2026, revealed the resident was seen for sacral and gluteal (buttock) wounds, and the sacral wound was definitely showing improvement. The resident had a stage 4 pressure ulcer on his right buttock/ischium that measured 4.0 x 8.7 x 1.2 cm, tunneled 5.3 cm at 3 o'clock, and undermined 0.1 cm at 9 to 10 o'clock. The plan was to cleanse the wounds to the right ischium with soap and water, apply white foam to the two tunnels, black foam to the wound bed, pressure of 125 mmHg, and to be changed on Tuesday, Friday, and Sundays, and as needed. The resident was to return to the clinic in two weeks. Review of Resident 4's Treatment Administration Records (TAR's) for February 2026 revealed that the treatments to the right buttock/ischium were completed at the wound clinic on February 17, 2026. A treatment note dated February 19, 2026, at 6:28 p.m. revealed the resident requested to have the wound vac treatment time changed to be done in the morning due to him not being able to sleep after the treatment was done in the evening. However, there was no documented evidence that the wound vac treatment to the resident's right buttocks/ischium was completed on the morning of February 20, 2026. A treatment note, dated February 21, 2026, at 10:26 p.m. revealed the resident refused the wound vac treatment and wanted to have it done in the morning. However, there was no documented evidence that the wound vac treatment to the resident's right buttocks/ischium was completed on the morning of February 22, 2026. A treatment note, dated February 24, 2026, at 2:08 p.m. revealed that the wound vac was not charging and a new one would be sent over night. There was no documented evidence that the wound vac had been changed from February 18 through February 23, 2026 (6 days) and no documented evidence that a registered nurse had assessed the wound condition at that time. The rounding physician was notified the wound vac wasn't charging, ordered wet to dry dressings every shift, and the wound clinic was to be called in the morning. A review of the TAR for February 2026 revealed there was no documented evidence that the wound vac was frequently checked to ensure that the power was on and delivering negative pressure per the manufacturer's instructions. There was no documented evidence that the wound clinic physician was notified that the wound vac was not being used, the condition of the wound at that time, or that wet to dry dressings were being applied to the right buttock/ischium, every shift. A wound consultation for Resident 4, dated March 3, 2026, revealed that the wounds were significantly worse and the wound vac needed to be kept on the wounds. The wound on the right buttock/ischium measured 15.5 x 10 x 5.2 cm, tunneled 7.5 cm at 3 o'clock, undermined 5.2 cm at 9 to 10 o'clock. Debridement of the right buttock/ischium wound was completed with removal of non-viable skin, abnormal edge, slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material), exudate (wound fluid or drainage), and necrotic (dead, non-viable tissue that impedes healing and increases the risk of infection, requiring prompt identification and removal) subcutaneous tissue. Interview with the Certified Wound Care Associate (Licensed Practical Nurse at Wound Clinic) on March 13, 2026, at 10:35 a.m. revealed Resident 4 did not arrive with a wound vac during his visit on March 3, 2026. She called the facility's supervisor, and the supervisor never called back and the wound clinic or the wound clinic physician was never informed that the resident was not using the wound vac. Interview with Licensed Practical Nurse 1 on March 13, 2026, at 2:59 p.m. revealed the wound vac was off at that time and the resident had some necrotic areas and slough on the outside of the wound. She reported that the wound smelled bad, and she thought something wasn't right with it. Interview with Licensed Practical Nurse 2 on March 17, 2026, at 8:52 a.m. revealed Resident 4's wound had been the worst it's ever been, and he was in more pain at night and had a hard time sleeping. Interview with Licensed Practical Nurse 3 on March 13, 2026, at 3:08 p.m. revealed that she was told there was necrotic tissue under the wound vac and the wound vac was discontinued. She reported that the wound vac wasn't charging, the wound vac went completely dead, and they had to prop up the wound vac so the cord would stay in. Interview with Registered Nurse 4 on March 16, 2026, at 10:38 a.m. confirmed that the resident's wound was getting worse, there was no wound assessment completed during that time and when wound clinic instructed her to call the wound clinic physician regarding the change in the wound condition. She stated that she left a message for the wound clinic physician but never spoke with him. Interview with Licensed Practical Nurse 5 on March 16, 2026, at 4:56 p.m. revealed Resident 4 did not like getting his wound vac changed during the evening due to pain with turning. She put a note in the computer to have the time of his wound vac treatment changed to morning, but didn't think it was changed. Interview with the Director of Nursing on March 17, 2026, at 6:40 p.m. and March 18, 2026, at 4:07 p.m. respectively, confirmed that there was no documented evidence that the wound vac was changed on the evening of February 19 or the mornings of February 20, 22, or 23, 2026, that there were not any routine checks of the wound vac ordered, was not made aware that the wound vac wasn't functioning until February 24, 2026, and there was no evidence of a wound assessment completed on February 25, 2206. An admission nursing note for Resident 3, dated February 6, 2026, at 10:36 p.m. revealed the resident had an abrasion on her left calf and a friction area to her left buttock. Both heels are reddened and need to be elevated off the bed for pressure relief. Physician's orders for Resident 3, dated February 6, 2026, included an order to cleanse left buttocks wound with soap and water, pat dry. Apply Zinc (a barrier cream) every shift. May discontinue when healed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 3 dated February 12, 2026, revealed that the resident was cognitively intact, required extensive assistance with care needs, and had diagnoses that included paraplegia (partial or complete inability to move lower legs) and diabetes (body cannot regulate blood sugar). A care plan for Resident 3, dated February 16, 2026, indicated the resident was at risk for skin breakdown due to the diagnoses of paraplegia and diabetes. Physician's orders for Resident 3, dated February 9, 2026, included an order for a wound care consultation. A nursing note dated February 9, 2026, at 7:57 p.m., revealed that the resident was seen by the rounding provider who updated several orders, including a consult for wound care. A physician's note for Resident 3, dated February 10, 2026, at 6:11 p.m., revealed that Resident 3 had an area on her bottom, and the resident's sister requested wound care to follow. A clinical note for Resident 3, dated February 19, 2026, at 8:33 a.m., revealed wounds with the following treatment: wound to right buttocks, preventative skin measures in place. A clinical note for Resident 3, dated February 20, 2026, at 9:53 am. revealed wounds with the following treatment: moisture-associated skin damage to right buttock, preventative skin measures in place. A clinical note for Resident 3, dated February 21, 2026, at 9:56 a.m., revealed wounds with the following treatment: moisture-associated skin damage to left buttock, preventative skin measures in place. A clinical note for Resident 3, dated February 22, 2026, at 11:08 a.m. revealed wounds with the following treatment: moisture-associated skin damage to buttocks, preventative skin measures in place. A wound care consultation for Resident 3, dated March 3, 2026, revealed new treatment orders for the resident's bilateral buttocks. Physician's orders for Resident 3, dated March 3, 2026, included an order for Zinc Oxide External Paste, apply to bilateral buttocks topically every shift for wound healing. Apply medical grade honey after cleansing with soap and water and patting dry. There was no documented evidence in the clinical record that Resident 3 was seen by a wound consultant from February 9, 2026, when ordered until March 3, 2026, and no documented evidence that an appointment had been made for the consult and/or the resident refused to be seen. Interview with the Director of Nursing on March 12, 2026, at 6:01 p.m. confirmed that Resident 3 was not seen by a wound consultant between February 9, 2026 and March 3, 2026 and had no documented evidence that the resident had been scheduled and/or refused to be seen. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, investigation reports, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in a fracture. Findings include: The facility's policy regarding abuse and neglect, dated October 24, 2023, indicated that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. That neglect was defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 5, 2023, revealed that the resident sometimes understood, sometimes understands, and had diagnoses of spinal stenosis (a narrowing of the spinal canal in the lower part of your back) and contractures (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of the muscles at multiple sites. The resident's care plan, dated June 7, 2020, revealed that she required an extensive assist from two staff for her bed mobility. A nursing note for Resident 2, dated November 26, 2023, at 10:33 p.m. revealed that at 9:00 p.m. the nurse was in room [ROOM NUMBER] and Nurse Aide 1 came out of room [ROOM NUMBER] and stated that he was performing care and when he rolled the resident, the resident rolled out of the left side of her bed between the two beds. Upon entering the resident's room, the resident was lying on her left side on her left arm. The resident was bleeding from her head. Pressure was applied, her head was cleaned, and an ice pack was applied. The resident stated that she had pain in her head, so Tylenol was administered per order. A nursing note for Resident 2, dated November 26, 2023, at 10:53 p.m., completed by the registered nurse, revealed that the resident was on the floor on the left side of her bed. She was lying on her left side in a fetal position. A small puddle of blood was on the floor coming from her head. A laceration was observed to the left side of her head right above her ear. Nurse Aide 1 stated that he was changing the resident's brief (independently) while she was in bed. When he rolled her onto her left side, she rolled out of bed onto the floor. The resident required the assistance of two staff with all care. The resident complained of a headache, and Tylenol was administered. The laceration was cleansed with soap and water and measured 1.0 centimeter (cm) by 0.1 cm by 0.1 cm., and ice was applied. A nursing note for Resident 2, dated November 27, 2023, at 9:45 a.m., and completed by the registered nurse, revealed that the resident was complaining of head pressure and pain. The resident stated that if she does not move her neck the pain is better. The resident stated that moving the head of her bed up or down increases the pressure in her head. The Certified Registered Nurse Practitioner (has advanced education and clinical training in a health care specialty area) was notified and assessed the resident. An order was placed to send to the resident to the emergency room . A nursing note for Resident 2, dated November 27, 2023, at 2:00 p.m. revealed that the writer spoke with the resident's daughter, and she reported that her mother was being transferred to another hospital to see neurosurgery (surgery of the nervous system) for a C2 fracture (a break in the second vertebra of the neck). It was confirmed with the emergency room that the resident will be transferred to another hospital and that the resident has a C2 fracture. Nurse Aide documentation for Resident 2, dated November 2023, revealed that Nurse Aide 1 documented as providing care to Resident 2 on November 3, 7, 11, 13, 15, 16, 17, 20, 21, 22, 25, and 26, 2023. The facility's investigation, dated November 26, 2023, revealed that at 9:00 p.m. the nurse was in room [ROOM NUMBER] and Nurse Aide 1 came out of room [ROOM NUMBER] stating that he was performing care and when he rolled the resident she rolled out of the left side of her bed between the two beds. An investigation statement by Nurse Aide 1, dated November 26, 2023, revealed that he was holding Resident 2 while cleaning her up in bed and she slipped through his hands off the bed and hit the floor. He did not ask for help. The investigation determined that Nurse Aide 1 did not ask for assistance from another staff member when providing care to Resident 2 while she was in bed. A Corrective Action Form for Nurse Aide 1, dated November 27, 2023, revealed that while performing care to Resident 2 the resident rolled out of bed and onto the floor causing a hematoma and laceration to left side of her head. The resident later became neurologically (result from injury or changes to the functioning of the brain, spine, or nerves) comprised and was transferred to the emergency room , with a C2 fracture noted on CT scan. Resident 2 is care planned for extensive assistance of two staff for bed mobility, and Nurse Aide 1 performed care alone. Nurse Aide 1 had previously been educated for using a mechanical lift without a second staff member and for care not performed by him. As a result of Nurse Aide 1's actions, termination will occur due to failure to follow the care plan and facility policy and procedure. An interview with the Director of Nursing on December 1, 2023, at 1:48 p.m. confirmed that Nurse Aide 1 had taken care of Resident 2 previously and was familiar with the resident's care, and confirmed that he provided care by himself and that there should have been two staff present when caring for the resident, and that neglect was substantiated. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible, by leaving a resident alone in the bathroom and failed to develop and implement new interventions for fall/injury prevention for one of six residents reviewed (Resident 2) who had a history of falls, which resulted in a fracture. Findings include: The facility's policy for assisting residents to the bathroom, dated September 27, 2022, indicated that when staff took the resident to the bathroom they were to provide the resident with as much privacy as possible and wait outside the door, if safety permitted, and ask the resident to signal when done. The facility's policy regarding falls, dated September 27, 2022, indicated that staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If falling recurs despite initial intervention, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 2, dated November 3, 2022, indicated that the resident was cognitively impaired, required extensive assistance from staff with daily care tasks, including transfers and ambulation (walking), had poor balance, recent falls, and had diagnoses that included dementia. A care plan, dated March 20, 2022, revealed that the resident was at risk for falls due to a history of falls, impaired balance/poor coordination, medication side effects, seizures, and unsteady gait, and staff were to keep his call bell in reach, encourage him to transfer and change his position slowly, have commonly used articles within close reach, wear nonskid shoes/slippers, provide assistance to transfer and ambulate as needed, place urinal/bedpan within the resident's reach, provide assistance with toileting or provide incontinent care as needed, and remind and assist as needed with toileting at routine times such as upon rising in morning, after meals, activities, therapy and at bedtime. An admission nursing assessment for Resident 2, dated March 19, 2022, revealed that the resident was high risk for falls, and his family stated that he had many falls within the last month and they would have to call the ambulance to get him off the floor. A nursing note for Resident 2, dated July 15, 2022, at 12:46 p.m. revealed that the resident was lying on the bathroom floor and his walker was with him. He transferred to the bathroom and was trying to get off the toilet and fell . He had two skin tears to his left hand and wrist. The care plan was updated to include a ring for assistance/help sign placed in his room and restroom. A nursing note, dated July 16, 2022, at 4:27 a.m. revealed that the resident was upset with not being able to stand and walk to the bathroom. A nursing note, dated July 27, 2022, at 5:31 a.m. revealed that the resident was unable to stand up and wanted to use the toilet, several attempts were made, and the urinal was then offered. A nursing note, dated August 26, 2022, at 6:53 p.m. revealed that the resident was found lying in bed with two skin tears on his right forearm and did not recall what happened. Staff also noted that the resident had self transferred earlier in the shift. However, there were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note, dated October 17, 2022, at 12:55 a.m. and 3:56 a.m. revealed that Resident 2 was found on the floor in front of the bathroom door and stated that he fell while shutting the door. The resident thinks that he rings the bell, but he does not, and has a sign in his room and bathroom reminding him to ring for assistance. The facility's investigation, dated October 17, 2022, revealed that Nurse Aide 1 put Resident 2 on the toilet, told him to ring the call bell when he was finished, and went to the Red Zone (COVID positive residents) to obtain vital signs. When she returned, she was informed that Resident 2 was on the floor. The intervention put into place was to stay outside of the resident's room while he was using the restroom, but there was no documented evidence to indicate that any new interventions were implemented to prevent him from transferring unassisted. A nursing note, dated November 15, 2022, at 5:02 p.m and 7:16 p.m. revealed that Resident 2 was found on the floor in his bathroom in severe distress. Staff heard him yelling and found him on the bathroom floor. He was transferred to the hospital and admitted with a fractured femur. The facility's investigation, dated November 15, 2022, revealed that Resident 2 did not ring for help and thought he could go to the bathroom on his own. Interview with Licensed Practical Nurse 2 on January 4, 2023, at 2:05 p.m. revealed that Resident 2 would get up unassisted sometimes and would ring sometimes, and they would find him in the bathroom. Interview with Nurse Aide 3 on January 4, 2023, at 2:07 p.m. revealed that Resident 2 did not get up unassisted for her, but she heard from other shifts that he would get up unassisted. Interview with Nurse Aide 4 on January 4, 2023, at 3:41 p.m. revealed that Resident 2 would self transfer to and from the bathroom unassisted and when he was given the call bell he would ring sometimes. Interview with the Assistant Director of Nursing on January 4, 2023, at 3:22 p.m. revealed that Resident 2 would do his own thing, unfortunately. Interview with the Director of Nursing on January 4, 2022, at 4:12 p.m. and 4:54 p.m. revealed that staff should not have left Resident 2 unattended in the bathroom on October 17, 2022, and was not able to find any new interventions implemented to prevent Resident 2 from transferring unassisted. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, residents' clinical records, and facility investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from any physical restraints not required to treat the resident's medical symptoms for one of 42 residents reviewed (Resident 104), resulting in psychosocial harm to the resident, who was physically restrained by staff holding a sheet across her arms and placing socks on her hands, and in physical harm by locking the resident's wheelchair brakes to prevent movement, which resulted in a fall with injury that required a transfer to the hospital. Findings include: The facility's restraint policy, dated July 27, 2021, revealed that restraints were only to be used for the safety and well-being of the residents, and only after other alternatives were tried unsuccessfully. Restraints were only to be used to treat the resident's medical symptoms, and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, a pre-restraining assessment and review was to be completed to determine the need for restraints. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 104, dated September 16, 2021, revealed that the resident was severely cognitively impaired, was not able to make her needs known, required extensive assistance for care activities, was incontinent, and did not exhibit any behaviors during the assessment period. The resident's care plan, dated May 27, 2021, indicated that she was resistive/noncompliant with treatment and care related to Alzheimer's (a type of dementia). Interventions included allowing flexibility in the resident's routine to accommodate mood, preferences and customary routine; if she was resisting care, staff were to leave (if safe to do so) and return later, and to provide non-care related conversation proactively before attempting care activities. A facility report regarding Resident 104, dated September 21, 2021, revealed that a hand-written note was found on a nursing unit, and the note instructed staff on how to provide care for Resident 104 by holding her down with a sheet, due to her being combative toward staff and scratching, kicking and hitting during care. The facility's records showed that an investigation was initiated and Resident 104 was unable to be interviewed due to impaired cognition. The Director of Nursing interviewed staff involved in Resident 104's care, and it was noted that Licensed Practical Nurse 2 instructed staff to use a sheet when providing care, to help prevent injury to the resident and staff. An undated witness statement from Licensed Practical Nurse 2 revealed that after helping with Resident 104's care on Friday, September 17, 2021, and seeing first-hand how combative the resident was, she was concerned about the way the resident would begin to kick and swing her arms at staff. She and other staff had a discussion afterward, and she suggested that if they had to hold an arm or leg to wash the resident, that they place a blanket or pillow between their hand and the resident so she would not get injured. The nurse asked that staff pass any helpful ideas about completing the resident's care to other staff. Licensed Practical Nurse 2 saw that Nurse Aide 3 wrote a note about it, but the nurse did not read through the note and was going to have the nurse aide pass the information on verbally during report. The statement indicated that the nurse did not intend for the resident to be abused and was trying to prevent injury to her or staff. The nurse did not want to allow the resident to lay in a soiled brief and clothes. Licensed Practical Nurse 2 did not work with the resident during care after that, so she did not see how things were being done. When Licensed Practical Nurse 2 had to give the resident an enema on Sunday, they quickly rolled the resident on her side and she gave the enema quickly. They did not restrain the resident, just held her over on her side. The statement indicated that staff started care with as few staff as possible to not over stimulate the resident and then call in more staff if needed. She tried getting more information from staff on the resident's previous wing, and they said the resident had the same behaviors for them, and that they provided her care last and would also start care with as little staff as possible. Licensed Practical Nurse 2 indicated that she did not tell Nurse Aide 3 to write the note and did not tell her what to put in it. She saw the note and started to read it but stuck it back on the counter and got pulled away to do something else and forgot about it. She planned to just toss the note and tell the nurse aide to give the information verbally during report. An undated, hand written note by Nurse Aide 3 labeled Advice for Assisting Resident 104 to Bed, included to place socks over the resident's hands to avoid scratching/pinching, that four staff were necessary to change the resident's pants - two people to hold a draw sheet over the resident's arms to gently restrain her from hitting staff. An undated witness statement from Nurse Aide 3 regarding Resident 104 revealed that between the dates of September 14-19, 2021, the nurse aide saw a draw sheet being used to restrain the resident. The statement indicated that it takes five people to get the resident ready for bed, and Nurse Aides 4 and 5 are always the nurse aides helping her to get ready for bed. Nurse Aide 4 starts as the only one in the room and talks to Resident 104 about what she is doing in a calm tone and asks her to wear socks over her hands to keep her hands warm as a way to prevent scratching. Nurse Aide 4 changes the resident's shirt while she is in the chair, keeping her covered the whole time and allowing Resident 104 to do most of the work getting her arms through the sleeves. The nurse aide then explains to the resident that she is going to help her get into bed. Resident 104 is calm until it comes time to change her pants, so staff ask her to put her arms across her chest and use a draw sheet to keep her from hitting and pinching staff. So two people are holding the draw sheet while one or two others hold her legs to keep her from kicking high enough to kick staff. Her mobility is not fully limited, just the range she can reach. As soon as a new brief is on, they release the resident and she calms back down, but will put her hands in her head and look distraught. Nurse Aide 3 indicated that she has tried to talk to the resident after care, to reassure her and check in on her, but she will ignore staff after care. An undated witness statement from Nurse Aide 4 regarding Resident 104 revealed that she put socks on the resident's hands to keep her from scratching staff. The statement indicated that Licensed Practical Nurse 2 told staff to put a sheet over the resident and hold her down to change her pants, so she would not get any marks on her. Around September 13, 2021, Nurse Aides 3, 4 and 5, and Licensed Practical Nurse 2 used a sheet to hold the resident during care. Nurse Aide 3 wrote the note after they put Resident 104 to bed and changed her. During a follow-up telephone interview with Nurse Aide 4 on September 22, 2021, she indicated that she attempts to follow the care plan first before using the above method. She also stated she has never done this to, or has seen this done, to any other resident. An undated witness statement from Nurse Aide 5 regarding Resident 104 revealed that on Friday, September 17, 2021, after doing Resident 104's care, Licensed Practical Nurse 2 told the staff to start using a draw sheet or bath blanket over the resident's arms to prevent bruising and skin tears. On Saturday, September 18, 2021, during the resident's care, staff used a draw sheet to hold the resident's arms down, per directions of Licensed Practical Nurse 2. On Sunday, September 19, 2021, while doing care on Resident 104, staff used a sheet to hold her arms still to prevent skin tear and bruising, per instructions from Licensed Practical Nurse 2. Licensed Practical Nurse 2 and Nurse Aides 3, 4, 5 and 8 were present at the time. The nurse aide indicated that she tried to follow care plans with different approaches and the resident was very pleasant at times. A telephone interview statement from Nurse Aide 6, dated September 22, 2021, revealed that one time on Saturday he asked for help with Resident 104's incontinent care from Nurse Aides 4 and 5. Nurse Aide 4 put a gown on the resident, removed her top while she was in the wheelchair, and transferred her from the wheelchair to bed. Nurse Aide 4 told him to hold a draw sheet and instructed him to hold the resident's arms down while changing her bottom. Nurse Aide 5 was on the other side of the bed holding the other side of the draw sheet. An undated witness statement from Nurse Aide 7 regarding Resident 104 revealed that Nurse Aides 4 and 5 told him to put socks on the resident's hands to keep her from scratching him. Nurse Aide 4 told him to put a gown up so the resident could not spit in his face. During an interview with Nurse Aide 7 on October 5, 2021, at 11:45 a.m., he stated that he was instructed to hold a gown up in front of Resident 104's face if he ever had the resident on his assignment. He never had the resident on his assignment and stated that he would never hold a gown over someone's face. A nursing note for Resident 104, dated September 21, 2021, at 9:00 p.m. revealed that the registered nurse completed a full-body assessment of the resident. She was confused, argumentative and combative with care. She had various stages of bruising on both arms, and both shins and thighs, none of which were new. There was a bruise that extended from the side of her neck to the collar bone, which was also old in nature. There was no noted ecchymosis on the torso or back. Observations of Resident 104 on October 4, 2021, at 11:09 a.m. revealed a heart-shaped bruise, approximately two inches in diameter, on the left collarbone area that was dark purple/pink in color. Upon interview with Nurse Aide 9 at that time, she indicated that the bruise was from being held down with a sheet and that it actually looked much better now. She stated that the bruise had extended down into her chest area and that the resident also had bruises on both arms and legs from being held down. A fall risk care plan for Resident 104, dated May 18, 2021, revealed that she was at risk for falls due to a history of falls, impaired balance/poor coordination, unsteady gait, ability to remove non-skid footwear and medication side effects. One of the interventions for Resident 104 included reinforcing wheelchair safety as needed, by locking the brakes on her wheelchair. A nursing note for Resident 104, dated June 4, 2021, at 10:32 a.m. revealed that she refused staff assistance with ambulation (walking) on the unit, and that she becomes upset when staff attempt to assist her. The note indicated that staff would continue to encourage the resident to utilize a wheelchair. A nursing note dated June 6, 2021, at 5:26 p.m. revealed that staff would continue to encourage the resident to use a wheelchair with rest periods. A facility report for Resident 104, dated June 17, 2021, revealed that a registered nurse observed the resident face down in the hallway at 4:00 p.m. The nurse aide had completed care and placed the resident back in the common area with her friends. Eventually Resident 104 got up and began walking down the hall; staff were unable to reach her as she fell face first and began to bleed. An assessment showed the resident was bleeding from the left side of the nose, and the bridge of the nose was deformed with swelling at the proximal end of the skull. Bruising was starting above the left eye and the resident bit her lip, which was bleeding as well. The physician was notified and gave an order to send the resident to the hospital for evaluation and treatment. A nursing note for Resident 104, dated June 17, 2021, at 4:04 p.m. revealed the resident was face down in the hallway with a nurse aide tending a bloody nose. The resident was rolled over and assessed and had bleeding was coming from the left side of the nose, and the bridge of the nose was deformed with swelling at the proximal point of the skull. She also had a bruise above her left eye, and she bit her lip which was bleeding as well. According to witnesses, the resident got up from her wheelchair and started walking away from it. She then fell forward hitting the concrete floor. A nursing note for Resident 104, dated June 17, 2021, at 9:39 p.m. revealed that the resident returned from the emergency room with a dianosis of nasal contusion. The facility's investigation, dated June 17, 2021, revealed that one of the predisposing environmental factors for Resident 104's fall was that her wheelchair brakes were locked. Upon interview with Registered Nurse 16 on October 7, 2021, at 11:56 a.m., she confirmed that on June 17, 2021, at 4:00 p.m., Resident 104's wheelchair brakes were locked when she was in the common area. She stated that all residents who were in wheelchairs had the brakes on their wheelchairs locked when brought out to the common area for meals. She also confirmed that on Resident 104's wing, the supper meal is not served until 5:00 p.m. There was no documented evidence in Resident 104's clinical record that a pre-restraining assessment and review was completed to determine the need for restraining the resident by locking her wheelchair brakes. An interview with the Director of Nursing on October 7, 2021, at 12:20 p.m. confirmed that Resident 104's wheelchair should not have been locked. An email from the Director of Nursing on October 7, 2021, at 2:51 p.m., revealed that the intervention to lock the brakes on Resident 104's wheelchair was placed on her care plan on May 18, 2021, due to impaired cognition, impulsive behavior, and poor safety awareness. It was initiated by nursing due to those factors and a history of falls. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.8(a) Use of restraints.

Based on review of policies, investigation documents, concern forms, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were free from physical abuse for two of 14 residents reviewed (Residents 3, 14), resulting in injury and fear for Resident 3. Findings include: The facility's policy regarding abuse, dated (MONTH) 20, (YEAR), indicated that residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal (physical) punishment, and involuntary seclusion. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, meant that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 13, (YEAR), indicated that the resident was moderately cognitively impaired; required the assistance of staff for walking and other daily tasks such as toileting, personal hygiene, and bathing; that her balance was not steady; and she had limited range of motion (joint movement) of the arm and leg on one side of her body. Nursing notes for Resident 3, dated (MONTH) 1 and 2, 2019, indicated that the resident had a large purple bruise covering the entire left foot and a large purple bruise from the spine to the side of her neck on the left side, and the resident reported that an alleged assailant grabbed her by the neck and stomped on her foot. Facility investigation documents, dated (MONTH) 1, 2019, indicated that on that day Resident 3 was found to have bruising covering the top of her left foot, which was purple in color and with slight swelling. The resident also had bruising on the left side of her neck, extending from the spine to the side of her neck. The resident indicated that a male staff member stomped on her foot and grabbed her by the neck. She was not able to provide the name of the staff member but was able to provide a physical description of him and the clothing he wore at the time of the incident. The resident then positively identified the staff member from his photograph. The investigation documents indicated that the resident reported that she was afraid of the staff member and did not want him to come into her room again. The facility's investigation indicated that the resident was consistent when repeating her allegations during multiple interviews, that based on the resident's physical description Nurse Aide 4 was identified as the perpetrator, and that the resident's allegations were substantiated. The investigation documents revealed that the alleged perpetrator was immediately suspended by the facility, and subsequently resigned his position at the facility. Upon interview with Resident 3 on (MONTH) 12, 2019, at 9:15 a.m. she stated that a man stomped on her foot, grabbed her by the neck, and that she was afraid of him. She also stated that she did not want him to provide care for her again. Interviews with the Director of Nursing on (MONTH) 12, 2019, at 1:30 p.m. and (MONTH) 19, 2019, at 8:30 a.m. confirmed that Resident 3's allegation was substantiated, and the facility ruled out all other male staff members as possible perpetrators based on the information provided by the resident, the description of the clothing worn, and the identification of the perpetrator using his photograph. The interviews also confirmed that the alleged perpetrator was immediately suspended by the facility, and subsequently resigned his position at the facility. A comprehensive MDS assessment for Resident 14, dated (MONTH) 15, (YEAR), indicated that the resident was able to make himself understood by others, was able to understand others, and was alert and oriented. A facility concern form, dated (MONTH) 4, 2019, revealed that Resident 14 reported that a Licensed Practical Nurse (LPN) smacked him as a reprimand. The resident demonstrated to facility staff by smacking a staff member's hand. The form indicated that the resident lightly tapped on top of the right hand. A statement of an interview with Resident 14, dated (MONTH) 4, 2019, indicated that when the LPN gave him a drink, the resident asked for his mug, and the LPN replied, Please. The resident informed the LPN that this was corny, and she did not need to teach him manners, and that was when she smacked him on the hand. The statement indicated that the resident felt that the LPN's intent was to reprimand him and he did not want the LPN to provide care to him. There was no documented evidence that the alleged incident was reported as abuse to required agencies. Interview with the Nursing Home Administrator on (MONTH) 12, 2019, at 8:00 a.m. revealed that the facility did not feel that the allegation reported by Resident 14 was abuse. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/13/18, 9/14/17, 6/7/17, 3/17/17. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/13/18, 3/17/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/13/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/13/18, 9/14/17, 6/7/17, 3/17/17. 28 Pa. Code 201.29(a)(d)(j) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/22/18, 9/13/18, 8/8/17, 6/7/17, 3/17/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/22/18, 5/9/18, 3/8/18, 9/14/17, 6/7/17, 3/17/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/22/18, 9/13/18, 5/9/18, 3/8/18, 11/9/17, 9/14/17, 8/8/17, 6/13/17, 6/7/17, 4/26/17, 3/17/17.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure physician's admission orders [REDACTED]. Findings include: The facility's policy regarding admission criteria, dated (MONTH) 20, (YEAR), indicated that prior to, or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders that covered medication. Nursing notes for Resident 8, dated (MONTH) 4, 2019, indicated the resident was admitted to the facility from another nursing care facility at 3:40 p.m. with [DIAGNOSES REDACTED]. short period of time, often called a mini-stroke), high blood pressure, diabetes (condition that causes the body to have difficulty controlling blood sugar levels), and a history of cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing of the arteries supplying blood and oxygen to the brain). At the time of admission, the resident's pulse was 67 beats per minute (normal rate for an adult is 60 to 100 beats per minute) and regular, and her blood pressure was 112/76 millimeters of mercury (mm/Hg) (normal values are 120/80 or less and readings over 120/80 are considered high blood pressure). The transferring nursing care facility sent a set of physician's orders [REDACTED]. However, a comparison of the physician's orders [REDACTED]. 5.0 milligrams (mg) of apixaban (Eliquis - used to prevent blood clots from a-fib) twice daily. 40 mg of [MEDICATION NAME] (assists the body to get rid of excess fluid) twice daily. Two, 50 mg tablets of [MEDICATION NAME] (treats high blood pressure and heart failure) three times daily. Two, 180 mg tablets of [MEDICATION NAME] LA extended release (used to treat a-fib and high blood pressure) once daily. Humalog (a fast-acting insulin used to lower blood sugar levels) before meals and at bedtime, based on a sliding scale (the amount of insulin given is determined by the result of a fingerstick blood sugar test). 100 mg of [MEDICATION NAME] (used to treat diabetes) once daily. 40 mg of atorvastatin calcium (treats high cholesterol) one time daily. There was no documented evidence that the above medication orders were reviewed with the attending physician at the receiving facility upon admission, or that the orders were reviewed with the physician until (MONTH) 6, 2019, at which time the medications were ordered by the attending physician. The resident's Medication Administration Record [REDACTED]. Vital sign records for Resident 8 for (MONTH) 2019 revealed that the resident's blood pressure readings (in mm/Hg) and pulse (in beats per minute - bpm) were: March 4 at 4:25 p.m. - 112/76 and 67 March 5 at 2:30 a.m. - 118/74 and 68 March 6 at 3:03 a.m. - 122/78 and 74 March 6 at 1:28 p.m. - 142/82 and 107 March 6 at 3:23 p.m. - 148/82 and 100 March 6 at 3:56 p.m. - 117/75 and 88 March 7 at 2:14 a.m. - 120/70 and 76 March 7 at 8:10 a.m. - 106/80 and 98 and irregular March 7 at 8:39 a.m. - 106/80 and 110 and irregular A note by a Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training and the authority to diagnose and treat medical conditions), dated (MONTH) 6, 2019, at 9:00 a.m. indicated that she was requested by the facility to evaluate Resident 8 as a new admission and due to a change in condition. The note indicated that the resident was previously hospitalized for [REDACTED]. cavity and the outside of the lungs), which required thoracentesis (removal of the fluid between the membranes lining the inside of the chest cavity and the outside of the lungs using a hollow needle inserted into the space). The resident confirmed that she was having shortness of breath and feeling extremely fatigued. The resident's heart rate was 110-120 beats per minute and respirations were 24 per minute and the resident had a-fib at an uncontrolled rate. The CRNP indicated that prior to discharge from the hospital to the previous (nursing care) facility, the resident had been ordered Eliquis and [MEDICATION NAME], and that [MEDICATION NAME] was increased. Due to [MEDICAL CONDITION](rapid heart rate) she would give [MEDICATION NAME] and [MEDICATION NAME] now, and she ordered Eliquis, [MEDICATION NAME], and [MEDICATION NAME] according to the recommendations of the cardiologist (heart specialist) when she had been a hospital inpatient prior to admission to the previous nursing facility. The note also indicated that the resident should continue to receive [MEDICATION NAME] at 40 mg twice daily, with an extra 20 mg given on (MONTH) 6, 2019, due to increased shortness of breath and [MEDICAL CONDITION] (swelling) in the lower extremities. Sliding scale insulin at meals and bedtime, and [MEDICATION NAME] were also to be started. A CRNP's note for Resident 8, dated (MONTH) 7, 2019, at 9:00 a.m. indicated that she was requested by the facility to evaluate the resident due to decreased responsiveness and lethargy (tiredness, weariness, lack of energy, or fatigue). She was noted to have an altered mental status and an increased respiratory rate at rest, and painful stimuli was required for the resident to respond. After a brief response, the resident quickly fell back to sleep and was unable to answer any further questions. Her heart rate was 110-130 beats per minute and irregular, and respirations were 26 breathes per minute. The note indicated that the resident had a-fib at an uncontrolled rate, and [MEDICAL CONDITION](rapid heartbeat) continued after her cardiac medications were resumed, with the rate remaining at 100-130 beats per minute. There was no improvement in the pulse or vital signs overnight. The CRNP spoke to the resident's family member, who wanted the resident transferred to the emergency room . Documentation received from the first emergency room the resident was transferred to on (MONTH) 7, 2019, indicated that at 9:42 a.m., the resident's blood pressure was 138/104 mmHg, her heart rate was 161 beats per minute, and this was a high-risk situation. At 12:35 p.m. her heart rate was 125 beats per minute and irregular, her blood pressure was down to 108/68 mmHg and her respirations were 20 breaths per minute. The resident was started on intravenous (IV - administered directly into a vein) [MEDICATION NAME] drip and received a bolus (an amount given all at one time) of [MEDICATION NAME] prior to the drip being started. She also received one bolus of [MEDICATION NAME] (medication used to lower blood pressure). A re-evaluation at the emergency room indicted that she continued to be in a-fib with RVR. Her condition was determined to be critical but stable. The resident was transferred to a second hospital at the request of her family on (MONTH) 7, 2019. Documentation from the second hospital the resident was transferred to on (MONTH) 7, 2019, indicated that the resident was assessed with [REDACTED]. The patient stated that she did not have some of her cardiac (heart) medications for two days but thinks she had them the past 24 hours. She was sent to an emergency room for increased shortness of breath and was found to be in a-fib with RVR. She was given two boluses of [MEDICATION NAME], 5.0 mg of [MEDICATION NAME], and 40 mg of [MEDICATION NAME] intravenously. A consultation report from Resident 8's admission to the hospital on (MONTH) 7, 2019, indicated that she had previously been admitted to the hospital in the last month with a-fib with RVR, and that she underwent thoracentesis during the hospitalization due to a large left pleural effusion. She also underwent synchronized electrical cardioversion (process where electricity is used to try to return the heart beat to a normal rhythm) to return to a normal heart beat, which was unsuccessful. She was discharged from the hospital to the first nursing facility on a high dose rate control therapy (medications) with [MEDICATION NAME] at 100 mg three times daily and [MEDICATION NAME] (a generic version of [MEDICATION NAME]) at 360 mg daily. Interview the Director of Nursing on (MONTH) 12, 2019, at 1:00 p.m. revealed that upon admission to their facility, the receiving nurse reviewed the discharge orders from the hospital to the previous facility with the attending physician, instead of the orders that came with the resident from the transferring facility. She confirmed that the most current physician's orders [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/13/18, 9/14/17, 6/7/17, 3/17/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/13/18, 3/17/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/13/18, 9/14/17, 6/7/17, 3/17/17. 28 Pa. Code 211.2(b) Physician services. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/13/18, 3/8/18. 11/9/17, 6/7/17. 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/22/18, 9/13/18, 8/8/17, 6/7/17, 3/17/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/22/18, 9/13/18, 5/9/18, 3/8/18, 11/9/17, 9/14/17, 8/8/17, 6/13/17, 6/7/17, 4/26/17, 3/17/17.

Based on review of American Heart Association guidelines, facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that cardiopulmonary resuscitation was initiated in a timely fashion for one of 16 residents reviewed (Resident CR1), failed to follow care planned interventions to prevent injury for one of 16 residents reviewed (Resident R8), and failed to obtain an apical pulse as ordered by the physician for one of 16 residents reviewed (Resident CR4). Findings include: The 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR - an emergency procedure performed when a person's breathing or heartbeat stops) and Emergency Cardiovascular Care Science, dated [DATE], revealed that the AHA guidelines for CPR stressed immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing (i.e., only gasps), which improved the chance of survival by providing heart and brain circulation. Early recognition of sudden [MEDICAL CONDITION] in adults was based on assessing responsiveness and the absence of normal breathing, and healthcare providers should take no more than 10 seconds to determine if a pulse was present. If other rescuers were present, the first rescuer should direct them to activate the emergency response system and get the automated external defibrillator (AED - portable device that detects a heart rhythm and can shock the heart if needed), and the first rescuer should start CPR immediately. The facility's policy and procedure regarding CPR, dated [DATE], revealed that the first nurse on the scene was to confirm cardiac and/or respiratory arrest, call for help loudly-even if no one was in sight, check the resident's airway and pulse, connect oxygen if available while awaiting the emergency cart, check the resident's medical record for code status (whether or not CPR is to be started depending on the resident's wishes and/or physician's orders [REDACTED]. The first nurse on the scene was then to begin CPR (if appropriate based on the resident's code status) and continue CPR at 30 chest compressions to 2 breaths until [DATE] arrived and took over the care of the resident. The policy also revealed that the first nurse responder was to assure that the Code Blue Worksheet was reviewed with the team and that a code critique was completed. The policy revealed that the role of the second responder was to assist the first responder as necessary and to be the coordinator of the event. The second responder was to ensure that someone immediately brought the code cart (emergency cart containing equipment and supplies that may be needed) and the medical record to the resident's location, call a Code Blue (a code used to indicate that a resident requires immediate resuscitation) and the location over the public address system, ensure that assignments were made for notifying [DATE], notifying the resident's family and physician, completing paperwork for an impending transfer to the hospital, waiting for EMS (Emergency Medical Services) personnel and escort them to the code site, and designating a scribe to record activities related to the Code Blue using the Code Blue Worksheet provided on the emergency cart. The second responder was to be available at all times to assist the first responder as necessary with CPR. The following clinical record information, facility witness statments, and staff interviews, revealed that Resident CR1 was found unresponsive and not breathing on [DATE], at 4:35 a.m., that Code Blue was called and CPR was started at approximately 4:45 a.m. (10 minutes after finding the resident unresponsive), and that EMS was called at 4:50 a.m. (15 minutes after finding the resident unresponsive). A nursing note for Resident CR1, dated [DATE], at 6:00 p.m. indicated that the resident was discharged from the hospital that day and was a full code (a patient who wants all resuscitation measures taken). The resident was diagnosed with [REDACTED]. The note indicated that the resident used oxygen at a flow rate of three liters per minute via nasal cannula (tubes inserted into the nostrils to deliver oxygen), and Bilevel Positive Airway Pressure ([MEDICAL CONDITION] - a device that delivers pressurized air from a tabletop unit through a facemask to support breathing) at bedtime. The note also indicated that the resident arrived at the facility at 6:20 p.m. and was alert and oriented. A nursing note for Resident CR1, dated [DATE], at 4:45 a.m. revealed that the resident was assessed and was found to have a faint pulse, that no heart beat was heard, and the resident was not breathing. A Code Blue was called and CPR was started after staff got the resident onto the floor. The note also indicated that an AED was in place, and that another staff member called [DATE] while CPR was provided by staff. Emergency Medical Services (EMS) staff took over CPR after they arrived at 5:00 a.m. EMS personnel contacted Medic Command (a medical command physician who communicates with and issues medical orders to EMS providers when they seek direction) after administering [MEDICATION NAME] (a medication administered during CPR to reverse [MEDICAL CONDITION]) and were advised to administer another [MEDICATION NAME] injection when it was time, and if there was no change in the cardiac monitor, then they were to stop (CPR). [MEDICATION NAME] was given and there was no change in the resident's status, and the resident ceased to breathe at 5:15 a.m. An EMS trip sheet for Resident CR1, dated [DATE], revealed that EMS was dispatched at 4:50 a.m., responded at 4:53 a.m., arrived at the facility at 4:59 a.m., and at the resident at 5:01 a.m. When they arrived on scene, they found the resident on the floor pulseless (no heart beat) and apneic (not breathing) with CPR in progress by facility staff. The facility's staff reported to them that they found the resident pulseless at 4:45 a.m. that morning, that the resident was last seen at 3:30 a.m., and had recently been discharged from the hospital with a [DIAGNOSES REDACTED]. A statement from Licensed Practical Nurse 8, dated [DATE], revealed that at 4:35 a.m. that morning, she walked into Resident CR1's room to administer her medications and the resident did not respond to her name, had no noticeable chest raises indicating respirations, and had a weak pulse upon palpitation (feeling with hand). The statement indicated that she then called a Code Blue, the registered nurse (RN) assessed the resident, CPR was started at 4:45 a.m., and [DATE] was called at 4:50 a.m. A statement from Licensed Practical Nurse 8, dated [DATE], at 8:20 a.m. revealed that she left the resident's room, walked to the desk and checked the resident's code status in the chart, then walked to the RN's office and called Registered Nurse 7 to the resident's room to confirm that the resident was unresponsive and not just deep sleeping. The registered nurse assessed the resident's respirations, pulse, and heartbeat with none being found. Licensed Practical Nurse 8 then went out to the desk and called Code Blue. A statement from Registered Nurse 7, dated [DATE], revealed that she was told by the licensed practical nurse that the resident was not breathing and she immediately went to the resident, called her name, checked for a heart beat, and gave a sternal rub (rubbing the sternum with the knuckles of your hand to elicit a response). Resident CR1 had no heart beat, was not breathing, and had a very faint pulse. She then left to get a code cart, Code Blue was called, the resident was assisted to the floor by four staff members, CPR was started, and the AED was placed on the resident. A statement from Licensed Practical Nurse 6, dated [DATE], revealed that at approximately 4:45 a.m. she heard Licensed Practical Nurse 8 call a Code Blue in Resident CR1's room. She responded a minute later and Licensed Practical Nurse 8 and Registered Nurse 7 were already in the room. The resident was lowered to the floor and as Licensed Practical Nurse 6 was moving the code cart to the wall outlet, Licensed Practical Nurse 5 arrived and Registered Nurse 7 told her to take the phone out of her pocket to call [DATE]. Licensed Practical Nurse 5 had the phone in her hand and was asking her how it worked when Licensed Practical Nurse 6 realized that she had her phone in her pocket and called [DATE]. A statement from Nurse Aide 9, dated [DATE], revealed that she responded to the Code Blue with Nurse Aide 10 and met Registered Nurse 7 and License Practical Nurse 8 at the nursing station and they all went in the room together. Once in the room, they all took a corner of the bed sheet and lowered the resident to the floor so the licensed practical nurse could start CPR. A statement from Licensed Practical Nurse 12, undated, revealed that on [DATE], at 4:45 a.m. a Code Blue was called and she immediately ran to the B-Wing where Registered Nurse 7 and Licensed Practical Nurse 8 had Resident CR1 on the floor doing compressions and had the AED on her. Registered Nurse 7 instructed her to call [DATE] and she ran to the facility's phone on B-Wing (at the nursing station). Nurse Aide 10 asked her what papers needed copied because she did not know and Licensed Practical Nurse 12 handed the phone to Licensed Practical Nurse 5 and went to make copies. She told Licensed Practical Nurse 5 to call [DATE]. A statement from Licensed Practical Nurse 5, dated [DATE], revealed that on [DATE], she responded to the Code Blue that was called at 4:45 a.m., and when she arrived at the B-wing nursing station, Licensed Practical Nurse 11 was on the phone. Licensed Practical Nurse 11 then asked her to talk with [DATE] and said that she would go make copies. When Licensed Practical Nurse 5 went to speak with [DATE] she realized nothing was dialed and called [DATE] again and nothing happened. She then remembered that the phones were not working and headed to Resident CR1's room to notify the registered nurse. When she got to the doorway, the registered nurse handed her a cell phone and she fumbled through the screens to get to the phone's keypad to dial [DATE], but was not successful. Licensed Practical Nurse 6 then pulled out her cell phone and said that she would call. As this was going on, she saw Licensed Practical Nurse 8 doing CPR and Registered Nurse 7 taking over. Interview with Licensed Practical Nurse 8 on [DATE], at 3:38 p.m. revealed that she went to give Resident CR1 her medications at 4:35 a.m., and the resident was unresponsive. She tried to arouse her, and she shook her, but the resident did not respond, and she did not see the resident's chest moving. She then ran out of the resident's room to the nursing station to check the resident's code status and called a Code Blue overhead. At that time, staff were responding and staff brought a crash cart and defibrillator. The resident was then lowered to the floor and CPR was started at 4:45 a.m. She indicated that the delay may have come from when she was trying to arouse the resident and that she was in shock. Interview with Registered Nurse 7 on [DATE], at 11:09 p.m. revealed that Licensed Practical Nurse 8 came to the Registered Nurse Supervisor's office and advised her that Resident CR1 was not breathing. They then responded to the resident's room and had one of the other licensed practical nurses call [DATE]. They performed CPR until EMS arrived at 5:00 a.m. An interview with Registered Nurse 7 on [DATE], at 11:45 a.m. revealed that Code Blue could have been called sooner when Licensed Practical Nurse 8 initially found Resident CR1 unresponsive and did not see her chest moving. She also indicated that [DATE] could have been called sooner by the nurse aide who left the resident's room after the resident was lowered to the floor. Interview with Licensed Practical Nurse 5 on [DATE], at 1:40 p.m. revealed that she responded to the code from the third floor. As she approached the B-Wing, Licensed Practical Nurse 11 was sitting at the nursing station holding the phone. Licensed Practical Nurse 11 asked her to talk with [DATE] and handed her the phone. She realized that the number was not dialed so she dialed [DATE] and the phone did not work. She then went to the resident's room and Registered Nurse 7 gave her the cell phone, but she did not know how to get the keypad to dial [DATE]. Licensed Practical Nurse 6 then said that she would call [DATE]. She indicated that Licensed Practical Nurse 6 waited until she could not use the cell phone and then called [DATE]. She also indicated that she was not trained on how to use the cell phone and was not informed that she could keep her personal cell phone on her. She fumbled through the screens of the cell phone, which caused a definite delay, and she felt that Licensed Practical Nurse 6 could have called [DATE] sooner. Interview with the Nursing Home Administrator on [DATE], at 4:06 p.m. revealed that she inserviced the facility's department heads and registered nurse supervisors on the use of the facility's cell phone due to a phone line outage on [DATE] and 16, 2017. Registered nurses and licensed practical nurses could also carry their personal cell phones to use in the event of an emergency. Interview with the Director of Nursing on [DATE], at 12:30 p.m. confirmed that Licensed Practical Nurse 8 did not call a Code Blue after finding Resident CR1 unresponsive with no noticeable chest risings, and that [DATE] could have been called sooner with the facility's emergency cell phone. The above statements and interviews revealed that Resident CR1 was found unresponsive and not breathing on [DATE], at 4:35 a.m., that Code Blue was called and CPR was started at approximately 4:45 a.m. (10 minutes after finding the resident unresponsive), and that EMS was called at 4:50 a.m. (15 minutes after finding the resident unresponsive). A [DIAGNOSES REDACTED]. A speech therapy discharge summary, dated [DATE], indicated that the resident was to be seated at 90 degrees (upright) for all meals and for 30 minutes after meals, and that education was provided to the resident's care givers. Resident R8's care plan, dated [DATE], also indicated that the resident was to be seated at 90 degrees for meals and for 30 minutes after meals, and an inservice training attendance list, undated, indicated that Nurse Aide 3 received training regarding this issue. Observations on [DATE], at 8:55 a.m. revealed that Resident R8 was in bed, there was no breakfast tray in her room at that time, and Nurse Aide 3 was in the process of raising the head of the resident's bed from approximately 30 degrees. Observations at 9:12 a.m. (approximately seventeen minutes later) revealed that there was a breakfast tray on the resident's over-bed table and the majority of the foods and liquids were missing from the tray. The head of the resident's bed was observed to be at an approximate 45 degree angle, instead of 90 degrees as ordered and care planned. A meal intake report, dated [DATE], revealed that Resident R8 ate between 76 and 100 percent of her breakfast. Interview with Nurse Aide 3 on [DATE], at 9:17 a.m. revealed that she forgot and thought that the head of Resident R8's bed was supposed to be at 30 degrees (reclined). Interviews with Speech Language Pathologist 4 and the Nursing Home Administrator on [DATE], at 9:45 a.m. and 4:55 p.m., respectively, confirmed that Resident R8 should have been positioned at 90 degrees during the breakfast meal and for an hour after the breakfast meal. A [DIAGNOSES REDACTED]. Resident CR4's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on [DATE], at 12:15 p.m. revealed that Resident CR4's pulse should have been taken prior to administering [MEDICATION NAME]. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of clinical records and facility policies, as well as resident and staff interviews, it was determined that the facility failed to adequately monitor residents' bowel function and ensure that physician's orders [REDACTED]. The facility also failed to ensure that physician's orders [REDACTED]. Findings include: A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R6, dated December 5, 2016, revealed that the resident was non-verbal, rarely understood, was incontinent of bowel and bladder, and was dependent on staff for all of her care. The resident's care plan, dated July 6, 2016, revealed that she had a history of [REDACTED]. Hospital records, dated August 2016, revealed that the resident had a history of [REDACTED]. physician's orders [REDACTED].(a liquid laxative inserted rectally) as needed if there were no results from the [MEDICATION NAME] suppository. Resident R6's bowel records for November 2016, revealed that the resident had a bowel movement on November 22, 2016, at 6:37 a.m. There was no documented evidence that the resident had a bowel movement on November 23-27, 2016, and there was no documented evidence that staff administered MOM, a [MEDICATION NAME] suppository, and/or a Fleets enema as ordered. A nursing note for Resident R6, dated November 27, 2016, at 10:15 a.m. revealed that the resident had a large coffee ground emesis (vomit containing partially digested blood, giving it a red-brown color), and the physician was notified and gave an order for [REDACTED]. A hospital CT scan of Resident R6's abdomen and pelvis, dated November 27, 2016, at 12:06 p.m. revealed that there was a large amount of stool in the rectum, consistent with marked (clearly noticible) fecal impaction, the stool in the rectum caused marked sigmoid distention (a section of the bowel is stretched to a larger size), and the rectum measured at least 10 x 10 centimeters in distention and was filled with hard stool material. A hospital history and physical for Resident R6, dated November 27, 2016, at 4:12 p.m. revealed that the resident had a large bowel obstruction that clearly caused her emesis, and it was quite apparent it was from an extremely large fecal impaction that would be difficult to extract given that the impaction was somewhere between the size of a softball and a soccer ball. Interview with the Director of Nursing 1 on March 17, 2017, at 12:20 p.m. confirmed that Resident R6 had a history of [REDACTED]. physician's orders [REDACTED]. The resident's bowel records for February and March 2017 revealed that the resident had a bowel movement on February 28, 2017, at 11:33 a.m. and there was no documented evidence that she had a bowel movement from this time through when she left for a [MEDICAL TREATMENT] treatment the morning of March 4, 2017. The resident's Medication Administration Record [REDACTED]. A nursing note for Resident R19, dated March 4, 2017, at 11:30 a.m. revealed that the facility was contacted by the resident's [MEDICAL TREATMENT] provider (a center that provides services to mechanically cleanse the blood due to a lack of normal kidney function) and informed that the [MEDICAL TREATMENT] provider transferred the resident to the hospital after she complained of chest pain. A nursing note, dated March 4, 2017, at 3:30 p.m. revealed that the facility was contacted by the hospital and informed that the resident had a significant amount of hard stool present, and that she was disimpacted (the process where the stool is manually removed from the rectum) at the hospital and they administered an enema to the resident. An X-ray report for Resident R19, dated March 4, 2017, revealed that the resident had a prominent colonic fecal retention with rectal impaction (large amount of hard, dry stool in the large intestine which could not be passed through the rectum) and a CT scan, dated March 4, 2017, confirmed the X-ray's findings. An emergency department final report, dated March 4, 2017, indicated that the resident was disimpacted at the emergency room for a large amount of stool, and there was a small amount of bleeding during the procedure. An enema was then administered, a small amount of stool was expelled, and then the resident was disimpacted a second time, with more stool being removed. A second enema was administered to help remove any remaining stool from the rectum. Interview with Resident R19 on March 17, 2017, at 11:00 a.m. confirmed that she was sent to the emergency room and that the staff had to give her enemas to remove stool. She stated that the staff at the nursing home did not offer her a suppository for her bowels on the day before she went to the emergency room . Interview with Director of Nursing 1 on March 17, 2017, at 3:43 p.m. revealed that a suppository should have been administered to Resident R19 seventy-two hours after her last bowel movement, which was during the day shift on March 3, 2017. She confirmed that there was no documented evidence that a suppository was administered, or offered and refused by the resident. physician's orders [REDACTED]. Resident R2's bowel records for February 2017, revealed that the resident had a bowel movement on February 4, 2017, at 11:21 a.m. The resident did not have a bowel movement on February 5, 6, 7, 8, 9 or 10, 2017. The resident's Medication Administration Records (MAR's) revealed that the staff administered MOM on February 8, 2017, at 9:30 a.m. (day 4) and a [MEDICATION NAME] suppository on February 9, 2017, at 10:00 a.m. However, there was no documented evidence that either the MOM or [MEDICATION NAME] suppository were effective in producing a bowel movement, and there was no documented evidence that the staff offered or administered a Fleets enema as ordered. Resident R2's MAR's revealed that the staff did not administer any additional medication to facilitate a bowel movement until February 11, 2017, at 9:00 a.m. when a second dose of MOM was administered, which was effective for a bowel movement during the evening shift (3:00 p.m. to 11:00 p.m.). Resident R2's bowel records also revealed that the resident did not have a bowel movement from February 12 through 19, 2017 (7 days). The resident's MAR's revealed that the staff administered a dose of MOM on February 15, 2017, at 9:30 a.m. (Day 4) and another dose on February 19, 2017 at 8:00 a.m. (day 8). There was no documented evidence that the staff administered or offered a [MEDICATION NAME] suppository and/or a Fleets enema when the first dose of MOM was not effective. The resident's bowel records for February and March 2017 revealed that the resident did not have a bowel movement from February 20 to 25 and from February 27 to March 3, 2017, and the resident's MAR's revealed no documented evidence that staff offered or administered any of the ordered bowel medications. An interview with Registered Nurse 12 on March 17, 2017, at 12:00 p.m. revealed that it was the facility's routine to administer MOM when a resident did not have a bowel movement in three days. If the MOM was ineffective, a [MEDICATION NAME] suppository was to be given on the next shift, and if the [MEDICATION NAME] was ineffective, then a Fleets enema was to be given on the next shift. She confirmed that the bowel protocol was not implemented or followed appropriately for Resident R2. physician's orders [REDACTED]. Bowel records for Resident R7 indicated that the resident did not have a bowel movement from January 11 through January 16, 2017 (6 days). The resident's MAR's revealed that the staff did not administer MOM and adminstered a [MEDICATION NAME] suppository on January 16, 2017, at 10:00 p.m. (day 6). Resident R7's bowel records for February 2017 revealed that the resident did not have a bowel movement from February 17 through 21, 2017 (5 days), and the resident's MAR's revealed that staff did not administer MOM until February 21, 2017, at 9:00 a.m. (day 5). An interview with Registered Nurse 13, on March 17, 2017, at 9:10 a.m. confirmed that there was no documented evidence that Resident R7 was offered or administered bowel medications as ordered by the physician. She also confirmed that there was no documented evidence to show that staff monitored the resident's bowel status during the times that she did not have a bowel movement. physician's orders [REDACTED]. suppository. Resident R11's bowel records for February and March 2017 revealed that the resident had a bowel movement on February 24, 2017, at 10:26 p.m. The resident did not have a bowel movement on February 25, 26, 27 and 28, 2017, and there was no documented evidence that the staff administered bowel medication(s) as ordered. physician's orders [REDACTED]. Resident R12's bowel records for February and March 2017 revealed that the resident had a bowel movement on February 26, 2017, at 9:54 p.m. The resident did not have a bowel movement on February 27 and 28, and March 1 and 2, 2017, and there was no documented evidence that the staff administered bowel medication(s) as ordered. An interview with Licensed Practical Nurse 7 on March 17, 2017, at 11:08 a.m. confirmed that MOM should be given when a resident has not had a bowel movement in three days. If the MOM was ineffective, a [MEDICATION NAME] suppository was to be given on the next shift, and if the [MEDICATION NAME] was ineffective, then a Fleets enema was to be given on the next shift. physician's orders [REDACTED]. Nursing notes for Resident R3, dated February 2, 7, 11, 16 and 25, 2017, and March 1, 7 and 11, 2017, revealed that the resident was transported to and from [MEDICAL TREATMENT] treatment via a wheelchair instead of a litter as ordered. A [MEDICAL TREATMENT] communication sheet, dated March 7, 2017, indicated that the resident reported that she had severe pain in the coccyx (tailbone) region, and a [MEDICAL TREATMENT] communication sheet, dated March 9, 2017, indicated that the resident stopped her [MEDICAL TREATMENT] treatment 10 minutes early due to pain. An interview with Resident R3 on March 15, 2017, at 5:16 p.m. revealed that she told multiple staff members that she had pain when transported to [MEDICAL TREATMENT] in a wheelchair. An interview with the Medical Records Director on March 15, 2017, at 3:59 p.m. confirmed that Resident R3 was being transported to [MEDICAL TREATMENT] treatments in a wheelchair. An interview with the Registered Nurse 1 on March 17, 2017, at 12:05 p.m. confirmed that there was no order to discontinue the use of a litter to transport Resident R3 to [MEDICAL TREATMENT] treatments and that the resident should have been transported via a litter. The facility's policy regarding changes in condition and physician notification, dated June 30, 2016, indicated that Licensed Nurses would ensure that physician's were notified about changes in the resident's condition, and that it was not sufficient to document that the physician was faxed without verbal follow-up. If there was no verbal contact with the physician within a reasonable time, the Director of Nursing or designee, or the Medical Director, were to be notified. A facsimile (fax) for Resident R3, dated March 8, 2017, advised the resident's physician that the resident had chronic complaints of pain in her coccyx area and requested a [MEDICATION NAME] (patch containing medication to relieve pain) for the coccyx area. The fax and the resident's clinical record contained no documented evidence that the physician replied to the fax until March 13, 2017, at which time the physician ordered an X-ray of the area and ordered a 5 percent [MEDICATION NAME] be applied to the area in the morning and removed at night. There was no documented evidence of verbal follow-up to the fax when a reply from the physician was not received in a timely manner. An interview with Registered Nurse 1 on March 17, 2017, at 12:05 p.m. confirmed that verbal follow-up should have been attempted when the physician did not reply to the fax in a timely manner. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 2/10/17, 12/19/16, 9/12/16, 7/18/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/10/17, 12/19/16, 10/25/16, 9/12/16, 7/18/16, 11/5/15, 9/24/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/10/17, 1/13/17, 12/19/16, 10/25/16, 9/12/16, 7/18/16, 12/3/15, 11/5/15, 9/24/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/2/17, 2/10/17, 1/13/17, 12/19/16, 11/17/16, 10/25/16, 9/12/16, 7/18/16, 6/11/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of seven residents reviewed (Residents R7, R8), resulting in harm to Resident R7 due to the development of a deep tissue injury and two pressure ulcers, and harm to Resident R8 due to a fall that resulted in a fractured arm. Findings include: A [DIAGNOSES REDACTED]. of the spinal cord are compressed). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R7, dated November 7, 2016, indicated that the resident was confused, was dependent on the assistance of two persons for bed mobility, was incontinent of bowel, required assistance with toileting, and had limited range of motion of her upper and lower extremities on both sides. A skin report and a nursing note, dated January 24, 2017, revealed that the resident had a Stage IV pressure sore (a wound caused by pressure that is severe and has spread to the underlying muscle or bone) on her coccyx (tail bone) and she was being seen by the wound clinic. The resident's care plan addressing daily tasks, dated April 24, 2016, indicated that she required the assistance of two for toileting and turning and repositioning, and that she was to be toileted/checked and changed every two hours with turning and repositioning. Information submitted by the facility on January 21, 2017, indicated that at 7:00 a.m. that day, Resident R7 verbalized to a nurse aide that her buttocks hurt. The nurse aide checked the resident and found that she was on a bedpan, which was then removed. A skin report, dated January 21, 2017, revealed that after the bedpan was removed, the resident had new pressure areas that were in the shape of a half horseshoe and which included a 21.0 x 2.0 centimeter (cm) vertical Stage I pressure area (an injury to the skin that is not open) on the right buttocks, a 13.0 x 1.5 cm horizontal deep tissue injury (injury to the underlying tissue below the skin surface that results from prolonged pressure) above the coccyx, and a 6.8 x 2.0 cm Stage I pressure area to the left lower flank. The information submitted by the facility revealed that the facility was unable to determine the actual length of time that Resident R7 was on the bedpan because all of the staff who were interviewed denied placing the resident on the bedpan. However, Nurse Aide 6 indicated that when she checked the resident at 5:30 a.m., she did not observe that the resident was on the bedpan. An interview with the Assistant Director of Nursing on February 1, 2017, at 10:20 a.m. confirmed that Resident R7's newly developed pressure areas were in a shape that was consistent with a bedpan. An interview with the Nursing Home Administrator on February 1, 2017, at 4:10 p.m. revealed that Resident R7 alleged that Nurse Aide 5 placed her on the bedpan; however, Nurse Aide 5 denied placing the resident on the bedpan. A quarterly MDS assessment for Resident R8, dated November 1, 2016, revealed that the resident was confused and had [DIAGNOSES REDACTED]. An incident report for Resident R8, dated January 7, 2017, revealed that the resident was found on the floor that day and had fallen while ambulating (walking) with her walker. She was transported to the hospital where an X-ray report showed a fractured left humerus (the large bone in the upper arm). Following this fall, the resident's care plan, dated January 10, 2017, indicated that the resident was at risk for further falls, and she was to use a lap buddy (a padded cushion-like device applied over the resident's upper thighs and held in place by the frame of the wheelchair) when in her wheelchair. Another new intervention that was added to the resident's care plan on January 10, 2017, was for the resident to be on 15-minute checks (visibly sighted by staff every 15 minutes to ensure her safety). An incident report for Resident R8, dated February 6, 2017, indicated the resident was found on the floor in her room at approximately 7:50 p.m. The resident was transported to the hospital where an X-ray showed a fractured right humerus. The resident's Frequent Observation Worksheet, dated February 6, 2017, indicated that visual observations that were scheduled to be completed at 7:30 p.m. and 7:45 p.m. were not completed as planned. A written statement provided by Licensed Practical Nurse 12, dated February 6, 2017, indicated that she had been completing Resident R8's required visual observations every 15 minutes, but she left the unit for her break at approximately 7:20 p.m. A written statement provided by Licensed Practical Nurse 9, dated February 7, 2016, indicated that when the staff member who was completing Resident R8's visual observations (Licensed Practical Nurse 12) left the unit for a break, she was not told that she was responsible for completing the required visual observations after that time. A written statement provided by Nurse Aide 10, dated February 6, 2017, indicated that she had removed Resident R8's lap buddy during the evening meal, and that she forgot to reapply it after the meal. An interview with Registered Nurse 11, on February 10, 2017, at 3:17 p.m. revealed she was the Registered Nurse supervisor at the time of Resident R8's fall on February 6, 2017, and that the resident's lap buddy was not in place at the time of the fall, and that 15-minute checks were not completed as required. She confirmed that these two interventions were part of the resident's care plan to prevent falls, and that they should have been completed as planned. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/13/17, 12/19/16, 11/17/16, 9/12/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15. 28 Pa. Code 211.11(d) Resident care plan Previously cited 10/25/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/13/17, 12/19/16, 11/17/16, 10/25/16, 9/12/16, 7/18/16, 6/11/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of seven residents reviewed (Resident R6), resulting in harm for Resident R6, whose psychosocial issues were not addressed, and who continued to display adjustment difficulties including being physically violent with other residents. Findings include: The facility's behavior management policy, dated June 30, 2016, revealed that the facility's behavior management program was provided by an interdisciplinary team and recognized that behaviors exhibited by residents required appropriate identification, data collection, intervention, management, and evaluation to assist the resident in obtaining their highest practical level of functioning. The interdisciplinary team was to work in partnership with the resident and family to establish effective interventions and goals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R6, dated November 16, 2016, revealed that the resident could usually be understood and could understand others, had no behaviors, used a wheelchair, and had [DIAGNOSES REDACTED]. The resident's care plan, reviewed by the facility on December 5, 2016, and January 30, 2017, revealed that the resident had verbal aggression, wandered (aimlessly), had physically abusive behaviors, was to be seen by the psychiatrist as needed, that staff were to monitor for any changes in behavior and report them to the physician, and there were to be signs directing other residents away from her room. A psychiatry note, dated September 13, 2016, revealed that Resident R6 had no outbursts or expressions of anger and her impulsive behaviors were not currently being displayed. The plan was to decrease the resident's [MEDICATION NAME] (an antipsychotic medication) to 25 milligrams (mg) at bedtime and to follow up within two months. An incident report, dated October 6, 2016, at 2:40 a.m. revealed that the staff saw that the door to Resident R6's room was closed and when they opened the door, Resident R5 was sitting on Resident R6's bed, and Resident R6 was on the floor. An incident report, dated January 3, 2017, at 4:15 p.m. revealed that Resident R6 and R7 were in Resident R6's bed, Resident R6 was pulling Resident R7's hair, and Resident R7 was trying to kick Resident R6. The physician was notified and gave no new orders, and (because staff thought that Resident R7 entered Resident R6's room through the adjoining bathroom) a sign was placed on the bathroom door to instruct Resident R7 not to enter Resident R6's room. A nursing note, dated January 13, 2017, at 5:20 p.m. revealed that Resident R6 was being verbally aggressive towards another resident and was following her down the hall and telling her that she was going to hit her so hard she would knock her head right off her shoulders. Resident R6 was yelling at the other resident that she needed to stop stealing her stuff. An interview with Licensed Practical Nurse 1 on February 1, 2017, at 7:17 p.m. revealed that Resident R6 was yelling at Resident R5 and they were immediately separated. However, there was no documented evidence that any interventions were put into place to protect Resident R5 from Resident R6. An incident report, dated January 27, 2017, at 4:15 p.m. revealed that while in the hallway, Resident R6 hit Resident R5 three times in the face and knocked her down, because she was annoying and took her dog. Resident R5 had bruising around the left eye, left cheek and upper lip. Additional interventions included a psychiatry consultation for Resident R6. There was no documented evidence that Resident R6 was seen by the psychiatrist for a follow-up visit two months after the visit on September 13, 2016, or that she was seen by the psychiatrist as a result of the incident that occurred on January 27, 2017. Observations on February 1, 2017, at 9:50 a.m. and at 10:36 a.m. revealed that Resident R6 was in her room, and there was no sign across or on her doorway directing other residents from coming into her room. An interview with Nurse Aide 2 on February 1, 2017, at 5:39 p.m. revealed that Resident R5 wandered all over the unit and would go into other residents' rooms. An interview with Nurse Aide 3 on February 1, 2017, at 5:44 p.m. revealed that Resident R6 wandered around the unit and would get very agitated if other residents were in her room. An interview with Registered Nurse 4 on February 1, 2017, at 5:57 p.m. confirmed that Resident R6 was not seen by the psychiatrist since the visit on September 13, 2016, and that a stop sign was to be in place to prevent other residents from wandering into Resident R6's room. She indicated that the lack of psychiatry services has been a concern for sometime. An interview with the Nursing Home Administrator on February 1, 2017, at 6:00 p.m. confirmed that Resident R6 had not been seen by a psychiatrist since September 13, 2016, and that the current psychiatrist only sees residents on the weekends and not everyone gets seen. 42 CFR 483.40(b)(1) Treatment/services for Mental/psychosocial Difficulties. Previously cited 10/25/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/12/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/13/17, 12/19/16, 10/25/16, 9/12/16, 7/18/16, 12/3/15, 11/5/15, 9/24/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/13/17, 12/19/16, 11/17/16, 10/25/16, 9/12/16, 7/18/16, 6/11/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15.

Based on review of facility policies, food temperature records, and clinical records, as well as staff interviews, it was determined that the facility failed to provide supervision and take precautions to prevent injury to a resident caused by hot coffee for one of 19 residents reviewed (Resident R8), resulting in first and second degree burns to the resident's legs. Findings include: The facility's policy regarding hot liquid management, dated June 30, 2016, indicated that coffee urns were to hold coffee at no greater than 180 degrees to 190 degrees Fahrenheit; that coffee was to be dispensed into insulated containers such as coffee pitchers, insulated mugs, or insulated bulk containers; and prior to delivering coffee to the units, the staff were to record the temperature of the coffee to ensure it was not greater than 165 degrees Fahrenheit. Review of food temperature records for December 1, 2016 through January 12, 2017, indicated that the dietary staff did not obtain and record coffee temperatures for the breakfast meal on December 7 and 12, 2016; the lunch meal on December 2, 7, 12, 15, 21 and 25, 2016; and the supper meal on December 3, 4, 7, 17, 18, 21, 23, 26, 27, 28 and 31, 2016, and January 1, 5, 6 and 11, 2017. The food temperature records also showed that the temperature of the coffee was greater than 165 degrees, and ranged between 168 to 178 degrees for the breakfast meal on December 3, 5, 6, 8-11, 13-17, 19, 20, 22-24, and 26-31, 2016, and January 1-4, 6, 7, 10 and 12, 2017. The temperatures of the coffee ranged between 166 to 191 degrees for the lunch meal on December 3-6, 8-11, 13-20, 22-24, 26-28, 30 and 31, 2016, and January 1-10, 2017, and ranged between 168 to 175 degrees for the supper meal on December 1, 2, 6, 8, 9, 13, 14, 25 and 30, 2016, and January 4, 10 and 12, 2017. In addition, the records indicated that hot water that was 169 or 170 degrees Fahrenheit was sent to the nursing units with the supper meal on December 6, 9, 25 and 30, 2016, and January 3, 2017. There was no documented evidence that the facility followed their policy for ensuring that the temperature of hot liquids sent to the nursing units was not greater than 165 degrees Fahrenheit. An interview with the Dietetic Technician on January 13, 2017, at 11:15 a.m. confirmed that the temperature of the coffee was to be obtained at the time it left the kitchen to go to the nursing units, and if the temperature was over 165 degrees Fahrenheit, it should be allowed to cool prior to sending it. The facility's policy regarding care plans, dated June 30, 2016, indicated that a resident's overall care plan was to be oriented towards managing risk factors to the extent possible, or indicating limits of such interventions. An undated [DIAGNOSES REDACTED]. The resident's care plan, dated December 18, 2016, indicated that the resident was to have Dycem (a non-slip material), and the Kardex (a listing of care and services staff are to provide for the resident), last updated December 19, 2016, indicated that the resident was to have the Dycem on her meal trays. The resident's care plan also indicated that the staff were to assist the resident to eat if she was fatigued at meals. The resident's care plan did not address her ability to safely consume hot drinks between meals. An occupational therapy plan of treatment for [REDACTED]. Occupational therapy progress notes for December 19, 2016 through January 6, 2017, indicated that the resident required maximum assistance with range of motion and the functional use of her upper extremities, that she had limited shoulder flexion (the ability to move her arms from her side to above her head), and she had bilateral hand clenching. The notes also indicated that for self-feeding, the resident had limited functional upper extremities use and that she used both hands to stabilize items. An occupational therapy note, dated December 21, 2016, indicated that Resident R8 was seen for self-feeding and she initially required placement of the utensils into her hands, placement of food onto the utensils, and hand-over-hand (the placement of the therapist's hands over the resident's hands to help the resident) to bring her arms and hands up to her mouth. After three attempts, the resident stated that she preferred to be fed. The resident used a large cup with a lid and a straw and had difficulty bringing it to her mouth. An occupational therapy note, dated December 28, 2016, indicated that Resident R8 was seen for self-feeding and she needed maximum assistance. The resident was unable to grasp the silverware in her right hand and was able to grasp the silverware with her left hand and bring it to her mouth with hand-over-hand assistance. The resident was able to use a Kennedy cup (cup with a lid and a drinking straw through the lid) with hand-over-hand assistance. A nursing note for Resident R8, dated January 12, 2017, at 3:00 p.m. indicated that the resident spilled a cup of coffee on herself and her right upper thigh, both inner thighs, and the back of the right upper thigh were reddened. The skin on the right upper thigh was noted to be loose and appeared to be beginning to blister, and blisters were noted to the back of the right upper thigh. The resident stated that her cup of coffee was on the tray table in front of her and she knocked it over. A physician's progress note for Resident R8, dated January 12, 2017, at 3:10 p.m. revealed that the resident had first degree (reddened skin) and second degree (blistered and reddened skin) burns to both legs and thighs. A twice daily treatment was ordered for the areas until healed. An interview with Nurse Aide 5 on January 12, 2017, at 4:25 p.m. revealed that she and Nurse Aide 7 were in Resident R8's room talking with the resident about getting her a cup of coffee. She stated that she left the room to assist another resident and Nurse Aide 7 went to get the coffee. She heard Nurse Aide 7 return and give the resident her coffee and tell the resident that it was time for her (the Nurse Aide) to leave. Nurse Aide 5 stated that shortly after this, she heard the resident scream but was not able to leave the other resident unattended. She then observed Nurse Aide 8 come out of a resident's room, and she asked Nurse Aide 8 to check on Resident R8. She then went to Resident R8's room after making sure the resident she was with was safe. Nurse Aide 5 stated that when she found out what had happened she asked Nurse Aide 7, who was in the hallway, to inform the nurse. When questioned about the cup the resident used for her coffee, she stated that it was a plastic cup that looked like a mason jar with a handle and lid, and a hard plastic straw through the lid. Nurse Aide 5 stated that she felt that the resident needed a flexible straw and that the resident was not able to pick the cup up. She indicated that she felt that the resident's hands appeared worse following her recent hospitalization in December 2016 and that it was not safe to leave the resident unattended with hot coffee, so she always sat with the resident while she drank coffee every afternoon. She also stated that the resident needed to be fed by staff for meals. Nurse Aide 5 was not aware of any information regarding the resident's safety with hot liquids on the Kardex or on the resident's care plan. An interview with Nurse Aide 7 on January 12, 2017, at 4:44 p.m. confirmed that she obtained coffee from the kitchen for Resident R8. She adjusted the over-bed table as requested by the resident, placed the thumb and second finger of the resident's right hand around the handle of her personal cup, and the resident braced the cup with her left hand. She gave the resident a couple sips of the coffee to ensure that it was the way the resident likes it, because the resident likes her coffee to be really hot, and then she left the room. She stated that there was Dycem on the resident's over-bed table, that the resident did not like using Dycem, and she did not remember if the coffee cup was on the Dycem or not. She stated that she was very sure that there was no information on the Kardex related to the resident's safety when drinking hot liquids and that the resident likes to be as independent as possible. An interview with the Director of Therapy on January 12, 2017, at 5:20 p.m. revealed that Resident R8 had a technique she used when she drank from her cup. The resident used the thumb and one finger on one hand, and the other hand to tip the cup to drink. He indicated that there was no evidence that an assessment to determine if the resident was safe when drinking hot liquids was completed. An interview with Resident R8 on January 12, 2017, at 6:35 p.m. revealed that she liked the cup she currently used because it was easy for her to use. She stated that she has coffee every afternoon and the nurse aides usually put the table over her bed and put the cup on the wood (bare surface of the table). On this occasion, she thinks the aide may have put the cup of coffee on a paper towel, and it may have been over the red stuff (Dycem) on her table, and that nothing slides if it is on that. The resident stated that she attempted to slide the cup toward herself and it tipped over, spilling the coffee on her. An interview with Nurse Aide 8 on January 12, 2017, at 6:40 p.m. revealed that she was the first staff member to enter the room after Resident R8's incident. She observed the resident's personal cup spilled over on the table, and the resident had hot coffee spilled on her legs. She stated that she threw the cup on the floor, moved the table, and started to use other sheets on the bed to try to get the coffee off the resident. Nurse Aide 5 entered the room and assisted her with getting the sheets off the bed to try to prevent any further burns. Nurse Aide 8 stated that she felt that it was not safe for the resident to be left unattended when she had her afternoon coffee, and she stayed in the room with the resident while she drank it. She stated that there was nothing on the Kardex to indicate that staff were to stay with the resident when she had hot coffee. Interview with the Assistant Dietary Manager on January 12, 2017, at 5:15 p.m. revealed that she did not know if the temperature of the coffee served to Resident R8 was obtained prior to sending it to the unit, and she was not sure who prepared it for the resident. An interview with the Dietetic Technician on January 13, 2017, at 11:15 a.m. confirmed that the dietary staff should have obtained the temperature of the coffee before it was sent to the nursing unit. There was no documented evidence that the temperature of the coffee served to Resident R8 was obtained by dietary staff. There was no documented evidence that the equipment and technique used by Resident R8 was assessed to ensure that she was safe to drink hot liquids independently. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accidents Hazards/Supervision/Devices. Previously cited 9/12/16, 3/23/16, 11/5/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/19/16, 11/17/16, 10/25/16, 9/12/16, 7/18/16, 6/11/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15.

Based on review of clinical records and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the care plan was followed for one of 34 residents reviewed (Resident CR3) who had a history of [REDACTED]. Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR3, dated August 28, 2016, revealed that the resident was confused, required extensive assistance with eating, received a mechanically altered diet, and had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. physician's orders [REDACTED]. Speech therapy notes, dated October 10-12, 2016, revealed that Resident CR3 was noted to hold his food in his mouth but cleared the food with liquids and verbal and tactile cues. Investigation information for Resident CR3 and a speech therapy note, dated October 13, 2016, revealed that Speech Therapist 10 was working with Resident CR3 in his room when the resident held a bite of pancake in his cheek and did not swallow it. Speech Therapist 10 went to the kitchenette to get some applesauce to assist the resident with swallowing the food. When Speech Therapist 10 returned from the kitchenette, Licensed Practical Nurse 11 had administered medications to Resident CR3 and the resident continued to hold these items in his mouth. The resident had some coughing and expelled a small amount of food. The resident's mouth was swabbed twice to clear it, and the resident was noted to have rattle-like breathing and was unable to cough. The resident's oxygen saturation (percentage of oxygen in the blood) dropped to 73 percent and continued to be in the 70's (low). The resident was suctioned but nothing was brought out with suctioning. Speech Therapist 10 tried to make the resident cough or swallow throughout the entire incident but was unable to get the resident to do so. The resident ceased to breath, and the cause of death was acute (recent) aspiration. Interview with Licensed Practical Nurse 11 on October 19, 2016, at 11:03 a.m. confirmed that she observed Speech Therapist 10 coming out of Resident CR3's room, and the Speech Therapist did not tell her that the resident had pocketed his food. She went into the resident's room, crushed his medications, placed them in pudding and administered them to the resident, but the resident would not swallow the medications and pudding. Licensed Practical Nurse 11 stated that if she would have known that the resident had pocketed his food, she would not have administered his medications. She confirmed that if the resident held his food in his mouth, the staff were to stop feeding him. Interview with Speech Therapist 10 on October 25, 2016, at 1:40 p.m. confirmed that she left Resident CR3 alone after she noted that the resident was holding food in his mouth, and she did not inform Licensed Practical Nurse 11 that the resident was holding some food in his mouth. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 9/12/16, 7/9/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/12/16, 7/18/16, 6/11/16, 4/8/16, 12/29/15, 12/3/15, 11/5/15, 9/24/15, 8/5/15, 7/9/15, 5/28/15, 5/13/15, 12/4/14, 10/17/14.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide ongoing pain evaluation and management for one of two residents reviewed (Resident R1), and failed to notify the physician timely regarding complaints of pain, which resulted in a delay in treatment for one of two residents reviewed (Resident R1). Findings include: The facility's policy regarding pain management, dated February 25, 2015, revealed that the facility was committed to pain management through interdisciplinary data collection and approach. A quarterly Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs) for Resident R1, dated August 6, 2015, revealed that the resident was confused, required extensive assistance with activities of daily living, had a history of [REDACTED]. physician's orders [REDACTED]. A facility investigation report, dated August 30, 2015, revealed that Resident R1 had a fall out of bed on August 28, 2015, at 1:30 a.m., and Licensed Practical Nurse 3 and Nurse Aide 9 picked the resident up and placed him back in bed. The report indicated that on August 30, 2015, Nurse Aides 1 and 2 went to turn the resident and he screamed out in pain very loudly, and Licensed Practical Nurse 3 responded to the scream and noted that the resident had severe pain. A nursing note, dated August 30, 2015, at 1:00 a.m., revealed that Licensed Practical Nurse 3 indicated that the resident cried out in pain with routine care and complained of left leg pain. There was no documented evidence that the resident was treated for his pain, until Tylenol was administered at 7:00 a.m., six hours later. Resident R1's Medication Administration Record [REDACTED]. The facility investigation report revealed that on the morning of August 30, 2015, at 9:00 a.m., Nurse Aides 4 and 5 gave Resident R1 a bed bath, and he continued to scream in pain, grabbed his leg, and his eyes were full of tears. A nursing note at 9:45 a.m. revealed that the resident continued to complain of left leg pain during routine care. There was no documented evidence that the resident's pain was assessed by a registered nurse until 10:00 a.m., at which time a nursing note indicated that the resident grimaced when his leg was moved. There was no documented evidence that the physician was notified about the resident's complaints of leg pain until 1:40 p.m., at which time an X-ray of the left leg was ordered, but there was no documented evidence that the resident was treated for his continued complaints of pain. An X-ray report, dated August 30, 2015, at 4:12 p.m., revealed that Resident R1 had an acute left femoral neck (hip) fracture, and a physician's orders [REDACTED]. Interview with Registered Nurse 6 on November 4, 2015, at 1:10 p.m., revealed that on August 30, 2015, Licensed Practical Nurse 3 made her aware, at the beginning of the day shift (7:00 a.m. to 3:00 p.m.), that Resident R1 was complaining of pain throughout the night, and she confirmed that she did not assess the resident until 10:00 a.m. She revealed that she did not immediately notify the physician about the resident's continued complaints of severe pain because she knew the physician was coming to the building later that day, and she would get orders at that time. Interview with the Director of Nursing on November 4, 2015, at 1:12 p.m., confirmed that Resident R1 was not assessed by a registered nurse in a timely manner, that the physician was not notified timely, and the resident did not receive timely or effective treatment for his pain. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 9/24/15, 7/9/15, 5/28/15, 12/4/14, 10/17/14, 1/17/14, 9/12/13. 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 9/24/15, 8/5/15, 7/9/15. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 9/24/15, 8/5/15, 7/9/15, 5/28/15, 5/13/15, 12/4/14, 10/17/14, 9/23/14, 2/20/14, 1/17/14, 9/12/13.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned for one of two residents reviewed (Resident R1) who fell and suffered a fracture. Findings include: The facility's policy regarding fall prevention, dated February 25, 2015, revealed that the staff were to implement an interdisciplinary care plan based on the resident's needs. A quarterly Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs) for Resident R1, dated August 6, 2015, revealed that the resident was confused, required extensive assistance with activities of daily living, had a history of [REDACTED]. A care plan, dated April 27, 2015, revealed that the resident had a history of [REDACTED]. A facility investigation report, dated August 30, 2015, revealed that Resident R1 had a fall out of bed on August 28, 2015, at 1:30 a.m., and Licensed Practical Nurse 3 and Nurse Aide 9 picked the resident up and placed him back in bed. There was no documented evidence that the resident had Gerihips on at the time of the fall. An X-ray report, dated August 30, 2015, at 4:12 p.m., revealed that Resident R1 had an acute left femoral neck (hip) fracture, and a physician's orders [REDACTED]. Interviews with Nurse Aide 2 and Nurse Aide 9 on November 4, 2015, at 1:30 p.m. and 2:15 p.m., respectively, revealed that Resident R1 never wore gerihips. Interview with the Director of Nursing on November 4, 2015, at 1:12 p.m., confirmed that there was no documented evidence that Resident R1 was wearing gerihips as care planned or that they were on at the time of the fall on August 28, 2015. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 9/24/15, 8/5/15, 7/9/15, 5/28/15, 5/13/15, 12/4/14, 10/17/14, 9/23/14, 2/20/14, 1/17/14, 9/12/13.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident having pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for two of five residents reviewed (Residents R2, R4). Findings include: Physician orders [REDACTED]. Observations on 7/7/11 at 7:40 p.m. revealed that the resident had two open pressure sores, one on the coccyx, and one on the left buttocks. The pressure sores were not covered with a dressing; they were covered with the incontinent brief. Interview at that time with Nurse Aide 1 revealed that the resident was incontinent at 5:30 p.m. and the pressure sore dressing was soiled with stool; therefore, she removed the soiled dressing at that time. She indicated that she had not notified the licensed practical nurse yet. Nurse Aide 1 provided incontinent care and applied A&D ointment to both open pressure sores. She squeezed the A&D ointment onto her gloved hand and then applied it to each pressure sore. Interview on 7/7/11 at 8:30 p.m. with Licensed Practical Nurse 3 revealed that she was not notified that the resident's dressing was removed at 5:30 p.m. and she indicated that she was not aware that the resident had a second pressure sore. Observations on 7/8/11 at 9:20 a.m. revealed that the dressings were dated 7/7/11 as being applied to both pressure sores on that date. Physician orders [REDACTED]. There was no documented evidence that the treatment was applied. There was no documented evidence of the pressure sore on the resident's buttocks, only the one on the coccyx. Interviews on 7/8/11 at 9:30 a.m. with Registered Nurse 2 revealed that she changed the pressure sore treatment on 7/5/11 without contacting the physician for an order. She indicated that she wrote the treatment order as though she received it from the physician, but she never contacted him to get the order. She indicated that she routinely wrote physician orders [REDACTED]. Interview on 7/8/11 at 1:15 p.m. with the Director of Nursing revealed that the pressure sore on the coccyx was worse than previously assessed and was now a Stage III, and there was a new Stage II pressure sore on the right buttock. Nursing notes dated 7/1/11 at 10:00 a.m. for Resident R4 revealed that the resident had a new Stage II pressure sore on the right buttock and that a treatment was applied. There was no documented evidence that the physician was notified of this pressure sore or that he gave an order to treat it. Observations on 7/7/11 at 8:00 p.m. revealed that as a nurse aide provided incontinent care the dressing on the resident's right buttocks was soiled; therefore, she removed it. There was a Stage II pressure sore on the right buttocks and both buttocks were reddened. Interview on 7/8/11 at 10:00 a.m. with Registered Nurse 2 revealed that she wrote a physician order [REDACTED]. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/1/10.