Every finding on record at Mountain Top Rehabilitation & Healthcare Center

Based on observations, clinical record review, review of select facility policies and procedures, and staff and resident interviews, the facility failed to provide Resident 34, who was dependent on staff for activities of daily living (ADLs), with the care and services necessary to maintain proper personal hygiene and grooming, including nail care and monitoring of a contracted hand. As a result of this failure, the resident developed an open wound to the palm that required treatment and caused pain. This deficient practice resulted in actual harm for one of 29 residents reviewed (Resident 34).Findings include: A review of the facility policy entitled Bath, Shower/Tub last reviewed by the facility on February 2, 2026 indicates it is the policy of the facility to provide residents with a bath/shower to promote cleanliness, provide comfort to the resident, to observe the condition of the resident's skin, to provide residents with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Step 20 indicates the staff is to dry the resident from head to waist before assisting him or her from the tub or shower. The staff is then instructed to observe the resident's skin for any rashes, reddened areas, skin discoloration, etc. A review of the facility procedure entitled, Fingernails/Toenails, Care of last reviewed by the facility on February 2, 2026, revealed the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. In preparation staff are to review the resident's care plan to assess for any special needs of the resident. The procedure is outlined as follows: Place the equipment on the bedside stand or overbed table. Arrange supplies so they can be easily reached. Wash and dry hands thoroughly. Fill wash basin one-half full of warm soapy water. Allow the first hand to soak in the warm soapy water for approximately 5 minutes. Encourage the resident to exercise his or her fingers while they are soaking. Rinse the hand that has been in the soapy water with clear, warm water. Dry the hand with a towel.Gently, remove the dirt from around and under each nail with an orange stick (small wooden tool made from orange wood to clean underneath the nails).Trim fingernails in an oval shape.Smooth the nails with a nail file or emery board, then repeat the procedure to the other hand. The facility policy guides staff to document the following: The date and time that the nail care was given, the name and title of the individual administering the nail care, the condition if the resident's nails, any redness or irritation of the skin on the hands, breaks or cracks in the skin, pain, any difficulties cutting the resident's nails, any problems or complaints made by the resident with his/her hands, and documentation of refusal or reason why the intervention was not completed A review of the clinical record revealed Resident 34 was admitted to the facility on [DATE], with diagnoses including reduced mobility and chronic obstructive pulmonary disease (a progressive lung disease that causes airflow limitation and shortness of breath). A review of Resident 34's Annual MDS Assessment (Minimum Data Set, a federally mandated standardized assessment process completed periodically to plan resident care) dated November 12, 2025, revealed the resident was totally dependent on staff assistance for bathing and required moderate assistance of staff members for personal hygiene, which can include combing hair, shaving, brushing teeth, applying makeup, and washing/drying face and hands. The MDS revealed the resident was cognitively intact as evidence by a BIMS score of 15 (Brief Interview for Mental Status is a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). A review of Resident 34's clinical record revealed a history of contracted right and left hands (a condition in which fingers are fixed in a bent position, commonly toward the palm, due to tightening of tissue beneath the skin). An orthopedic evaluation dated December 9, 2025, confirmed flexion contractures (chronic, often painful condition where a joint, most commonly the knee, hip, or finger, becomes stiff and stuck in a bent or flexed position, resisting active or passive straightening) of digits three through five of both hands. Resident 34's care plan, initiated January 11, 2025, identified self-care deficits and required two staff members to assist with bathing due to shortness of breath, weakness, and cognitive impairment. The goal of this focus was that the resident will accept assistance during bathing or showering. The plan included bilateral carrot splints (a cylindrical device placed in the palm to separate fingers, reduce skin breakdown, and promote hygiene) to both hands at night. The care plan also documented the resident preferred showers. A revised care plan dated March 18, 2025, directed staff to check nail length and trim and clean nails on bath days and as necessary. A physician order dated February 8, 2025, required a weekly licensed nurse skin inspection every Saturday evening during the 3:00 Pm to 11:00 PM shift. A review of Resident 34's December 2025 Treatment Administration Record (TAR) revealed a skin inspection on Saturday December 13, 2025, was completed; however, the clinical record did not contain documentation describing the results of those assessments. The record did not reflect assessment of the contracted fingers or nail condition. The TAR for January 2026, revealed a skin inspection was signed off as completed on January 3, 2026, January 10, 2026, January 24, 2026, and January 31, 2026. The clinical record did not have a full assessment of the skin documented. The clinical record could not support any documentation of results of the skin inspection. A review of Resident 34's clinical record indicated that from December 1, 2025, to the end of survey February 20, 2026, the resident did not exhibit any behaviors related to refusing assistance with care. A review of the Documentation Survey Reports for November 2025 through February 2026 revealed the facility failed to document required shift skin observations for Resident 34 on the following dates and shifts: November 1, 2025-night shiftNovember 6, 2025-night shiftNovember 8, 2025-day shiftNovember 8, 2025-night shiftNovember 9, 2025-day, evening, and night shiftsNovember 19, 2025-night shiftNovember 23, 2025-day shiftNovember 30, 2025-night shiftJanuary 4, 2026-night shiftJanuary 6, 2026-evening shiftJanuary 9, 2026-night shiftFebruary 5, 2026-day shiftFebruary 6, 2026-night shiftFebruary 8, 2026-night shiftFebruary 11, 2026-night shiftFebruary 15, 2026-night shift Additional review revealed that on documented shifts, staff consistently recorded no new skin issues; however, the clinical record did not contain evidence that staff assessed the contracted fingers or the palm area where the injury later developed. An interview with Resident 34 conducted on February 17, 2026, at 12:34 PM revealed the resident prefers showers over bed baths, Resident 34 stated that when staff are busy, they give her a bed bath because it is quicker than providing her with a shower, due to her needing mechanical lift assistance for transfers. A review of the Documentation Survey Reports for November 2025, December 2025, January 2026, and February 2026 revealed the facility provided Resident 34 with bed baths on the following dates, despite documentation in the care plan that the resident preferred showers: November 1, 2025; November 5, 2025; November 15, 2025; November 19, 2025; November 26, 2025; December 6, 2025; December 10, 2025; December 13, 2025; January 7, 2026; January 10, 2026; January 24, 2026; January 31, 2026; February 7, 2026; February 11, 2026; February 14, 2026; and February 18, 2026. Review of the Documentation Survey Reports revealed staff provided Resident 34 with a shower three times in November 2025, four times in December 2025, three times in January 2026, and one time in February 2026. Between November 2025 and the survey end date, the facility scheduled Resident 34 to receive 32 showers. The facility provided only 11 of the 32 scheduled showers. The clinical record did not contain documentation that Resident 34 refused showers on the dates bed baths were provided. A review of Resident 34's clinical record from November 2025 through the survey end date did not contain documentation that staff provided nail care as required by facility policy and the resident's care plan. An interview with Resident 34 on February 18, 2026, at 9:00 AM, revealed Resident 34 stated that when staff provided showers, they washed the tops of her hands but did not wash underneath her contracted fingers. Resident 34 stated that her contractures are painful, and that the right hand was more painful than the left and had worsened recently. Resident 34 stated she informed staff that her hands were painful and that staff don't do much with my hands. She stated that therapy provided carrot splints to be inserted at nighttime. She reported she could not independently insert the splint into her right hand and that staff did not assist her by lifting her fingers to place the splint between her fingers and palm as directed. The clinical record contained no documentation of nail care from November 2025 through the survey end date of February 20, 2026. An observation on February 19, 2026, at 2:38 PM with the assistance of Employee 4, LPN (licensed practical nurse), Employee 4, separated the resident's contracted fingers on her right hand, the surveyor observed a strong foul odor, thickened and elongated mycotic (common fungal infections causing nails to become thick, brittle, and yellow or white, often separating from the bed) fingernails, and the middle fingernail curling into the palm of the contracted hand. An open skin area was identified in the mid-palm region. Measurement of the open area revealed 1.2 cm in greatest width where the nail had embedded. Following identification of the open area and fungal involvement to the palm of Resident 34's right hand on February 19, 2026, the facility obtained physician orders dated February 20, 2026, directing staff to cleanse the palms of both hands with soap and water and apply antifungal powder twice daily. These orders initiated medical treatment for skin breakdown and infection that developed while the resident was dependent on staff for hygiene and nail care. Interview with the Director of Physical Therapy (PT) on February 20, 2026, at 9:32 AM revealed therapy evaluated Resident 34 on January 20, 2026, due to bilateral hand contractures. The Director of PT stated that during the January 20, 2026, assessment, the skin of both hands was intact. Review of the physical therapy documentation dated January 20, 2026, revealed therapy instructed nursing staff to apply bilateral carrot splints to the resident's hands at night. The documentation reflected nursing staff acknowledgment and signature that education was provided. The education included instructions to monitor skin integrity and report any concerns to therapy as indicated. During an interview on February 20, 2026, at 1:00 PM Resident 34 stated staff had not provided nail care and that her fingernails had grown long enough to dig into her palm. The resident stated she used her teeth to tear off the elongated portion of the nail because it was digging into her hand. The resident stated staff washed under her contracted fingers earlier that morning. Resident 34 stated, Staff have never paid this much attention to me before. They usually tell me I have anxiety and leave me alone. The clinical record did not demonstrate that staff consistently provided nail care, routinely inspected the contracted hand for skin integrity, ensured consistent application of bilateral carrot splints as recommended by therapy on January 20, 2026, or timely identified developing skin breakdown. Therapy documented that the skin was intact on January 20, 2026. On February 19, 2026, an open area measuring 1.2 cm in greatest width was identified on the resident's palm. Resident 34 required staff assistance with activities of daily living due to bilateral hand contractures. The facility did not demonstrate consistent implementation of care plan interventions to maintain proper grooming, nail care, and hand hygiene for this dependent resident. As a result of the facility's failure to consistently provide necessary ADL assistance and monitor skin integrity, Resident 34 developed an open skin area on the palm caused by elongated fingernails pressing into the contracted hand. The open area required cleansing and treatment, and the resident reported pain. This failure resulted in actual harm to the resident, as evidenced by the development of a measurable open wound (1.2 cm), the need for clinical treatment, and the resident's report of pain. During an interview conducted on February 20, 2026, at 1:50 PM, the Nursing Home Administrator and Director of Nursing reviewed these findings. The facility did not provide documentation demonstrating consistent provision of required care and services or timely identification of the resident's hand injury. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services.

Based on observations, clinical record review, review of facility policies, and staff interviews, the facility failed to ensure a resident who entered the facility with existing pressure-related skin damage received necessary care and services to prevent additional pressure injuries and prevent worsening of existing wounds. This failure resulted in actual harm, unstageable to Stage 4 pressure areas, for one of 29 residents reviewed (Resident 11.) Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines, indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy entitled Prevention of Pressure Injuries, last reviewed by the facility on February 2, 2026, revealed it is the facility's policy to use a standardized pressure injury screening tool to determine and document resident risk factors for developing pressure injuries, inspect skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs), establish and implement a nutritional care plan for any resident at risk of malnutrition, monitor the resident for weight loss and intake of food and fluids, and select appropriate support surfaces and pressure redistribution interventions based on the resident's risk factors. A pre-admission external provider wound note dated October 7, 2025, indicated recommendations for Resident 11 to be repositioned every two hours and to utilize pillows or wedges to offload pressure while in bed. A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that included pressure-induced deep tissue damage of the sacrum (damage to the skin and underlying tissue caused by prolonged pressure, often over bony prominence) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 16, 2025, revealed that Resident 11 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 to 7 indicated severe cognitive impairment). A care plan initiated November 6, 2025, identified risk for impaired skin integrity related to impaired cognition and interventions implemented directed staff to turn and reposition as needed, consult dietitian as needed, and elevate heels off the mattress. A second care plan initiated November 19, 2025, identified altered nutritional status and underweight condition for age and directed staff to provide feeding/dining assistance, monitor weight, notify physician and dietitian of significant changes, and refer to occupational therapy and speech pathology services for evaluation and treatment as needed. A physician order dated October 9, 2025, required offloading heels (keeps heels elevated off bed or surface so no weight rests on them, which prevents reduced blood flow and helps avoid pressure injuries) while in bed every shift for heel protection. The facility discontinued the order November 1, 2025, when Resident 11 was hospitalized from [DATE], through November 3, 2025, and did not renew the order upon readmission November 3, 2025. A review of the documentation survey reports (record of interventions and tasks implemented) and treatment administration record for November 1, 2025, through January 2026, revealed no documented evidence that Resident 11's heels were elevated off the mattress as indicated in the plan of care. Clinical records also contained no documentation staff implemented routine turning and repositioning interventions to reduce Resident 11's risk of developing pressure injuries from November 2025 through January 2026. Staff documented repositioning only as a non-pharmacological intervention before administering pain medication rather than as a scheduled preventive intervention. A Braden Scale assessment (a standardized clinical assessment that measures risk of pressure injury based on sensory perception, moisture, activity, mobility, nutrition, and friction) dated December 20, 2025, indicated moderate risk for pressure injury. Clinical record review revealed Resident 11 experienced clinically significant, unplanned weight loss following admission. The resident lost more than 5 percent of body weight within 30 days and a total of 10 percent within four months. A body mass index of 19.5 kg/m2 indicated the resident was underweight for advanced age. Although the registered dietitian (RD) initiated protein supplementation, the facility did not document consistent weight monitoring and did not implement additional nutritional interventions despite continued decline. Unplanned weight loss and undernutrition reduce subcutaneous tissue and muscle mass that normally cushion bony prominences such as the heels. Loss of protective tissue increases susceptibility to pressure-related tissue damage. A progress note dated January 8, 2026, at 5:09 PM documented therapy staff identified Resident 11 had open draining wounds on both heels. The left heel measured 3.5 cm by 1.5 cm, and the right heel measured 5.0 cm by 3.5 cm with moderate sanguineous drainage, meaning blood-tinged fluid. Staff applied treatment, elevated heels, and notified the physician and representative. A progress note dated January 13, 2026, at 1:50 PM documented evaluation by an external wound care provider. The provider noted protective heel boots at bedside and nursing staff reported the resident refused to wear them. The provider recommended protective heel boots when out of bed and heel offloading while in bed. The clinical record from admission October 9, 2025, through January 13, 2026, contained no documented evidence staff implemented heel boots and no documentation that the Resident 11 refused to wear them. A pressure injury, also called a pressure ulcer or bedsore, is damage to skin and underlying tissue caused by prolonged pressure that reduces blood flow, usually over bony areas such as heels or the sacrum. Stages indicate severity:Stage 3: Full thickness skin loss with visible fat tissue.Stage 4: Full thickness tissue loss exposing muscle, tendon, or bone.Unstageable: Depth cannot be determined because dead tissue covers the wound. A review of external wound care provider notes dated January 13, 2026, through February 17, 2026, revealed that Resident 11's bilateral heel injuries were assessed as:January 13, 2026, right heel- unstageable measuring 6.0 cm x 3.3 cm x 0.1 cmJanuary 20, 2026, right heel- unstageable measuring 3.0 cm x 3.0 cm x 0.1 cmJanuary 27, 2026, right heel- unstageable measuring 3.4 cm x 3.2 cm x 0.1 cmFebruary 3, 2026, right heel- unstageable measuring 2.5 cm x 3.0 cm x 0.2 cmFebruary 10, 2026, right heel-unstageable measuring 3.0 cm x 3.0 cm x 0.2 cmFebruary 17, 2026, right heel- unstageable measuring 2.5 cm x 2.5 cm x 0.2 cmJanuary 13, 2026, left heel- unstageable measuring 2.0 cm x 4.0 cm x 0.1 cmJanuary 20, 2026, left heel- unstageable measuring 1.6 cm x 1.5 cm x 0.1 cmJanuary 27, 2026, left heel- unstageable measuring1.5 cm x 1.5 cm x 0.1 cmFebruary 3, 2026, left heel- unstageable measuring 1.1 cm x 1.1 cm x 0.1 cmFebruary 10, 2026, left heel-stage 4 measuring 1.0 cm x 1.1 cm x 0.1 cmFebruary 17, 2026, left heel- stage 3 measuring 0.9 cm x 0.7 cm x 0.1 cmThis documentation demonstrates progression from unstageable tissue damage to a Stage 4 pressure injury, indicating full thickness tissue loss exposing deeper structures. Clinical records reviewed through survey completion date of February 20, 2026, contained no documented evidence staff implemented the external wound care provider's January 13, 2026, recommendations for heel boots or heel offloading. During wound care observation February 20, 2026, at 10:58 AM, Employee 1, Licensed Practical Nurse (LPN) measured the right heel wound at 2.5 cm x 2.0 cm x 0.1 cm with a pink/red wound bed with slough (a type of soft, moist, dead tissue, typically yellow, tan, gray, or white in color, that forms in the wound bed), granulated wound edges (red or deep pink, moist, and bumpy), and some serosanguinous drainage (thin, watery, pale pink to light red fluid). The wound had no notable odor. Employee 1, LPN, confirmed Resident 11's left heel injury measured 1.0 cm x 0.5 cm x 0.1 cm with a pink wound base, little slough, granulated wound edges, and minimal serosanguinous drainage During an interview on February 20, 2026, at 11:50 AM the above findings were reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that recommended interventions to reduce Resident 11's risk of developing pressure injuries, including turning and repositioning, floating heels while in bed, and protective heel boots when out of bed, were implemented as recommended prior to admission or as developed in the plan of care during his stay. The NHA also did not provide documentation demonstrating the Stage 4 left heel injury or unstageable right heel injury was unavoidable. The facility failed to provide necessary care and services to prevent development and worsening of pressure injuries and failed to follow physician orders, care plans, and professional standards of practice resulting in harm. Refer F692 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policies, physician orders, weight records, MDS assessments, and staff and resident interviews, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status to the extent possible. The facility failed to reassess and adjust enteral nutrition and oral intake in response to significant progressive weight loss for one resident (Resident 31), resulting in actual harm as evidenced by a 36.8 pound (21.1 percent) unplanned weight loss in two months. The facility further failed to timely monitor weights and implement interventions for one resident (Resident 11), resulting in continued significant weight loss and development of bilateral unstageable pressure injuries and failed to obtain ordered monthly weights for one resident (Resident 15). These failures occurred for 3 of 29 residents reviewed. Findings include: Review of the facility Enteral Nutrition Policy (tube feeding, liquid nutrition delivered through a tube into the gastrointestinal tract) last reviewed February 2, 2026, indicated that adequate nutritional support through enteral nutrition is provided to residents as ordered. The dietitian with input from the provider and nurse estimates calorie, protein, and fluid needs, determines whether the resident's current intake is adequate to meet his or her nutritional needs, recommends special food formulations, and calculates fluids to be provided (beyond free fluids in formula). The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. Review of the facility Weighing and Measuring the Resident Policy last reviewed February 2, 2026, indicated that the purpose of the policy is to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight for the resident. Weight is usually measured upon admission and monthly during the resident's stay. Report significant weight loss or gain to the nurse supervisor. Notify the nurse supervisor if the resident refuses the procedure. The threshold for significant unplanned and undesired weight loss will be based on: 1 month, 5 percent weight loss is significant, greater than 5 percent is severe3 months, 7.5 percent weight loss is significant, greater than 7.5 percent is severe6 months, 10 percent weight loss is significant, great than 10 percent is severe. A review of a facility policy entitled Nutritional Assessment, last reviewed by the facility on February 2, 2026, revealed it is the facility's policy to conduct a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, for each resident. The registered dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The policy indicated individualized care plans will be developed that address or minimize to the extent possible the resident's risk of nutritional complications. A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke caused by disrupted blood flow to the brain), left-sided hemiplegia (paralysis on the left side of the body), and dysphagia (difficulty swallowing). Physician orders for Resident 31 dated November 17, 2025, directed NPO (nothing by mouth) and Isosource 1.5 at 60 ml/hour (milliliters per hour) continuously via PEG tube (percutaneous endoscopic gastrostomy, a feeding tube inserted through the abdominal wall into the stomach when oral intake is not adequate) with 250 cc (cubic centimeters) water flush every six hours. A review of Resident 31's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 23, 2025, revealed that Resident 31 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). Review of Resident 31's weight record revealed an initial documented weight on November 20, 2025, (three days after admission) was 169.6 pounds. The resident's height was 5 feet 5 inches. The resident's calculated ideal body weight range was noted to be 144 to 174 pounds. A review of Resident 31's clinical record revealed that on November 24, 2025, staff documented in an SBAR note (Situation, Background, Assessment, Recommendation, a structured communication tool used to report changes in condition) that the resident exhibited edema (swelling caused by excess fluid), fever, and unresponsiveness. The physician ordered transfer to the hospital. The hospital admitted the resident with diagnoses of adult failure to thrive (overall decline in physical functioning and nutritional status) and bilateral pleural effusions (collection of fluid around both lungs that can impair breathing). Resident 31 returned to the facility on December 4, 2025, weighing 174 pounds. Physician orders dated December 4, 2025, directed NPO (nothing by mouth), Isosource 1.5 at 60 ml/hour continuously via PEG tube, 250 cc water flush every six hours, and weekly weights for four weeks. On December 5, 2025, the Registered Dietitian (RD) calculated Resident 31's daily needs as 2059 to 2401 calories, 82 to 102.9 grams of protein, and 2059 to 2401 milliliters of fluid. The RD documented that the current feeding regimen met estimated needs and recommended increasing the feeding rate to 80 ml per hour for 18 hours daily and adding 30 cc liquid protein mixed with 60 cc water via PEG tube for additional nutritional support. A physician order dated December 6, 2025, was implemented for liquid protein 30 cc mixed with 60 cc water via PEG tube daily and on December 8, 2025, implemented Isosource 1.5 ml at 80 ml/hr for 18 hours via PEG begin at 6:00 PM and off at 12:00 PM. Despite these interventions, the resident experienced progressive and severe weight loss as follows: December 4, 2025, 174 poundsDecember 10, 2025, 160.4 pounds (13.6 pound or 7.8 percent significant weight loss in 6 days, no reweight completed, no evidence of physician or RD notification)December 17, 2025, 158.6 pounds December 24, 2025, 146.6 pounds (27.4 pounds or 15.7 percent significant weight loss in 20 days, no evidence of physician or RD notification) December 31, 2025, 144.4 poundsJanuary 4, 2026, 145.2 pounds February 12, 2026, 137.2 pounds, reweight taken and noted as 137.2 pounds (36.8 pounds or 21.1 percent significant weight loss in 2 months and 7 days)February 19, 2026, 138 pounds. On February 2, 2026, nursing staff documented that Resident 31 returned from a video fluoroscopy (an X-ray test used to evaluate how a person swallows food and liquids). The results showed no aspiration (food or liquid entering the airway) and no penetration (food or liquid entering the upper airway but not passing below the vocal cords). Staff notified speech therapy of the results. On the same date, February 2, 2026, the physician ordered a puree diet (foods blended or mashed into a smooth, pudding-like consistency that requires no chewing) with lemon ice on each tray. A review of Resident 31's clinical record revealed no documented evidence that the Registered Dietitian (RD) reevaluated the resident's tube feeding regimen or overall nutritional needs in response to the resident's significant and progressive weight loss between December 5, 2025, and February 10, 2026. During this period, the resident's weight continued to decline substantially. The record contained no documentation that the facility identified this ongoing significant weight loss in accordance with facility policy thresholds or acted promptly to address it. The record lacked documentation that the RD reassessed the adequacy of calories, protein, fluids, or the overall nutritional support plan during this period of rapid decline. On February 10, 2026, eight days after the physician ordered the puree diet, the RD documented awareness that Resident 31 had started a puree diet with thin liquids. The resident reported feeling full from the tube feeding and stated he did not want to eat some meals. The RD reduced the tube feeding to overnight administration at 85 ml/hour for 12 hours from 6:00 PM to 6:00 AM daily, providing 1,530 calories per day. The RD documented that staff would continue to monitor PO intake (PO, meaning by mouth/oral) and weights. On February 12, 2026, after Resident 31's weight reached 137.2 pounds, the RD documented that the resident triggered for significant weight loss within one month. The RD noted minimal oral intake and increased the tube feeding to 90 ml/ hour for 12 hours and increased liquid protein to three times daily to promote nutritional adequacy and weight recovery. The revised tube feeding provided 1,620 calories per day. The RD initiated weekly weights at that time and continue to motor PO intakes and tube feeding tolerance. During an interview on February 19, 2026, Resident 31 stated he did not like puree foods and was not eating much of the diet. He reported his usual weight was at least 165 pounds and expressed concern that he had lost too much weight. The resident's representative confirmed that speech therapy was working with him to improve oral intake and introduce foods that were not pureed. During an interview on February 20, 2026, at 9:00 AM the RD confirmed he began employment on January 26, 2026, and stated that Resident 31's tube feeding, oral intake, and weights are now being monitored to prevent additional weight loss and ensure the resident's nutritional needs are met to the extent possible. The RD confirmed there was no documented evidence that the resident's nutritional needs were reevaluated between December 5, 2025, and February 10, 2026, despite significant weight loss during that period. During an interview on February 20, 2026, at 11:00 AM the Director of Nursing was unable to provide documentation demonstrating the facility timely monitored and reassessed Resident 31's nutritional needs to prevent significant weight loss and maintain nutritional parameters to the extent possible for the resident who was dependent on tube feeding to meet his nutritional needs. The facility's failure to timely identify, reassess, and adjust enteral and oral nutritional interventions in response to documented significant and progressive weight loss resulted in actual harm to Resident 31, as evidenced by a severe 36.8 pound (21.1 percent) unplanned weight loss, reflecting significant nutritional decline in two months. Clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that included pressure-induced deep tissue damage of the sacrum (damage to the skin and underlying tissue caused by prolonged pressure, often over bony prominence) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of an admission Minimum Data Set assessment dated [DATE], revealed that Resident 11 is severely cognitively impaired with a BIMS score of 4; a score of 0 to 7 indicates severe cognitive impairment. A clinical record review revealed a care plan indicating Resident 11 was at risk for altered nutritional status and was underweight for his age, initiated on November 19, 2025. Interventions implemented to ensure Resident 11 would not have significant weight change included providing feeding and dining assistance as needed, periodically obtaining the resident's weights, evaluating and reporting to the registered dietitian, physician, and family when significant weight changes occur, and referring to occupational therapy and speech pathology services for evaluation and treatment as needed. A clinical record review revealed a care plan indicating Resident 11 has an activities of daily life (ADL) self-care performance deficit initiated on November 6, 2025. Interventions implemented to ensure Resident 11's ADL needs would be met included supervision-level assistance while eating, initiated on November 6, 2025. Resident 11 weighed 154.0 pounds on October 9, 2025, upon admission), and 144.0 pounds on November 4, 2025, reflecting a 6.49 percent weight loss, or 10 pounds, in 30 days. A loss greater than 5 percent in one month constitutes significant weight loss. There was no documented evidence that the facility notified the registered dietitian or that the registered dietitian was aware Resident 11 had significant weight loss until 15 days later on November 19, 2025. A nutritional risk assessment dated [DATE], at 4:45 PM documented that Resident 11 was underweight for advanced age with a body mass index (BMI a numerical value calculated by weight and height that estimates whether body weight is underweight normal or overweight) of 19.5 kg/m2 (kilogram per square meter). Significant weight loss was noted with a 6.5 percent loss over three to four weeks. The assessment indicated Resident 11 was independent with setup provided for meals, with assistance from staff at times. The RD initiated liquid protein twice daily to support weight stabilization and planned continued monitoring and remain available for any nutrition-related needs and concerns. The clinical record did not indicate the physician was notified about Resident 11's significant weight loss as measured on November 4, 2025. Resident 11 weighed 144.8 pounds on December 1, 2025. The facility did not document a weight for January 2026, despite facility policy requiring monthly weights. On February 5, 2026, Resident 11 weighed 138.6 pounds, representing a 10 percent loss or 15.4 pounds in less than four months. The clinical record contained no evidence that staff attempted to obtain or document the resident's weight between December 1, 2025, and February 5, 2026, a period of 66 days. The clinical record contained no documented evidence that the facility identified this continued significant weight loss in accordance with facility policy thresholds. The record lacked documentation that staff implemented additional dietary interventions despite ongoing weight decline from December 2025 through February 2026.A progress note dated January 22, 2026, at 4:10 PM documented that a significant weight change could not be determined at that time. The note documented that Resident 11 had bilateral unstageable pressure injuries on his heels. An unstageable pressure injury is a wound covered by dead yellow, tan, brown, or black tissue that prevents visualization of the depth of the wound. The RD documented that the current nutrition plan was appropriate to meet the resident's needs for weight stability or gain and wound healing and indicated she would continue to monitor and remain available for any nutrition-related needs or concerns. Despite the RD documenting that a significant weight loss could not be determined on January 22, 2026, the facility had not obtained a current weight since December 1, 2025. The record contained no evidence that staff attempted to obtain a weight at that time to evaluate the resident's nutritional status. Resident 11's clinical record also lacked documentation that the facility implemented timely interventions after identifying the weight of February 5, 2026, weight. The facility did not initiate further evaluation until February 16, 2026, when speech-language pathology assessed the resident for swallowing dysfunction (difficulty swallowing safely or effectively). An occupational therapy Discharge summary dated [DATE], documented that Resident 11 required moderate assistance with eating, meaning staff provided 50 to 74 percent of the effort required to complete the task. A prior evaluation dated November 4, 2025, documented that the resident required only minimal assistance, meaning staff provided 25 percent or less physical support. such as guiding the utensil, stabilizing a plate, or helping with opening packaging), The clinical record revealed that the resident's care plan did not reflect the updated need for increased assistance with meals. A meal intake review from January 26, 2026, through February 18, 2026, indicated five meals that the resident was documented as independent or setup only and consumed less than 50 percent of the meal. Specifically, Resident 11 consumed 0 to 25 percent of dinner on January 26, 2026, and 26 to 50 percent of meals on January 31, 2026 (dinner), February 1, 2026 (dinner), February 13, 2026 (breakfast), and February 18, 2026 (lunch). The clinical record contained no documentation explaining why staff did not provide additional assistance with meals despite reduced intake and documented therapy recommendations. Following surveyor inquiry, the facility updated the resident's care plan on February 19, 2026, to reflect the need for assistance of one staff member during meals to ensure activities of daily living (basic self-care tasks such as eating) were met. During an interview on February 20, 2026, at 11:50 AM the Nursing Home Administrator was unable to provide documented evidence that the facility implemented timely interventions after identifying Resident 11's significant weight loss of 10 percent in less than 4 months on February 5, 2026. The Nursing Home Administrator was also unable to explain the 66-day lapse in weight monitoring from December 1, 2025, through February 5, 2026, despite the resident developing bilateral unstageable pressure injuries. The facility did not provide documentation demonstrating that the resident's weight loss was unavoidable. A review of the clinical record revealed that Resident 15 has diagnoses including Huntington's disease (an inherited neurological disorder that causes progressive breakdown of nerve cells in the brain, leading to cognitive decline, movement disorders, and functional deterioration). A physician's order dated August 6, 2025, directed staff to obtain monthly weights to monitor for changes in Resident 15's nutritional status. A review of Resident 15's weight record on February 18, 2026, revealed documented weights of 170.2 pounds on October 7, 2025, 169.2 pounds on November 6, 2025, and 176 pounds on December 6, 2025. The facility did not document a weight for January 2026 or February 2026, despite the active physician order and facility policy requiring monthly weight monitoring. After surveyor inquiry, staff obtained a weight of 166.2 pounds on February 20, 2026. During an interview on February 19, 2026, at 1:00 PM the Nursing Home Administrator confirmed the facility did not obtain or document Resident 15's January 2026 monthly weight as required. The facility did not provide documentation demonstrating that staff monitored the resident's weight in accordance with physician order and policy to identify potential nutritional decline in a resident with a progressive neurological condition. Refer F68628 Pa Code 211.5 (f) Medical records 28 Pa Code 211.10 (a)(c)(d) Resident care policies 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of scheduled facility mealtimes, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by six out of six residents during a group interview (Residents 6, 19, 58, 64, 80, and 101). Findings include: A review of the facility policy titled Dining Options for Meal Service, last reviewed by the facility on February 2, 2026, revealed it is the facility policy that meals will be served regularly according to the community schedule of dining times, with no more than 14 hours between the time the evening meal is offered and the breakfast meal is offered. The policy indicates that an HS snack (evening snack) must be offered to all residents. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours. Specifically, residents eating in the dining room are scheduled to receive dinner at 5:00 PM.Breakfast is served in resident rooms with:Nursing Unit 2 resident rooms 80 to 93 are scheduled to receive breakfast at 7:15 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 15 minutes.Nursing Unit 1 resident rooms 1 to 36 are scheduled to receive breakfast at 7:30 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 30 minutes.Nursing Unit 2 resident rooms 60 to 78 are scheduled to receive breakfast at 7:45 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 45 minutes.Nursing Unit 1 resident rooms 37 to 57 are scheduled to receive breakfast at 8:00 AM. The scheduled time between dinner and breakfast the next day is 15 hours. During a resident council interview on February 19, 2026, at 10:00 AM, six out of six residents (Residents 6, 19, 58, 64, 80, and 101) indicated that a snack is not offered between dinner and breakfast the following day. Resident 6 explained that only one nurse offers snacks to residents in the evening, and she is not a regular nurse. Residents 19, 58, 64, 80, and 101 explained that they are not offered evening snacks. During an interview on February 20, 2026, at approximately 11:30 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was not able to provide documented evidence that snacks were consistently offered to residents in the evening. The NHA confirmed it is the facility's policy to offer residents nourishing snacks in the evening. 28 Pa. Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs and failed to follow physician orders for the management of a Central Venous Catheter (CVC) and Peripherally Inserted Central Catheter (PICC) line for two of 29 sampled residents (Residents 3 and 75).Findings include: A review of the facility policy entitled Central Venous Catheter Care and Dressing Changes, last reviewed February 2, 2026, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Change the dressing if it becomes damp, loosened, or visibly soiled, at least every seven days, and immediately if the dressing or site appears compromised. For PICCs (peripherally inserted central catheter, a thin, flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream), measure arm circumference and compare to baseline when clinically indicated to assess for edema (swelling caused by fluid accumulation) and possible deep-vein thrombosis (a blood clot in a deep vein). The policy required staff to report signs and symptoms of complications to the physician, supervisor, and oncoming shift. A review of the facility policy entitled Administration Set/Tubing Changes, last reviewed February 2, 2026, revealed it is the policy to change the primary or secondary intermittent (IV tubing used to deliver medications that are not running continuously) administration sets every twenty-four hours or if suspected contamination of tubing has occurred and label the tubing with the date, time, and initials. Place a sterile end cap (a protective sterile cover placed on IV tubing to prevent contamination) on the primary and/or secondary intermittent tubing when it is disconnected from the catheter. A review of the facility policy entitled Administering Medications, last reviewed February 2, 2026, revealed it is the policy that medications are administered in a safe and timely manner and as prescribed. A review of the clinical record of Resident 3 revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of an Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 26, 2026, revealed that Resident 3 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 to 12 indicates cognition is moderately impaired). A review of outside hospital documentation revealed that Resident 3 had a central venous catheter (a sterile, flexible tube inserted into a large vein, typically in the chest, to administer medications directly into the bloodstream) was inserted into the resident's right chest on January 30, 2026. Physician orders dated February 1, 2026, directed staff to maintain a PICC line and keep an emergency kit (sterile materials and clamps to stop bleeding and cap the catheter to reduce the risk of air entering the bloodstream) at the bedside. An additional physician order dated February 1, 2026, directed staff to change the central venous line dressing and caps every seven days and as needed. A physician order dated February 10, 2026, directed staff to administer Ampicillin (an antibiotic medication used to treat bacterial infections) 2 grams intravenously every six hours until March 10, 2026, for a bacterial infection related to a right knee prosthetic (implanted artificial joint) infection. On February 18, 2026, at 11:00 AM, observation of Resident 3 revealed the central line in the right chest had no dressing in place (a sterile dressing protects the catheter insertion site from environmental contamination and reduces infection risk). Resident 3 stated the dressing had fallen off, did not know how long it had been off, and had not notified staff. At that time, observation of the IV pole revealed an empty antibiotic bag attached to IV tubing that was not labeled with a date, time, or initials. The tubing was hanging freely without a sterile end cap on the distal end. Employee 3, Licensed Practical Nurse (LPN), confirmed these observations. A review of the clinical record of Resident 75 revealed the resident was admitted to the facility on [DATE], with diagnoses that included cauda equina syndrome (a rare surgical emergency caused by severe compression of nerve roots at the base of the spinal cord) and osteomyelitis (a bone infection). A review of an admission MDS dated [DATE], revealed that Resident 75 had moderately impaired cognition with a BIMS score of 11 (a score of 8 to 12 indicates cognition is moderately impaired). Outside hospital documentation dated January 30, 2026, revealed a PICC line was inserted in the resident's right arm. Physician orders dated January 30, 2026, directed staff to change the PICC dressing and caps every seven days and as needed. Observation on February 18, 2026, at 12:30 PM, in the presence of Employee 3, LPN, revealed the PICC dressing was dated February 8, 2026. The dressing should have been changed on February 15, 2026, in accordance with the seven-day requirement. Employee 3 acknowledged the dressing was overdue. A second observation on February 19, 2026, at 9:00 AM, revealed the dressing remained dated February 8, 2026, and had not been changed. A review of the February 2026 Treatment Administration Record (TAR) revealed the dressing change scheduled for February 15, 2026, was not signed and left blank. A physician order for Resident 75 dated November 8, 2025, directed staff to administer Cefepime HCL (a broad-spectrum intravenous antibiotic used to treat serious bacterial infections) 100 grams intravenously three times daily until March 5, 2026. A review of Resident 75's February 2026 Medication Administration Record (MAR) revealed the following doses were left blank and not signed as administered: February 7, 2026, at 10:00 PM,February 11, 2026, at 2:00 PM,February 12, 2026, at 2:00 PM,February 13, 2026, at 10:00 PM,February 16, 2026, at 10:00 PM. Blank entries on the MAR indicate the facility did not document administration of ordered IV antibiotics. A physician order for Resident 75, dated January 30, 2026, directed staff to measure and document the circumference of the upper arm at the PICC insertion site every evening shift. Measuring arm circumference identifies swelling that may indicate infection or thrombosis. A review of the February 2026 MAR revealed:Arm circumference measured 22 centimeters from February 1, 2026, through February 6, 2026.February 7, 2026, was left blank.Measurements remained 22 centimeters from February 8 through February 15, 2026.February 16, 2026, was left blank.February 17, 2026, measured 22 centimeters.February 18, 2026, measured 25 centimeters.February 19, 2026, was left blank. Following surveyor inquiry, Employee 3 measured the resident's arm circumference on February 20, 2026, at 10:40 AM, and obtained a measurement of 27 centimeters. This reflected a 5-centimeter increase from the documented baseline of 22 centimeters. Employee 3 stated she was unsure why there was a discrepancy in measurements, why the increase was not investigated, and why the physician was not notified. During interviews on February 19 and February 20, 2026, the Director of Nursing reviewed and confirmed the above findings regarding Resident 3's central venous catheter and Resident 75's PICC line management. The facility failed to follow its own policies and physician orders related to sterile dressing maintenance, tubing changes, antibiotic administration, monitoring of catheter sites, documentation, and physician notification. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas in two of two shower rooms.Findings included: Interview with Resident 7, a cognitively intact resident, on February 18, 2026, at 11:30 AM revealed a concern with the floor in the shower room being black. Resident 7 also stated that the shower room often has a foul odor. Observation of the Unit 2 shower room on February 18, 2026, at 11:40 AM revealed a faded, heavily worn floor with a 14 inch by 7 inch black oval area on the floor leading into the shower stall and peeled paint on the floor of the shower stall (first stall located closest to the entry door of the shower room). There was a two inch by one inch piece of plastic laminate missing from the front corner of the sink area in the shower room. Observation of the Unit 1 shower room on February 18, 2026 at 1:30PM revealed the shower floor to have a build up of what appeared to be soap scum on the shower floor, the shower floor was observed to be lined with anti-slip strips black in color, with a total of 14 strips in place, 7 of the 14 strips were lifted on the sides and not intact. The anti-slip strips appeared to be worn and not in place, defeating the purpose of the anti-slip action. Two of the strips appeared to have black hair attached to the sides of the strips that were lifting up. An observation of the bariatric shower bed (a padded bed used to assist in showering dependent bariatric/large residents) located in the Unit 1 bathroom revealed the shower bed was dry and visibly not in use, the shower bed was observed to have a buildup of powder in the corners of the bed. Interview with the Nursing Home Administrator (NHA) on February 18, 2026, at 2:00 PM confirmed the black on the floor was an epoxy (resin and hardener used as a protective coating on floors) that was used to repair the floor in the past, did not match the floor color, and was not applied in a manner to maintain a homelike interior The NHA confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner. Interview with the Director of Nursing on February 19, 2026, at 10:00 AM reviewed the above findings of the facility's failure to ensure both shower rooms were homelike, clean, and maintained. 28 Pa Code 201.18(e)(2.1) Management

Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance, including experiences reported by 5 out of 6 residents during a resident group interview (Residents 19, 58, 64, 80, and 101). Findings include: During a resident group interview on February 19, 2026, at 10:00 AM, five out of six alert and oriented residents (Residents 19, 58, 64, 80, and 101) indicated that they have concerns about long wait times for care. One out of the six residents in attendance indicated that she is independent and does not need to ring her call bell for staff assistance. During the group interview, Resident 64 indicated that he often waits 30 minutes to an hour for staff to assist him when he rings his call bell for assistance. He explained that this has been an ongoing concern. During the group interview, Resident 101 indicated that she usually waits 30 minutes for staff to respond to her needs for care. Resident 101 explained that she gets frustrated when staff come into her room, turn her call bell off, and do not provide care, because they often do not return until she rings the call bell again for assistance. During the group interview, Resident 80 indicated that she experiences long wait times for care but was unable to provide information on how long she waits. She explained that there is not enough staff to get her up on the day shift, so she has staff on the night shift assist her out of bed and get ready for the day at 5:30 AM. During the group interview, Residents 19 and 58 indicated that they wait 30 minutes for staff to respond to their call bell for assistance. They indicated they know staff are busy providing care for residents throughout the facility but are frustrated with the long wait times they experience for care. During an interview on February 20, 2026, at 11:30 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care.28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on observation, review of select facility policy, state laws, and professional licenses, as well as staff interview, it was determined the facility failed to ensure professional staff were licensed, certified, or registered in accordance with state laws upon hire for one of five personnel files reviewed (Employee 2).Findings include: Pennsylvania's Professional Nursing Law, Section 8 (a) indicated that each person who met the professional nursing licensure requirements would be issued a certificate setting forth that the person was licensed to practice professional nursing. Review of the facility Credentialing of Nursing Service Personnel Policy last reviewed February 2, 2026, indicated that nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment. Nursing personnel requiring a license or certification are not permitted to perform direct resident care services until all licensing and background checks have been completed.Observation on February 18, 2026, at 10:30 AM revealed that Employee 2 Licensed Practical Nurse (LPN) was working on the D Hall on Unit 2. Interview with the director of nursing (DON) on February 18, 2026, at 1:00 PM revealed that Employee 2 (LPN) was newly hired and had been sent home. The DON noted that he was notified by human resources that upon review of her personnel file there was inadequate proof that Employee 2 (LPN) had a valid Pennsylvania LPN license. Review of Employee 2's (LPN) personnel file revealed that she was hired as an LPN on January 28, 2026. Employee 2 (LPN) received a Practical Nursing Program Diploma on November 14, 2025. An Exam Appointment History revealed that Employee 2 (LPN) took the Practical Nurses Exam on January 23, 2026, and passed. However, there was no evidence of a Pennsylvania Practical Nurse license in her personnel file. Interview with the DON on February 20, 2026, at 9:40 AM revealed that Employee 2's (LPN) Practical Nurse license was issued on February 18, 2026, with an effective date of February 18, 2026, and expiration date of June 30, 2026. The DON confirmed the delay in the license being issued was due to the need for verification being provided to the state licensing board for Employee 2's (LPN) required mandatory Child Abuse online training. Once the verification of the completed mandatory Child Abuse online training was received the employee's license was issued. Review of Employee 2 (LPN) time punches revealed that prior to February 18, 2026, the employee worked at the facility on the following dates before being issued a license from the Pennsylvania Bureau of Professional and Occupational Affairs: January 28, 2026, February 2, 3, 4, 5, 7, 9,11,12,13,15, 16, and February 17, 2026. Interview with the Nursing Home Administrator (NHA) on February 20, 2026, at 10:30 AM confirmed that human resources did not complete a license verification upon hire for Employee 2 (LPN) as per facility policy. The NHA confirmed that Employee 2 (LPN) should not have been able to work at the facility without a verified license. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19 (1)(3) Personnel policies and procedures. 28 Pa. Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (Cart A). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility February 2, 2026, indicated that if a multi-use medication vial/injectable (container of liquid medication intended for injection of more than one dose) had been opened and accessed (needle was inserted through the rubber stopper and medication was withdrawn) the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for that opened vial. An observation of the medication cart located on Unit 1 Hall Cart A on February 19, 2026, at 8:22 AM, in the presence of Employee 5 (Registered Nurse-RN), of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Aspart (a short acting insulin medication used to lower blood sugar) and two (2) multi-dose pens of Insulin Lispro (a rapid acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated with an opened date or expiration date, despite the sticker on the pen having an area to document the date opened and expiration date. Further observation revealed one (1) multi-dose insulin pen of Insulin Aspart (a short-acting insulin used to lower blood sugar) with a date on the sticker of the pen documenting the pen was opened and currently in use, with an opened date of January 2, 2026, with no expiration date documented. Review of manufacturer safety information revealed the multi-dose pen of Insulin Aspart is to be discarded 28 days after opening indicating the dated pen should have been discarded on January 30, 2026. Interview with Employee 5, Registered Nurse, on February 20, 2026, at 8:24 AM, confirmed that two multi-dose insulin pens of Insulin Lispro and one insulin pen of Insulin Aspart had been opened, were available for use, were actively being used for medication administration, and were not labeled with expiration dates. Employee 5 further confirmed that the Insulin Aspart pen should have been discarded 28 days after opening; however, it remained in the medication cart and available for use beyond that timeframe. Interview with the Director of Nursing (DON) on February 20, 2026, at 11:00 AM, reviewed the above findings of the facility's failure to ensure the facility staff adhere to the policy of dating and storing multi-dose pens of insulin. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 29 residents sampled (Resident 64).Findings include: A review of the facility policy titled Administering Medications, last reviewed by the facility on February 2, 2026, revealed that medications are to be administered by licensed nurses or other staff authorized to do so by the state, as ordered by the physician, and in accordance with professional standards of practice to prevent contamination, infection, and medication errors. The policy further requires that the licensed nurse administering a medication immediately document the resident's name, date and time of administration, dose, route of administration, and the signature of the nurse on the medication administration record. The policy requires the individual administering the medication to initial the residents Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next medication. A review of the facility policy Controlled Substances last reviewed by the facility on February 2, 2026, revealed that controlled substance inventory is monitored and reconciled to identify loss, or potential diversion in a manner that minimizes the time between loss/diversion and detection/ follow up. The policy requires nursing staff to count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The policy outlines that the coming on duty nurse and the going off duty nurse make the count together and document and report any discrepancies to the director of nursing. The policy documented the system of reconciling the receipt, dispensing, and disposition of controlled substances includes records of personnel access and usage, medication administration records, declining inventory records, and destruction, waste and return to pharmacy records. A review of the clinical record revealed Resident 64 was admitted to the facility on [DATE], with hydrocephalus (an abnormal accumulation of fluid within the brain's ventricles, causing them to widen and exert harmful pressure on brain tissue) and cerebral infarction (a life-threatening, often disabling medical emergency caused by blocked blood flow to the brain, leading to tissue death). A review of the clinical record revealed a physician's order dated January 9, 2026, for Oxycodone 5mg tablets, administer 5mg by mouth every 4 hours as needed for severe pain 8-10. Oxycodone is a Schedule II controlled substance, a medication with accepted medical use but regulated due to its potential for misuse or dependence. Review of facility records revealed the facility utilized a Controlled Drug Receipt/Record/Disposition Form (a narcotic log used to track the receipt, use, and disposition of controlled substances) and a Medication Administration Record (MAR, the clinical record used to document each dose of medication administered, including date, time, medication, dose, and the administering staff member). A comparison of Resident 64's Controlled Drug Receipt/Record/Disposition Form with the MAR for January 2026 and February 2026 revealed repeated discrepancies between medications signed out on the controlled substance record and medications documented as administered on the MAR. Specifically, staff either signed out Oxycodone 5 mg from the narcotic log without documenting administration on the MAR, or documented administration on the MAR without a corresponding entry on the narcotic log. The discrepancies included the following:Documented on MAR but not recorded on the narcotic log:January 13, 2026, at 12:41 PMJanuary 19, 2026, at 7:51 AMJanuary 22, 2026, at 7:43 PMJanuary 28, 2026, at 7:00 PM Signed out on the narcotic log but not documented as administered on the MAR:January 15, 2026, at 7:05 PMJanuary 22, 2026, at 5:45 PMJanuary 24, 2026, at 10:17 AMJanuary 25, 2026, at 5:00 AMFebruary 1, 2026, at 1:37 PMFebruary 4, 2026, at 9:00 PMFebruary 5, 2026, at 9:00 PMFebruary 7, 2026, at 9:00 PMFebruary 8, 2026, at 9:00 PMFebruary 12, 2026, at 10:25 AMFebruary 13, 2026, at 1:45 PMFebruary 13, 2026, at 7:00 PMFebruary 14, 2026, at 7:00 PMFebruary 15, 2026, at 7:00 PMFebruary 16, 2026, at 8:40 AM These inconsistencies demonstrated the facility failed to ensure accurate documentation and reconciliation of controlled substances. When staff do not reconcile the narcotic log with the MAR, the facility cannot account for the medication's administration, raising concerns regarding medication diversion, medication errors, and resident safety. A review of the facility Narcotic Count Sheets (shift-to-shift verification forms requiring both the oncoming and off-going nurse to physically count and verify controlled substances at each shift change) revealed the following:On February 18, 2026, at 9:00 AM, review of the January 2026 Narcotic Count Sheet for the C Hall cart revealed the following missing signatures:January 5, 2026, Second shift oncoming nurseJanuary 9, 2026, Third shift oncoming and off-going nursesJanuary 13, 2026, Third shift off-going nurseJanuary 27, 2026, Third shift off-going nurse On February 18, 2026, review of the January 2026 Narcotic Count Sheet for the A Hall cart revealed the following missing signatures:January 2, 2026, First shift oncoming nurseJanuary 7, 2026, First shift off-going nurseJanuary 15, 2026, Third shift off-going nurseJanuary 16, 2026, Third shift off-going nurse On February 19, 2026, review of the January 2026 Narcotic Count Sheet for the B Hall cart revealed the following missing signatures:January 13, 2026, First shift oncoming nurseJanuary 13, 2026, Second shift oncoming and off-going nursesJanuary 27, 2026, Second shift oncoming and off-going nursesJanuary 27, 2026, Third shift off-going nurseJanuary 30, 2026, First shift oncoming nurseJanuary 30, 2026, Third shift off-going nurseFebruary 17, 2026, Third shift off-going nurseFebruary 19, 2026, First shift oncoming nurse Interview with Employee 5, Registered Nurse on February 19, 2026, at 8:46 AM revealed she had not signed the narcotic log because she had not yet verified the count, despite facility policy requiring the oncoming and off-going nurses to complete the count together at the time of shift change. During an interview on February 19, 2026, at 12:00 PM, the Director of Nursing reviewed the above findings regarding the facility's failure to ensure accurate reconciliation of Resident 64's controlled substances and failure to consistently complete required shift-to-shift narcotic counts. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to ensure staff administered a narcotic pain medication in accordance with the physician's order for one of 21 residents reviewed for medication administration, Resident 64. Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. Review of a facility policy, last reviewed February 2, 2026, revealed staff are responsible to implement medication regimens as ordered by the physician. The policy indicated staff must administer medications as ordered, monitor the resident's response, and document administration and effectiveness A review of Resident 64's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included vascular headaches (intense, throbbing, or pulsating pains caused by the constriction, swelling, or inflammation of blood vessels in the head), and idiopathic peripheral autonomic neuropathy (damage to nerves outside the brain and spinal cord that may affect automatic body functions). Review of a physician order, initially dated January 9, 2026, revealed Resident 64 was prescribed Oxycodone 5 milligrams (mg), a narcotic pain medication used to treat moderate to severe pain, to be administered one tablet by mouth every four hours PRN (as needed) for severe pain rated 8 to 10. The order specified use of a pain scale in which 0 to 3 indicates mild pain, 4 to 7 indicates moderate pain, and 8 to 10 indicates severe pain. A review of Resident 64's January 2026 Medication Administration Record (MAR) revealed staff administered Oxycodone 5 milligrams 47 times. Of those 47 administrations, 23 doses were given when the documented pain rating did not meet the physician ordered parameter of 8 to 10. Staff administered the medication outside of ordered parameters on the following dates and times: January 9, 2026, at 8:01 PM for a pain scale of 7.January 11, 2026, at 7:05 PM for a pain scale of 7.January 16, 2026, at 8:33 AM for a pain scale of 7.January 16, 2026, at 1:00 PM for a pain scale of 7.January 16, 2026, at 7:30 PM for a pain scale of 7.January 17, 2026, at 9:22 AM for a pain scale of 7.January 19, 2026, at 12:53 PM for a pain scale of 7.January 19, 2026, at 7:05 PM for a pain scale of 7.January 20, 2026, at 7:05 PM for a pain scale of 1.January 21, 2026, at 7:02 PM for a pain scale of 7.January 23, 2026, at 9:13 AM for a pain scale of 6.January 23, 2026, at 7:03 PM for a pain scale of 6.January 26, 2026, at 10:12 AM for a pain scale of 5.January 26, 2026, at 6:49 PM for a pain scale of 7.January 27, 2026, at 7:05 PM for a pain scale of 7.January 28, 2026, at 7:41 AM for a pain scale of 5.January 29, 2026, at 9:04 AM for a pain scale of 7.January 29, 2026, at 7:06 PM for a pain scale of 7.January 30, 2026, at 8:40 AM for a pain scale of 7.January 30, 2026, at 1:29 PM for a pain scale of 6.January 30, 2026, at 8:02 PM for a pain scale of 0.January 31, 2026, at 9:15 AM for a pain scale of 0.January 31, 2026, at 10:43 PM for a pain scale of 5. Review of the February 2026 Medication Administration Record revealed staff administered Oxycodone 5 milligrams 24 times. Of those 24 administrations, 14 doses were given when the documented pain rating did not meet the physician ordered parameter of 8 to 10. Staff administered the medication outside of ordered parameters on the following dates and times: February 2, 2026, at 7:31 PM for a pain scale of 4.February 3, 2026, at 7:53 PM for a pain scale of 7.February 5, 2026, at 8:47 AM for a pain scale of 7.February 5, 2026, at 1:23 PM for a pain scale of 5.February 6, 2026, at 7:58 AM for a pain scale of 6.February 6, 2026, at 6:59 PM for a pain scale of 6.February 9, 2026, at 7:09 PM for a pain scale of 7.February 11, 2026, at 7:07 PM for a pain scale of 7.February 12, 2026, at 7:05 PM for a pain scale of 6.February 13, 2026, at 7:59 AM for a pain scale of 4.February 15, 2026, at 9:22 AM for a pain scale of 6.February 16, 2026, at 7:07 PM for a pain scale of 7.February 18, 2026, at 7:05 PM for a pain scale of 6.February 19, 2026, at 9:02 AM for a pain scale of 7. An interview with the Director of Nursing on February 20,2026, at 11:10AM reviewed the above findings which demonstrated staff administered the narcotic pain medication outside of the physician ordered pain scale parameter for Resident 64. 28 Pa. Code 211.10(c)Resident care polices.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for one resident out of 29 sampled (Resident 16).Findings included: A review of a facility policy entitled Urinary Catheter Care, last reviewed February 2, 2026, indicated that nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is placed and remove the catheter as soon as it is no longer needed. A review of Resident 16's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues). A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 29, 2026, revealed that Resident 16 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13 to 15 indicates cognition is intact). A review of admission physician orders dated November 14, 2025, included an order for insertion and maintenance of a Foley catheter (an indwelling urinary catheter, which is a flexible tube inserted through the urethra into the bladder to continuously drain urine), size 16 French (French is the unit of measurement used to describe the external diameter of a catheter; a 16 French catheter measures approximately 5.3 millimeters in diameter), with a 10 cubic centimeter (cc) balloon (a small inflatable balloon at the catheter tip that is filled with sterile water once inside the bladder to hold the catheter in place), attached to a straight drainage bag to gravity drainage (a urine collection bag that passively drains urine from the bladder by gravity without suction). The indication for the catheter was obstructive uropathy with urinary retention (obstructive uropathy is a blockage that impedes urine flow through the urinary tract; urinary retention is the inability to empty the bladder completely). A review of the admission nursing evaluation dated November 14, 2025, assessed Resident 16 as experiencing urinary incontinence (involuntary loss of urine), despite the presence of a physician order for an indwelling Foley catheter at the time of admission. A review of a facility document titled Foley Catheter Justification, dated December 9, 2025, indicated that staff are not to insert or maintain a urinary catheter unless valid medical justification exists and must discontinue the catheter as soon as it is no longer clinically warranted. The form documented that Resident 16 had a bladder outlet obstruction (a blockage at the base or neck of the bladder that reduces or prevents urine flow), and staff determined to continue the Foley catheter. A review of physician and Certified Registered Nurse Practitioner progress notes dated November 2025, December 2025, January 2026, and February 2026 through the survey end date of February 20, 2026, failed to document ongoing clinical evaluation of the continued need for the indwelling Foley catheter. The progress notes did not reference a past medical history of obstructive uropathy with urinary retention or provide assessment findings supporting continued catheter use. During an interview conducted on February 19, 2026, at 9:00 AM, Resident 16 stated that she was hospitalized in early November 2025 for respiratory failure (a condition in which the lungs cannot adequately exchange oxygen and carbon dioxide). She stated hospital staff inserted the Foley catheter when she was intubated (placement of a tube into the trachea, or windpipe, to maintain an open airway and provide mechanical breathing support). Resident 16 stated she had not previously experienced urinary retention and had not required catheterization before that hospitalization. She expressed a desire to have the Foley catheter removed so she could feel more normal, particularly if discharged home.A review of outside hospital documentation dated November 2025, titled Post Acute Placement Packet, which accompanied the referral for admission, did not include a diagnosis of obstructive uropathy or urinary retention. Resident 16's clinical record failed to contain documented, clinically acceptable justification for the continued placement and use of the indwelling Foley catheter and failed to demonstrate timely reassessment of the catheter's ongoing necessity. During an interview on February 19, 2026, at 2:30 PM the aforementioned information was reviewed with the Director of Nursing and confirmed there was no physician documentation to clinically support the use of the indwelling Foley catheter for Resident 16 related to obstructive uropathy with retention. 28 Pa. Code 211.10 (a)(c) Resident care policies.28 Pa. Code: 211.12 (c)(d)(3)(5) Nursing Services.

Based on observations, review of clinical records and staff and resident interview, it was determined the facility failed to consistently implement appropriate interventions based on individual resident needs to promote resident safety and prevent potential hazards for one resident out of 29 sampled residents. (Resident 18). Findings include: A review of clinical records revealed that Resident 18 was admitted to the facility on [DATE], with diagnosis to include major depressive disorder (a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment in daily life) and anxiety (response to stress that becomes a disorder when it causes persistent, excessive fear or worry disproportionate to the situation) A review of Resident 18's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 23, 2025, revealed that Resident 18 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Review of the resident's comprehensive plan of care, initially dated October 20, 2025, revealed the resident required assistance of two staff members for activities of daily living (ADLs). ADLs refer to basic self care tasks such as bathing, transferring, toileting, dressing, eating, and personal hygiene. The care plan indicated the resident required assistance with bathing, transfers, personal hygiene, and eating set up, including the use of lidded cups for liquids. The care plan also identified that Resident 18 had the potential to exhibit mood and behavioral symptoms, including tearfulness, accusatory behavior toward staff, ordering non approved medications, and gifting staff, related to her diagnosis of depression. Interventions included administering medications as ordered, approaching the resident calmly, allowing expression of feelings, and offering emotional support. An additional care area, initiated October 20, 2025, identified use of psychotropic medications. Psychotropic medications are drugs that affect mood, perception, or behavior and may carry risks of side effects that impair judgment, coordination, or impulse control. The care plan directed staff to monitor for adverse effects, including confusion, dizziness, unsteadiness, impaired thinking, worsening depression, irritability, aggression, and suicidal ideations. On February 18, 2026, at 9:45 AM, observation revealed Resident 18 lying in bed with a pair of scissors placed on her bedside table within immediate reach. During interview at that time, the resident stated she used the scissors to open mail when staff were not available. The resident declined photographs of the scissors and became tearful, and the interview concluded. Review of the clinical record revealed no documentation that the facility assessed Resident 18's ability to safely possess or use scissors. The record contained no interdisciplinary assessment evaluating risks associated with sharp objects, despite the resident's psychiatric diagnoses, documented behavioral symptoms, use of psychotropic medications, and need for extensive assistance with ADLs. The record also lacked documentation that the resident had scissors in her possession or that staff implemented safety interventions related to sharp objects. The record did not demonstrate that the facility evaluated whether unrestricted access to scissors constituted an accident hazard Interview with Employee 7, Nurse Aide, revealed that when the facility determines a resident can safely use scissors, staff typically secure them in the resident's nightstand to prevent access by other residents. Employee 7 stated she previously attempted to lock the scissors in Resident 18's nightstand; however, the resident refused and became tearful. Employee 7 confirmed that, as observed, the scissors remained accessible on the bedside table. Interview with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:00 PM, confirmed that no documented assessment had been completed to determine Resident 18's ability to safely use or possess scissors. As of the end of survey on February 20, 2026, the facility did not provide evidence of an interdisciplinary assessment, physician consultation, behavioral evaluation, or care plan revision addressing the resident's access to scissors or alternative safety measures such as supervised use or provision of safety scissors (cutting instruments designed with rounded or blunt tips to reduce the risk of puncture injury). 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure licensed nurses accurately administered prescribed medication consistent with professional standards of practice for one of 29 sampled residents (Resident 31). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Administering Medications last reviewed by the facility on February 2, 2026, revealed that medications are administered as prescribed and in a safe and timely manner. Medications are administered in accordance with prescriber orders. A clinical record review revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke, caused by disrupted blood flow to the brain) and left sided hemiplegia (paralysis or severe weakness on the left side of the body). Review of a physician's order dated December 5, 2025, revealed an order for Midodrine HCL (hydrochloride) 5 mg one tablet via PEG tube (Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) before meals for hypotension, hold medication for systolic blood pressure greater than 100 mmHg (systolic blood pressure is the top number in the blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood). Review of the Medication Administration Record (MAR) for December 2025, January 2026, and February 1, 2026 through 18, 2026, revealed that Midodrine was administered 15 times outside of the physician ordered parameters, as evidenced by the following documented blood pressure readings at the time of administration: December 10, 2025, 4:00 PM BP 112/68 mm/Hg (millimeters of hemoglobin)December 12, 2025, 11:00 AM BP 122/70 mm/HgDecember 17, 2025, 7:00 AM BP 102/60 mm/HgDecember 18, 2025, 11:00 AM BP 122/94 mm/HgDecember 20, 2025, 11:00 AM BP 102/76 mm/HgDecember 21, 2025, 7:00 AM BP 120/60 mm/HgDecember 26, 2025, 7:00 AM BP110/76 mm/HgJanuary 5, 2026, 11:00 AM BP 115/63 mm/HgJanuary 9, 2026, 11:00 AM BP112/89 mm/HgJanuary 20, 2026, 11:00 AM BP 111/62 mm/HgJanuary 22, 2026, 7:00 AM BP 102/74 mm/HgJanuary 23, 2026, 11:00 AM BP 104/56 mm/HgFebruary 9, 2026, 11:00 AM BP 108/58 mm/HgFebruary 10, 2026,11:00 AM BP109/68 mm/HgFebruary 17, 2026, 7:00 AM BP 118/78 mm/Hg These administrations occurred despite the physician's explicit hold parameters to hold medication for a systolic reading of greater than 100 mm/Hg During an interview on February 20, 2026, at 9:45 AM, the director of nursing acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. 28 Pa. Code 211.5(f)(ii)(ix) Medical records. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan that reflected the resident's current medical status and required interventions for one of 29 residents sampled (Resident 3).Findings include: A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), and congestive heart failure (CHF, a condition in which the heart doesn't pump blood as well as it should). A review of an Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that Resident 3 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 to 12 indicates cognition is moderately impaired). A review of a physician's order for Resident 3 dated [DATE], revealed an order for full code status indicating CPR should be attempted in the event of cardiopulmonary arrest. A review of a POLST form (Physicians Orders for Life-Sustaining Treatment form designed to improve resident care by creating a portable medical order form that records residents' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) for Resident 3 dated [DATE], revealed that the resident had elected CPR/Attempt Resuscitation status. (CPR (cardiopulmonary resuscitation) is to be performed in the event of cardiopulmonary arrest (if breathing stops or if the heart stops beating). A review of the Resident 3's comprehensive care plan, initiated [DATE], and most recently revised February 13, 2026, identified the resident's code status (overall medical directive that specifies what life sustaining interventions should be initiated if a resident experiences a cardiac or respiratory arrest when breathing stops or the heart stops beating) as DNR, with an established goal that the resident's code status preference would be honored. Resident 3's care plan failed to include updated goals, interventions, or monitoring related to the resident's full code status. A physician's order dated [DATE], directed oxygen administration at 4 liters (L) via nasal cannula continuously related to COPD. A review of Resident 3's comprehensive plan of care, initiated on [DATE], and most recently revised on February 13, 2026, failed to include updated goals, interventions, or monitoring related to the resident's continuous oxygen therapy. A physician's order dated [DATE], directed a fluid restriction of 1800 ml (milliliters) per day, with 290 ml allotted for nursing during the day, 290 ml for nursing during the evening, 290 ml for nursing during the night, and 840 ml for dietary. A review of Resident 3's care plan revealed a focus on impaired cardiovascular status due to COPD and CHF, initiated on [DATE], and last revised on February 13, 2026, with interventions to reflect a 2200 ml fluid restriction. Resident 3's care plan failed to include updated goals, interventions, or monitoring related to the resident's fluid restriction. A physician's order dated [DATE], directed to give Apixaban (generic for Eliquis, an anticoagulant ,blood thinning medication) 5 mg, one tablet every morning and at bedtime. A review of Resident 3's comprehensive plan of care, initiated on [DATE], and most recently revised on February 13, 2026, failed to include updated goals, interventions, or monitoring related to the resident's anticoagulant therapy. A physician's order dated [DATE], directed to give Humalog insulin (a rapid acting insulin medication used to lower blood sugar) subcutaneously before meals and at bedtime per sliding scale related to diabetes. A review of Resident 3's comprehensive plan of care, initiated on [DATE], and most recently revised on February 13, 2026, failed to include updated goals, interventions, or monitoring related to the resident's diabetes and insulin therapy. A review of outside hospital paperwork revealed that Resident 3 had a central venous catheter (a thin, flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream) inserted in their right chest on [DATE]. A physician's order dated February 1, 2026, revealed an order for a PICC line (a thin, flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream) and to maintain an emergency kit at the bedside. A physician's order dated February 10, 2026, directed to give Ampicillin (an antibiotic medication) 2 gm intravenously (IV, through a vein) every six hours until [DATE], for a bacterial infection due to a right knee prosthetic infection. A review of Resident 3's comprehensive plan of care, initiated on [DATE], and most recently revised on February 13, 2026, failed to include updated goals, interventions, or monitoring related to the resident's PICC line and IV antibiotic therapy. Following surveyor inquiry, Resident 3's care plan was updated to reflect the resident's current plan of care related to oxygen therapy, PICC line therapy, anticoagulant therapy, code status, diabetes and insulin therapy, and fluid restriction on February 19, 2026. During an interview on February 19, 2026, at 2:00 PM the Director of Nursing confirmed the facility failed to review and revise Resident 3's care plan to accurately reflect the resident's current medical condition, risks, and required treatments. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, facility policy, investigative documentation provided by the facility, and staff interviews, the facility failed to protect one of 21 sampled residents (Resident 34) from neglect when staff did not implement the resident's individualized care plan intervention requiring the assistance of two staff members for all bed mobility. This deficiency is cited as past noncompliance. Findings include: A review of a facility policy titled Abuse, Neglect, and Exploitation, last reviewed by the facility on February 2, 2026, revealed it is the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse and neglect. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 34 was admitted to the facility on [DATE], with diagnoses, which included reduced mobility, and chronic obstruction pulmonary disorder (is a progressive, irreversible lung disease characterized by long-term airway obstruction and inflammation). A review of Resident 34's Annual MDS Assessment (Minimum Data Set, a federally mandated standardized assessment process completed periodically to plan resident care) dated November 12, 2025, revealed the resident was totally dependent on staff assistance for bathing and required moderate assistance of staff members for personal hygiene, upper and lower body dressing, toileting hygiene, rolling left and right in bed, sitting up in bed, and required assistance lying down in bed. The MDS revealed the resident was cognitively intact as evidence by a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). A review of the individualized care plan initiated January 11, 2025, revealed Resident 34 had an activities of daily living self-care deficit related to shortness of breath and weakness. Activities of daily living are routine personal care tasks such as bathing, dressing, toileting, and mobility. The care plan intervention required the assistance of two staff members for all bed mobility. A review of a Task List Report (a report that indicates the date when interventions were added to the Kardex, a quick reference for staff that includes a summary of resident required care information) revealed Resident 34 was to be an assistance level of two (employees) for all care on March 25, 2025.A progress note dated September 20, 2025, at 11:15 AM documented Resident 34 experienced a fall from bed. Upon arrival, the nurse observed the resident lying prone (face down position) on the floor next to the left side of the bed. The nurse documented that the resident required a four-person assist to be rolled and noted a 3 centimeter (cm) by 3 cm laceration (a tear or cut in the skin) above the left eyebrow.A facility-provided investigative document dated September 20, 2025, included a written statement from Employee 8, Nurse Aide. Employee 8 documented she responded to the resident's call bell and placed the resident on a bedpan. After completion, Employee 8 asked the resident to roll over. The statement indicated the resident rolled off the bed onto the floor. Employee 8 documented she was aware the resident required assistance of two staff members but proceeded alone because no other staff member was available at that time. During an interview on February 18, 2026, at 1:00 PM, Resident 34 stated she requested assistance to use the bathroom. She stated that when Employee 8 asked her to roll over, she responded that she was on the edge of the bed. The resident stated Employee 8 indicated she would roll her, and she subsequently rolled off the bed onto the floor, hitting her head. A review of progress notes revealed Resident 34 was transferred to the emergency department and returned on September 20, 2025, at 5:30 PM with sutures in place to the forehead. A progress note dated September 21, 2025, at 10:32 AM documented bruising to the fourth and fifth fingers of the left hand measuring 9 cm by 5 cm and bruising to the left eye. A progress note dated September 25, 2025, at 1:26 PM documented the resident was transferred again to the emergency department for continued pain, and diagnostic evaluation confirmed a fracture of the left hand. Telephone contact attempts to Employee 8 Nurse Aide on February 19 and February 20, 2026, were unsuccessful. A review of Employee 8's personnel file revealed she signed an attestation on September 9, 2025, acknowledging completion of orientation, which included training on the facility's abuse and neglect policy, safe bed mobility procedures, safe transfer and lift techniques, and documentation requirements within the electronic health record. During an interview on February 19, 2026, at 12:45 PM, the Director of Nursing confirmed the facility investigation determined Employee 8 did not follow Resident 34's care plan requiring assistance of two staff members for bed mobility. The Director of Nursing confirmed Employee 8 was immediately removed from the staffing schedule pending investigation and subsequently reassigned to a transportation position without direct resident care responsibilities. The deficient practice was cited as past noncompliance, The facility implemented corrective actions immediately following the incident. The resident was assessed and transferred for medical evaluation. Employee 8 was immediately suspended pending investigation outcome. The facility reviewed all residents' records to confirm current bed mobility assistance levels and ensure care plans and Kardex entries accurately reflected required assistance levels. The facility completed skin inspections for residents requiring two-person assistance with bed mobility. Nursing staff received re-education on adherence to individualized care plans and the facility's Abuse and Neglect policy. To sustain compliance, nursing administration initiated random audits of five resident care interactions to verify that staff performed bed mobility according to individualized care plans and Kardex instructions. Audits were conducted daily for one week, biweekly for two weeks, and weekly for one month. Audit results were reported to the facility's Quality Assurance and Performance Improvement Committee for review and follow-up. The facility achieved compliance with this requirement on September 24, 2025. This deficiency is cited as past noncompliance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of facility policy, clinical records, and staff interviews, the facility failed to ensure residents' rights to formulate and have advance directives implemented. The facility failed to maintain accurate and consistent documentation of residents' resuscitation status by failing to revise a comprehensive care plan to reflect the resident's current code status (Resident 3), ensure physician orders reflected the resident's documented resuscitation wishes (Resident 75), and obtain and maintain a completed Physician Orders for Life-Sustaining Treatment (POLST) form consistent with a physician's Do Not Resuscitate (DNR) order (Resident 103), for 3 of 29 residents reviewed.Findings include: A review of a facility policy titled Advance Directives, last reviewed by the facility on February 2, 2026, revealed it is the facility policy that the resident has the right to formulate an advance directive, including the right to accept or decline or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Further review revealed that a Physicians Orders for Life-Sustaining Treatment (POLST) paradigm form is designed to improve resident care by creating a portable medical order form that records residents' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency. A review of a facility policy titled Do Not Resuscitate Order, last reviewed by the facility on February 2, 2026, revealed it was the facility policy that in addition to the advance directive or Do Not Resuscitate order (DNR a medical order directing that cardiopulmonary resuscitation, a life-saving procedure performed when the heart or breathing stops, should not be attempted with a goal of allowing a natural death), state-specific forms may be used to specify whether to administer CPR in case of a medical emergency, and state-specific forms include a POLST form. A review of the clinical record of Resident 3 revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of an Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that Resident 3 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 to 12 indicates cognition is moderately impaired). A review of the Resident 3's comprehensive care plan, initiated [DATE], and most recently revised February 13, 2026, identified the resident's code status (overall medical directive that specifies what life sustaining interventions should be initiated if a resident experiences a cardiac or respiratory arrest when breathing stops or the heart stops beating) as DNR, with an established goal that the resident's code status preference would be honored. However, a review of a physician's order for Resident 3 dated [DATE], identified an order for Full Code status, indicating CPR should be attempted in the event of cardiopulmonary arrest. Further review of a POLST form dated [DATE], indicated the resident elected CPR/Attempt Resuscitation in the event of cardiopulmonary arrest. The facility did not revise Resident 3's comprehensive care plan to reflect the resident's Full Code status until February 19, 2026, following surveyor inquiry. As a result, the care plan did not accurately reflect the resident's most current resuscitation preference for over two months. A review of the clinical record of Resident 75 revealed the resident was admitted to the facility on [DATE], with diagnoses that included cauda equina syndrome (a rare surgical emergency caused by severe compression of nerve roots at the base of the spinal cord) and diabetes. A review of an admission MDS dated [DATE], revealed that Resident 75 had moderately impaired cognition with a BIMS score of 11 (a score of 8 to 12 indicates cognition is moderately impaired). A review of Resident 75's clinical record revealed a completed and signed POLST dated February 9, 2026. The POLST indicated the resident elected CPR/Attempt Resuscitation status, and CPR was to be performed in the event of cardiopulmonary arrest. A review of Resident 75's current physician orders through the end of the survey on February 20, 2026, did not identify any physician order addressing code status. The facility did not ensure that physician orders reflected the resident's elected Full Code status as documented on the POLST, resulting in the absence of a corresponding medical order in the record. A review of the clinical record of Resident 103 revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of an admission MDS assessment dated [DATE], revealed that Resident 103 had moderately impaired cognition with a BIMS score of 11 (a score of 8 to 12 indicates cognition is moderately impaired). A review of Resident 103's current physician orders revealed an order dated [DATE], in the electronic health record and identified the resident's code status as DNR, indicating CPR was not to be performed in the event of cardiopulmonary arrest. However, review of Resident 103's POLST dated [DATE], revealed the form was incomplete. Section A, which requires documentation of whether the resident elects CPR or DNR status, was left blank. The facility did not ensure the POLST form was completed to reflect the physician's DNR order. On February 20, 2026, following surveyor inquiry, the facility obtained an updated POLST reflecting DNR status, signed by Resident 103's representative. On February 20, 2026, at 10:00 AM, the Director of Nursing confirmed the above findings for Residents 3, 75, and 103. The facility failed to maintain consistent, accurate, and complete documentation of residents' resuscitation preferences across care plans, physician orders, and POLST forms. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observations, a review of clinical records, and select facility policy and staff interview, it was determined the facility failed to ensure that self-administration of medications was clinically appropriate for one of the 29 residents sampled (Resident 58).Findings include: A review of facility policy titled Self-Administration of Medications, last reviewed by the facility February 2, 2026, revealed residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. A clinical record review revealed Resident 58 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease(a progressive lung disease, primarily caused by smoking, that causes long-term breathing problems like chronic cough, wheezing, and shortness of breath) and emphysema (a chronic, progressive obstructive lung disease caused primarily by smoking, which destroys the alveoli (air sacs) and reduces lung elasticity, trapping air and limiting oxygen intake). A review of a Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 26, 2025, revealed that Resident 58 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed a physician's order for Resident 58 to receive Deep Sea Nasal Solution, directed to take 1 spray in both nostrils one time a day for a dry nose. The clinical record revealed a physician's order for Resident 58 to receive Trelegy Ellipta Inhalation Aerosol Powder Breath inhaler, to be administered 1 puff orally one time a day for COPD. During an observation on February 18, 2026, at 12:15 PM, Resident 58 was observed ambulating in her room. On the bedside table the Trelegy inhaler and the deep-sea nasal solution and a tube of hydrocortisone cream 1% was observed. An interview with Resident 58 conducted at the time of observation revealed the staff leave her medications for her and when she is finished, she walks the medication back to the medication cart so the medication can be stored. The interview revealed the hydrocortisone cream was given to the resident from her dermatologist and that she does not return the cream to the cart, that it is always at her bedside and she uses it on her skin when she feels she needs to. A clinical record review failed to reveal documented evidence indicating Resident 58 was assessed and deemed clinically appropriate and safe to self-administer her own medications. In addition, the clinical record did not reveal an order for hydrocortisone cream 1%. A review of the clinical record did not reveal any outpatient visits that could confirm an order for the hydrocortisone cream. During an interview on February 18, 2026, at 1:30 PM, with Employee 6, Registered Nurse, it was confirmed Resident 58 did not have an active order to self-administer medication. The interview revealed the resident should not have had the medications left at the bedside and did not have an active order for self-administration of medication. An interview with the Director of Nursing conducted on February 19, 2026, at 10:00AM reviewed the above findings of the facility's failure to assess Resident 58 to ensure she could safely self-administer medications as required in the facility policy. 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on a review of clinical records, transfer notices, and staff interviews, it was determined the facility failed to notify the resident and the resident's representative(s) of the transfer in writing and in a language and manner they understand for 1 out of 29 residents reviewed (Resident 98).Findings include: A clinical record review revealed Resident 98 was admitted to the facility on [DATE]. Further clinical record review revealed Resident 98 was transferred to a community hospital on January 14, 2026, and was readmitted to the facility on [DATE]. The facility was unable to provide documented evidence that the resident or resident representative was notified of the reasons for the transfer in writing and in a language and manner they understand. During an interview on February 20, 2026, at approximately 11:30 AM, the nursing home administrator was unable to provide documented evidence that Resident 98 and their representatives, as applicable, were notified of the reasons for the transfers on the aforementioned date. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of clinical records, select facility policy, investigation documentation provided by the facility, and resident and staff interviews, it was determined the facility the facility failed to protect one of four sampled residents (Resident 1) from neglect by not providing the care and services necessary to prevent a fall from bed. This deficiency is cited at past noncompliance.Findings include:A review of the facility's Resident Abuse policy, last revised July 2025, revealed the facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in the policy. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included chronic respiratory failure with hypoxia (long-term inability of the lungs to adequately oxygenate the blood and/or remove carbon dioxide) and diabetes. A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated June 23, 2025, indicated the resident had a BIMS (brief interview for mental status) score of 12 (8-12 indicates moderately cognitively impaired), and required staff assistance for all aspects of toileting hygiene, and required staff provide assistance to roll the resident from left side to right side. A review of the resident's care plan for decreased ADLs (activities of daily living) self-care performance initially dated October 23, 2024, indicated the resident required extensive assistance for personal hygiene (which would include incontinence care) and the assistance of two staff for bed mobility. Review of investigation documentation provided by the facility revealed on July 16, 2025, 5:00 AM Resident 1 was found on the floor on the right side of the bed between the right side of the bed and the divider curtain in the room. The bed was not in the lowest position. The resident had a raised bluish/purple area the size of a golf ball slightly raised above the bridge of the nose on the forehead. The resident verbally complained of her head hurting. During interview with Resident 1 on July 22, 2025, at approximately 11:00 AM the resident could not remember the details of the fall but did recall that she was on her side in bed because she needed incontinence care after a bowel movement, the nurse aide left to obtain washcloths, and she rolled out of bed and landed on her face. Review of information submitted by the facility revealed the physician was contacted following the fall and an order was received to transfer the resident to the emergency room for a CT scan ( computerizes tomography an imaging test that helps to detect diseases and injuries). The CT scan revealed an acute fracture of the bony nasal septum (break in the nose that separates the nasal passages). The facility identified that the resident was an assist of two for bed mobility. Employee 1 (nurse aide) was gathering supplies when the resident rolled from the bed to the floor. Employee 1 confirmed that she left Resident 1 on her side in the bed while she went to the bathroom to get washcloths, and the resident rolled off the side of the bed. Employee 1 (nurse aide) was educated and suspended upon investigation. An interview with the Director of Nursing (DON) on July 22, 2025, at approximately 12:30 PM confirmed that Resident 1 should not have been left alone during care which resulted in the resident rolling out of bed onto the floor. This deficiency is cited as past non-compliance. The facility's corrective action plan was to transport Resident 1 to the emergency room. The facility investigated and determined the resident was left unattended in bed by Employee 1 (nurse aide) ultimately leading to the resident falling out of bed. The facility's corrective action plan included current alert and oriented residents with a status of assist of two for bed mobility were interviewed to ensure repositioning and care was being performed per the residents' plan of care/Kardex (a system for organizing and accessing resident information). An audit was completed of current residents' bed mobility/Kardex to ensure accuracy. Skin checks were performed on residents with assist times two for bed mobility by the licensed nurse to ensure there were no new skin observations related to bed mobility or care. To prevent this from reoccurring nursing staff were re-educated to following the care plan/Kardex for resident care and the facility Abuse and Neglect Policy. To monitor and maintain ongoing compliance the DON or designee will audit five random resident care interactions to ensure the plan of care is being followed for bed mobility staff assistance and bed positioning, five days a week times one week, then three days per week times one week, then weekly times one month. The facility's corrections were completed on July 20, 2025, which was verified during the survey of July 22, 2025. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of the clinical records and staff interview it was determined that the facility failed to consistently implement sufficient and planned measures to prevent the development and worsening of two pressure sores for one resident out of one sampled resident (Resident 29) with pressure sores. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed Resident 29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment ( MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 8, 2020, revealed that the resident required extensive assistance with activities of daily living, bed mobility and transfers and was identified at risk for pressure ulcers. A review of the Braden Scale (a tool used to determine/predict pressure sore development) dated October 14, 2019, prior to the development of a pressure injury, revealed that the resident received a score of 17.0, indicating that the resident was at mild risk for pressure sore development. Review of the Resident 29's plan of care, initiated September 24, 2019, revealed that the resident was identified to be at risk for pressure ulcer development. The facility planned approaches to float heels bilaterally when in bed initiated April 19, 2020, observe for changes in skin conditions and report abnormalities initiated September 24, 2019, pressure reduction for bed/chair September 24, 2019, and apply skin prep to bilateral heels initiated April 19, 2020, and to conduct weekly skin audits by a licensed nurse dated June 26, 2020. Review of Resident 29's April 2020 Treatment Administration Record revealed an order for [REDACTED]. Review of Resident 29's progress note dated April 27, 2020, revealed an entry indicating a darkened area was noted on Resident 29's left heel measuring 1.5 centimeters x 0.5 centimeters. The April 2020 Treatment Administration Record revealed documentation indicating that the skin prep was applied and floating of bilateral heels was consistently performed. However, the Resident developed a Stage II pressure injury on the left heel. Further review of the April 2020 Treatment Administration Record indicated that Resident 29 had an order for [REDACTED]. Review of facility event investigation form for pressure ulcers dated April 27, 2020, revealed the resident was at high risk for pressure ulcers and the pressure area was unavoidable. which was inconsistent with the resident's most recent assessment as the Braden Scale dated October 14, 2019, which indicated that the resident was at mild risk for pressure sore development. The facility's event investigation indicated that the resident's left heel was a Stage II pressure injury. Further review of the facility investigations into the resident's pressure revealed no documented evidence as to when the resident's heel was last observed and its condition/appearance and any potential contributing factors to its development. There was no documented evidence of wound tracking to monitor the healing or decline of the pressure area on Resident 29's left heel. A progress note dated May 11, 2020, indicated the left heel pressure injury was resolved and will continue skin prep two times daily. A progress note entry dated June 11, 2020, at 11:26 a.m. indicated that the resident again developed a Deep Tissue Injury (DTI) in location of previous healed DTI, measuring 2.0 centimeters x 2 .0 centimeters x 0.1 centimeters. The progress note indicated the resident was educated regarding keeping her feet off the table bar when the table is in front of her. No new interventions were implemented at this time. Review of wound evaluation of the left heel revealed on June 17, 2020, revealed that skin prep was in place every shift prior to the redevelopment of the DTI. However, review of the June 2020 Treatment administration record revealed the order for skin prep only during the day and evening shift. A review of the Braden Scale dated August 14, 2020, prior to the development of a pressure injury, revealed that the resident received a score of 13.0, indicating that the resident was at moderate risk for pressure sore development. No new interventions were implemented at this time Review of wound evaluations revealed there was no written evidence of an evaluation of the resident's left heel pressure sore from September 18, 2020, through November 3, 2020. Review of the wound evaluation of the resident's left heel on November 4, 2020, completed following surveyor inquiry, revealed that the wound measured 1.0 centimeters (length) x 1.0 centimeters (width) x 2.0 centimeters (depth) indicating a worsening of the pressure injury (pressure sore had increased depth). Review of the clinical record revealed a progress note entry dated September 28, 2020, at 3:05 p.m. indicating that another pressure area was found during a.m. care on Resident 29's coccyx (bones at the end of the spine), which was unstageable. Review of the facility event dated September 28, 2020, revealed that the resident required extensive assistance with bed mobility and transfers. It was noted that the resident will now be repositioned every 2 hours after the development of an unstageable pressure ulcer. The resident's care plan dated September 24, 2019, indicated the use of pressure reduction for bed/chair, but there was no evidence that the resident was using a pressure relieving device/mattress on the resident's bed prior to the development of the unstageable wound on the coccyx. A review of the Braden Scale dated September 28, 2020, performed after the development of a pressure sore on the resident's sacrum, revealed that the resident received a score of 8.0, indicating that the resident was at very high risk for pressure sore development. At the time of the survey ending November 6, 2020, the facility was unable to provide documented evidence that staff were repositioning the resident every 2 hours as planned. Review of the September 2020 Treatment Administration Record revealed that Resident 29 had an order for [REDACTED]. Review of a wound evaluation dated September 28, 2020, identified the wound as an unstageable measuring 8 centimeters x 3 centimeters x 0.1 centimeters was necrotic and red in color. The wound evaluation did not provide complete documentation of the wound to include the presence of pain, description of wound bed and periwound. There were no assessments of the unstageable pressure sore on the resident's coccyx between October 21, 2020, through November 3, 2020. Observation of the resident's pressure sores on November 5, 2020, revealed the left heel measuring 1-centimeter x 1 centimeter x 2 centimeters and the coccyx measuring 3 centimeters x 9 centimeters x .25 centimeters indicating that the surface areas and depth of both wounds had increased in size and worsened since the facility's last evaluation. Interview with the Assistant Director of Nursing on November 5, 2020, at approximately 2:00 p.m., confirmed that the facility was unable to provide documented evidence of any assessments of the resident's pressure sores conducted during the time periods referenced above. The ADON confirmed there was no documented evidence of that preventative measures had consistently been provided to deter pressure sore development, that the resident's skin integrity had been consistently inspected as planned and that resident's pressure sores had been consistently and accurately monitored and assessed for healing. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 5/11/18, 11/17/18, 2/28/19, 4/18/19, 8/26/19, 10/29/20

Based on a review of clinical records, medication error reports, select incident and accident reports and select facility policy and staff and resident interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 21 residents reviewed (Resident 246). Findings include: A review of facility policy entitled, Administrating Medications, last revised by the facility (MONTH) 11, (YEAR), revealed that medications shall be administered in a safe and timely manner. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band, (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel. In addition, the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the clinical record of Resident 246 revealed admission to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated (MONTH) 2, (YEAR), revealed that the resident was cognitively intact, understood others and was able to make her needs known. Review of an, Investigation of Incident and, Medication Error, reports dated (MONTH) 29, (YEAR), at 8:15 AM revealed that Employee 1 (Licensed Practical Nurse - LPN), was on job orientation and prepared morning medications for administration to Resident 246 on the morning of (MONTH) 29, (YEAR), at 8:15 AM. Employee 2 (Registered Nurse - RN) administered the medications, which had been prepared by Employee 1, to Resident 246 on (MONTH) 29, (YEAR), at approximately 8:15 AM. However, the medications poured by Employee 1, were prescribed for administration to Resident 29, the resident residing in the next bedroom. In error, Employee 2 administered Resident 29's medications to Resident 246. Resident 246 erroneously received the following medications: [REDACTED]. (a diabetic medication), a Multi-vitamin (supplement), [MEDICATION NAME] 10 mg (a medication used to treat and prevent asthma), [MEDICATION NAME] 60 mg (a medication used to treat high blood pressure), Saline Mist two sprays each nostril (a medication used to treat dryness in the nasal passages), [MEDICATION NAME] two puffs (a medication used to treat asthma), Tylenol with [MEDICATION NAME] #3 300-30 mg, two each (a narcotic pain reliever) and vitamin D3 50,000 units (a supplement). A review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. These included: Xarelto 10 mg (an anticoagulant), [MEDICATION NAME] 10 mg (an antidepressant), Aspirin 81 mg (an anti-platelet), [MEDICATION NAME] 100 mg (a medication used to treat high blood pressure), Potassium Chloride 10 meq (a potassium supplement), [MEDICATION NAME] 100 mg (a stool softener) and [MEDICATION NAME] 40 mg (an ant-diuretic medication). Further review of the Medication Error report dated (MONTH) 29, (YEAR), revealed the resident (246) was found lethargic and sluggish in room, resident noted to have been given wrong medication at 8:15 AM; CRNP (Certified Registered Nurse Practitioner) notified and present; oxygen at 2 liters applied; 911 phoned and transferred to ER; resident remained conscious upon exiting facility. Further review of the Medication Error report revealed that Employee 2 failed to follow the five rights (right patient, right medication, right dose, right time and right route) and administered the medications to the wrong patient, resulting in the resident being sent to the emergency room A review of an attached witness statement (a description of the event/incident by staff) signed by Employee 2 revealed that Employee 1 approached Employee 2 asking her, if she (Employee 2) can give 22 pills (to resident) I'm not allowed in there. Employee 2 replied, sure as she stood next to Employee 1 as she (Employee 1) began to pour the meds. Employee 2 asked, shouldn't I pour them (the medications) and Employee 1 replied, I'll do it, she gets a lot of them. Employee 2 questioned, Does she take all of them at one time and Employee 1 replied, oh yeah, she gets them all together. Employee 2 proceeded to a resident's room when Employee 1 stated, it's on the left and Employee 2 asked the resident, who was sitting in the alcove, who she was and the resident replied that she was the resident when asked. Resident 246 took all the meds, except one, at around 8:15 AM noted Employee 2 in the witness statement. The statement further noted that at 8:25 AM Employee 2 returned to administer another medication, when she noted the resident, was a little groggy. At 8:40 AM staff reported that the resident was slow to respond, so I and Employee 1, along with a nurse aide entered room. Employee 2 stated, seemed like too much medicine at once, to which, Employee 1 stated, you didn't give her the meds did you and, this is when she alerted me to the error; the meds I gave you were for the resident in room [ROOM NUMBER]. The CRNP was onsite and notified. The resident was kept awake and alert until ambulance arrived at 8:45 AM. A review of a late entry nursing noted dated (MONTH) 29, (YEAR), at 8:40 AM revealed that when the RN entered the room the resident was noted to have an altered L[NAME] (level or loss of consciousness) AEB (as evidenced by) responding to both verbal and tactile stimulation, not 'unresponsive'; as noted in the prior nursing entry dated (MONTH) 29, (YEAR), at 8:40 AM. A corresponding Med Error Timeline undated, revealed that at 8:40 AM a NA (Nurse Aide) entered the room and found the resident slumped over the bedside table and notified the nurse. A review of a CRNP progress note dated (MONTH) 29, (YEAR), revealed the CRNP was called into a room where the patient (resident) was unresponsive; EMTs (Emergency Medical Technician) in room. The RN supervisor noted that the nurse at the facility gave her all of her morning pills this AM but then gave her another resident's medication, as well, within 10 minutes of the first medication administration. The RN supervisor reported that he notified the family of her impending transfer to ER Further review of the CRNP progress note indicated that the resident was an, acutely ill-appearing female patient in the wheelchair with nursing and EMT by her side. Patient is unresponsive to verbal and tactile stimulation. She is cool, clammy with pallor. Her muscle tone is limp and flaccid. Interview with the Director of Nursing (DON) on (MONTH) 10, (YEAR), at approximately 9:10 AM confirmed the significant medication error had occurred for Resident 246 on (MONTH) 29, (YEAR). The DON stated that Resident 246 received Resident 29's 9:00 AM medications in error and that nursing staff, Employees 1 and 2, failed to follow facility policy and professional standards of nursing practice for medication administration. Refer F658 28 Pa. Code 211.9(a)(1)(k) Pharmacy services Previously cited 5/19/16 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 10/31/17, 7/16/17, 4/7/17, 1/14/17, 5/19/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/31/17, 7/16/17, 4/7/17, 5/19/16

Based on a review of clinical records, select incident and accident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to provide sufficient staff assistance and utilize safe technique during care to prevent accidents resulting in minor injury (a skin tear) to one resident (Resident 63) and severe injury (fractured collar bone) to one resident (Resident 71) of 24 residents reviewed. Findings include: A review of the clinical record revealed that Resident 63 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 6, (YEAR), revealed that the resident was moderately cognitively impaired and required extensive assistance with two persons for bed mobility and for transfers between surfaces. Review of the Occupational Therapy Discharge summary dated (MONTH) 8, (YEAR), indicated that the resident continued to require moderate assistance of two for toilet transfers. Review of the Visual/Bedside Kardex Report (directions for direct care staff) indicated that the resident was transferred using a mechanical lift with assistance of two. Review of the information dated (MONTH) 31, (YEAR), submitted by the facility the resident requested to use the bathroom at approximately 9:30 AM on (MONTH) 31, (YEAR), and Employee 3 (NA - Nurse Aide) transferred the resident onto the toilet by himself and caused a skin tear to the resident's right lower extremity. According to the submitted facility documentation, the resident's care plan indicated that the resident was to transfer with two and a Hoyer lift (a type of mechanical lift) and Employee 3 did not follow the resident's care plan for safe transfers. Employee 3 in a statement given on (MONTH) 31, (YEAR), did indicate that he transferred the resident by himself from the wheelchair to the toilet and then noticed the skin tear on her leg as he was changing the resident's soiled brief. During an interview on (MONTH) 8, (YEAR), at 1:45 PM the Director of Nursing could not explain why Employee 3 transferred Resident 63 by himself and did not follow the resident's plan of care. A review of the clinical record revealed that Resident 71 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. The resident began receiving Hospice services (type of care that involves medical, emotional and spiritual services/resources for people who are in the last stages of a terminal illness) (MONTH) 18, (YEAR). A significant change Minimum Data Set assessment dated (MONTH) 7, (YEAR), indicated that the resident was severely cognitively impaired and required the extensive assistance of two staff with activities of daily living (ADL-routine activities that people tend do every day without needing assistance, eating, bathing, dressing, toileting, transferring (walking) and bowel/bladder continence) including ambulation, transfers and bed mobility. The resident's care plan dated (MONTH) 29, (YEAR), revealed a problematic area of the resident's deficit in mood and behavior with a care planned intervention for the presence of two attendants (staff) in the resident's room for care at all times. Review of Resident 71's current Care Card and staff Tasks in the area of Behavior/Mood also directed the use of two attendants (staff) in the room for care at all times. Review of the Physical Therapy (PT) summary dated (MONTH) 19, (YEAR), revealed two short-term goals for the resident to safely perform bed mobility tasks with total dependence (two staff) and use of side rails and increase static sitting balance to poor spontaneously righting self when needed in order to prepare for transfers. The resident's goals were unmet due to the resident's dependency in bed mobility (requiring two staff) and cognitive status. Interview with the Rehab Manager on (MONTH) 10, (YEAR), at approximately 9:27 AM confirmed that Resident 71 was, Total Dependence, and required the assist of two staff for bed mobility. A nurses' note dated (MONTH) 4, (YEAR), at 3:45 AM noted NA (Nurse Aide) called this writer to residents room, observed resident laying on floor on right side against wall, RN (Registered Nurse) into assess, resident assisted back to bed via Hoyer (mechanical) lift, hematoma (a solid swelling of clotted blood within the tissues) noted to right side of head, ice applied, resident complaint of pain right upper extremity, medicated as ordered, neuro checks administered, MD (physician) aware, new order received, obtain X-ray of right shoulder and right arm, RP (responsible party) aware. Review a mobile X-ray dated (MONTH) 4, (YEAR), at 8:00 PM revealed results indicating that the resident had a non-displaced fracture distal end of right clavicle (collar bone). A facility investigative report form entitled, Investigation of Incident, report, used to collect and analyze circumstances of the resident fall, dated (MONTH) 4, (YEAR), at 3:45 PM revealed that the nurse aide who had been providing incontinent care to the resident, rolled the resident over and the resident rolled out of bed on the left side of bed landing on her right side. Resident complained of pain on right shoulder. The X-rays ordered revealed a right clavicle fracture. Further review of the report revealed the resident usually understands; however, she can be confused at times and has impaired hearing. Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 4 (NA), revealed that the NA saw the resident's light on and heard the resident screaming. The NA stated the resident was covered in BM (feces) so she (the NA) rolled her (the resident) on her side to wash her and she (the resident) moved and fell off the bed. An interview with Director of Nursing (DON) on (MONTH) 10, (YEAR), at approximately 9:20 AM confirmed that the staff failed to provide sufficient activities of daily living assistance as planned for this resident and failed to use safe nursing technique when rolling and a re-positioning the resident in bed. The nurse aide rolled the resident away from the nurse aide, without additional staff assistance at the bedside, during the provision of incontinence care, and the resident rolled out of bed and sustained a fracture. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/31/17, 1/14/17 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 10/31/17, 7/16/17, 4/17/17, 1/14/17, 5/19/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/31/17, 7/16/17, 4/7/17, 5/19/16

Based on a review of clinical records, facility documentation and select facility policies and procedures and staff interview, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication administration resulting in a significant medication error and change in condition due to a medication overdose for one resident (Resident 246) of 21 residents reviewed. Findings include: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.14. (a) A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place and (b) the LPN administers medication and carries out the therapeutic treatment ordered for the patient. A review of the facility policy and procedures for, Administrating Medications, last revised by the facility (MONTH) 11, (YEAR), revealed that medications shall be administered in a safe and timely manner. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band, (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel. In addition, the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of a facility, Investigation of Incident, report dated (MONTH) 29, (YEAR), revealed that Employee 1, (Licensed Practical Nurse - LPN), who was on orientation, pulled (placed medications in medication cup) Resident 29's medications for administration at approximately 8:15 a.m. Medications pulled included: [MEDICATION NAME] 150 mg (an antidepressant), [MEDICATION NAME] 2 mg (an antidepressant), Vitamin D (supplement), Klonopin .5mg (an anti-anxiety medication), [MEDICATION NAME] 10 mg (a muscle relaxant), [MEDICATION NAME] 300 mg (a medication used to treat chronic pain), [MEDICATION NAME] 15 mg (a non-steroidal anti-[MEDICAL CONDITION] medication), [MEDICATION NAME] 500 mg. (a diabetic medication), a Multi-vitamin, [MEDICATION NAME] 10 mg (a medication used to treat and prevent asthma), [MEDICATION NAME] 60 mg (a medication used to treat high blood pressure), Saline Mist two sprays each nostril (a medication used to treat dryness in the nasal passages), [MEDICATION NAME] two puffs (a medication used to treat asthma), Tylenol with [MEDICATION NAME] #3 300-30 mg, two each (a narcotic pain reliever) and vitamin D3 50,000 units (a supplement). At 8:15 a.m., Employee 2 (Registered Nurse - RN) erroneously administered Resident 29's medications, which Employee 1 had prepared, to Resident 246 A review of a, Medication Error report dated (MONTH) 29, (YEAR), revealed the resident was found lethargic and sluggish in room, resident noted to have been given wrong medication at 8:15 a.m . CRNP (Certified Registered Nurse Practitioner) notified and present, oxygen at 2 liters applied; 911 phoned and transferred to ER, resident remained conscious upon exiting facility. Further review of the, Medication Error report revealed that Employee 2 failed to follow the five rights (right patient, right medication, right dose, right time and right route) and administered the medications to the wrong patient, resulting in the resident being sent to the emergency room . A review of Resident 246's (MONTH) (YEAR), Medication Administration Record [REDACTED]. During an interview with the Director of Nursing (DON) on (MONTH) 10, (YEAR), at approximately 9:15 AM, the DON confirmed that Employee 2 failed to verify the right resident and right medications were prior to the administration of the medications and had administered medications poured by another nurse, Employee 1. Refer to F760 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 10/31/17, 7/16/17, 4/7/17, 1/14/17, 5/19/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/31/17, 7/16/17, 4/7/17, 5/19/16

Based on observation, review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to provide sufficient staff supervision and effective safety measures to prevent a fall with serious head injury for one resident at risk for falls out of 11 residents sampled (Resident CR1) Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED].{blood clot}) in [DATE]. The resident was receiving Coumadin 1.5 mg (an anticoagulant medication, which thins the blood to decrease clotting, but increases the risk of bleeding) by mouth in the evening on Mondays and Fridays for her chronic embolism and thrombosis. An annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE], indicated that the resident's cognition was severely impaired with a BIMS score of 3 (brief interview for mental status - a tool to assess cognitive function, a score of ,[DATE] indicates severe cognitive impairment) and she was unable to make her needs known to others. The resident was dependent on staff for activities of daily living (ADLs - refer to such activities as bathing dressing, toileting, eating and ambulation). The resident was identified to be at risk for falls. The resident had a fall from a Broda chair (chair used for positioning and comfort) on [DATE], and a fall from her bed on [DATE], without serious injury. A review of the resident's plan of care dated as revised by the facility [DATE], indicated that the resident was at risk for falls. The care plan indicated that as per the resident's RP (responsible party) the resident was to sit in a straight back chair for meals in main dining room. The resident's care plan indicated that the resident was to be positioned out of bed in a rocking Broda chair in dropped seat position with pressure reducing cushion, for one hour in the morning, one hour midday and one hour in the evening. A review of an incident/accident report dated [DATE], at 9:27 PM revealed that Resident CR1 was seated in a wheelchair in front of the nurses' station when she leaned over and fell forward out of the wheelchair striking her forehead off the floor, which resulted in a hematoma (collection of blood underneath the skin due to trauma) to the resident's forehead. Ice was applied. Employee 4, an RN (Registered Nurse) stated that she attempted to reach the resident, but was unable to reach the resident in time to prevent the fall. Employee 4 had been behind the nurses' station and the resident was in the hallway in front of the nurses' station. The resident was in view of the nurse, but the resident was not readily accessible to staff within the nursing station due to the physical configuration of the nurse's station, which was verified by observation at the time of the survey ending [DATE]. A statement by Employee 1, a nurse aide, indicated that Resident CR1 was to be toileted around 7:00 PM and transferred into bed; unless she is agitated and climbing out of bed, then she will be placed at the nursing station. Employee 5, a nurse aide, noted that she attempted to take the resident to the bathroom at approximately 8:45 PM and get her changed for bed, but the resident began to hit the nurse aide. Employee 5 then placed the resident in her wheelchair at the nurse's station. A statement written by Employee 3, an RN, indicated that the resident was sitting in her wheelchair by the nurses station. Her nurse aide (Employee 5) attempted several times to put her to bed and change her clothes, but the resident became combative and was biting the nurse aide. Employee 3's statement indicated that food and fluid were offered, but the resident continued to be combative. Nursing noted on [DATE], at 7:20 AM that the resident was seated in a wheelchair next to nurses' station; ecchymosis (bruise) to the resident's forehead and left eye were noted. The resident's left knee and right foot were also swollen. At approximately 8:30 AM on [DATE], the resident's responsible party and physician were notified of the swelling. The physician ordered an x-ray to right foot, ankle and knee ordered, which showed no fractures. On [DATE], at 10:48 AM nursing noted that the resident had increased difficulty swallowing, increased lethargy and confusion. There was moderate swelling in both eyes with ecchymosis present. The resident's responsible party refused to have resident sent to emergency room at this time, but agreed to a CT (computerized tomography (CT) scan combines a series of X-ray images taken from different angles using a computer. CT scan images provide more detailed information than X-rays) of her head and neck. The CT showed moderate tissue swelling over the left frontal (forehead) and periorbital (around the eyes)area and swelling to the right side as well. On [DATE], the resident's responsible party was concerned about the resident's status after the recent fall and the resident was sent to the emergency room . A review of the emergency room record dated [DATE], indicated that the resident was diagnosed with [REDACTED]. The resident, upon admission to the hospital, was unresponsive with low blood pressure. The CT scan indicated that the resident had bilateral (both sides) acute subdural hematomas. The resident was admitted to inpatient Hospice for end of life care and expired on [DATE], at 10:05 AM. An interview with the Director of Therapies, Employee 2, on [DATE], at 12:15 PM revealed that the resident had been assessed for safety in a Broda chair on February 22, 2017. The resident maintained proper alignment and safety during the Broda chair assessment. However, the resident's responsible party requested that the resident be seated in a wheelchair, when not seated in the Broda chair (planned for use for one hour, three times a day). Employee 2 stated that the resident was not safe in a wheelchair. The resident was very small in stature (4 feet 8 inches) and required a small wheelchair. Employee 2 also stated that the resident had kyphotic posture (excessive rounding of the upper spine), which could cause her to lean forward. The NHA (nursing home administrator) stated during interview on [DATE], at 12:30 PM that the resident's responsible party dictated the resident's care at the facility and requested that the resident be placed in a wheelchair, when not in the Broda chair. Interview with Employee 2 and review of clinical documentation revealed no documented evidence of an evaluation for the resident's use of the wheelchair, including an evaluation of any potential modifications, adjustments or additions that may increase the resident's safety in wheelchair, prior to accommodating the responsible party's request that the resident be seated in the wheelchair. On the night of the resident's fall from the wheelchair and head injury, the resident had displayed restless and combative behaviors. The resident was seated in a wheelchair, which the facility was aware to be unsafe for the resident. The facility failed to provide necessary staff supervision, at the frequency and level required, during periods of restless and unsafe/agitated behaviors to prevent the fall with serious head injury. Nursing documentation dated [DATE], after the resident's fall from the wheelchair, indicated that the facility added the use of a lap buddy (pillow that snugs into the frame of the wheelchair and is meant to gently remind the occupant to ask for help before getting up and provide support while leaning forward in the chair) when out of bed to the wheelchair and Broda chair for safety. The resident's responsible party also agreed to a physical and occupational therapy screen and/or treatment for [REDACTED]. During an interview with the Nursing Home Administrator and the Director of Nursing on [DATE] at approximately 2:05 p.m. these administrative staff members were unable provide evidence that sufficient staff supervision or effective safety measures had been implemented to prevent this fall with serious head injury for a resident with a history of falls and unsafe behaviors. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited [DATE], [DATE]

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility to accurately assess a resident's pain and reliance on pain medications and develop and implement an appropriate management program based on the resident's clinical and psychological needs for one resident out of 21 sampled (Resident 90). The facility also failed to provide two residents out of 21 sampled with appropriate care and services for diabetes management (Residents 20 and 21). Findings include: During a group interview with residents on June 25, 2013 at 10:30 a.m., Resident 20 and Resident 21 stated that staff wakes them between 5:00 a.m. and 6:00 a.m. to check their blood sugar. A review of Resident 20's physician's orders [REDACTED]. The resident's current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] An interview with the Employee 1 (A hall charge nurse) and Employee 2 (B hall charge nurse) revealed that the blood glucose monitoring is done on the 11 PM to 7 AM shift and that the residents who have elevated blood glucose levels and require sliding scale coverage get their insulin after breakfast. A review of a facility's policy for Pain Control reviewed by the facility January 2013, revealed that the facility will identify individuals who have pain or who are at risk for having pain. Such assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition and any time pain is suspected. Staff will use a standardized pain assessment instrument appropriate to the resident's cognitive level. The facility will also evaluate how pain is affecting mood, activities of daily living, sleep, social isolation, and falls. The physician will help identify causes of pain by examining the resident directly, reviewing the resident ' s history, and having a sufficiently detailed discussion with the resident and staff. Periodically, as clinically indicated, the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain, including active conditions that exacerbate pain, consequences of pain, and effectiveness of current interventions for pain. The physician will adjust medications accordingly, based on effectiveness and side effects. The physician should document periodically why the reduction of [MEDICATION NAME] is not feasible. A review of the clinical record revealed that Resident 90 was [AGE] year old and cognitively intact. He was admitted [DATE] with diagnoses that included a history of opioid abuse, intravenous drug abuse, and a history of [MEDICAL CONDITION]. He was hit by a car in December 2012 and sustained multiple fractures of the head and upper body. He was admitted to the facility with an unstageable necrotic (dead skin) open area on his coccyx, measuring 3.8 cm x 1.5 cm. A review of the resident's care plan for pain management dated January 21, 2013 revealed that staff will notify the physician if the resident's pain medication is not effective. A review of an admission pain assessment dated [DATE] revealed that Resident 90, in the past 5 days, was on a scheduled pain medication regimen. The resident received as needed pain medication and did not receive any non-medication interventions for pain. This resident was identified with frequent pain with no pattern noted, and his pain was rated on a 1-10 scale as 10 with only moderate relief with pain medication. [MEDICATION NAME] was identified as the non-pharmacologic\pharmacologic treatment for [REDACTED]. Admission physician's orders [REDACTED].{marijuana is an herbal form of cannabis} sometimes used to treat loss of appetite and causes many effects on your central nervous system) 2.5 mg twice a day as an appetite stimulant. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of nurse's notes dated February 13, 2013 revealed no documentation regarding the changes in the resident's pain medication, the addition of the antianxiety medication or evidence that the physician assessed this resident's level of pain prior to making these changes in the resident's medication regimen.. Physicians orders dated February 15, 2013, and the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of pain evaluation flow record dated December 29, 2012 through February 13, 2013, revealed that 4 times a day on most days, this resident's pain was rated from 8 to 10 on the pain scale of 1-10, and was documented as back pain. The same pain flow record dated from February 14, 2013 through April 5, 2013 8:15 PM revealed that 4 times a day, on most days, Resident 90 had no pain even although this resident continued to receive the as needed [MEDICATION NAME] sulfate 15 mg every 4 hours. A review of nurse's notes dated February 2, 2013 through April 4, 2013 revealed no reference to this resident having any pain, any complaints of pain or any changes in his level of pain control. A review of physician's progress notes dated from December 31, 2012 through April 3, 2013 revealed no documentation of this resident's pain, the appropriateness and effectiveness of the resident's pain management program, clinical justification for the resident's need for the amount of opioid medication prescribed or the reason for the medication changes ordered in February 2013. There was no evidence at the time of the survey of a thorough and accurate assessment of the resident's physical and psychosocial status related to the the pain medication changes that occurred. A review of a resident incident/accident report dated March 13, 2013, revealed that Resident 90 was observed with an open area of skin on his left calf area. A review of a weekly skin alteration work sheet dated March 23, 2013 revealed that the resident had a facility acquired unstageable area on his left heel. The physician was contacted and treatments to this area were ordered. March 2013 medication administration records indicated that Resident 90 continued to receive his around the clock pain medication along with the antianxiety and appetite stimulant medications during the month of March 2013. A review of nurse's notes dated April 5, 2013, on the evening shift revealed that Resident 90 was sent to the emergency room for a red swollen, draining area on the left leg. A review of nurses notes dated April 19, 2013 at 4 PM revealed that "Resident is readmitted to the facility. PICC (peripherally inserted central catheter or PICC line, is a form of intravenous access that can be used for a prolonged period of time) inserted in right arm. [MEDICAL CONDITION] (a surgical procedure in which a stoma is formed by drawing the healthy end of the large intestine through an incision in the anterior abdominal wall and suturing it into place) to left lower quadrant (of the abdomen) patent for loose stool). Stage 4 areas noted to coccyx measuring 13 cm x 12 cm x 2 cm with depth measuring 3.5 cm at 1 o ' clock." A review of readmission physicians orders dated April 19, 2013 revealed [MEDICATION NAME] 0.25 mg by mouth twice a day, (no [DIAGNOSES REDACTED]. Further readmit orders included [MEDICATION NAME] ([MEDICATION NAME], a very potent centrally acting [MEDICATION NAME] medication of the opioid class, a narcotic ) 2 mg, 1 by mouth every 4 hours as needed for severe pain and [MEDICATION NAME] 2 mg IV (intravenous, administered through the PICC line) every 4 hours as needed for severe pain. Both the IV and by mouth orders for the [MEDICATION NAME] medication indicated that they were to be given for severe pain. There was no indication how nursing staff were to make the determination for either route of administration of this pain medication. A review of nurses notes dated April 22, 2013 revealed "medicated for pain as needed and was effective." A review of a physician's orders [REDACTED]. A corresponding nurses note dated April 23, 2013 at 11:25 AM revealed "resident agitated over MD order to change route of pain medication from IV push to by mouth and began cursing at nurse about same. Resident refused to allow nurse to change dressings x 3 attempts. Refused care from nurse aide this shift." Nurses notes dated April 23, 2013 at 12:43 PM revealed that Resident 90 was taken to the hospital emergency room for evaluation and treatment for [REDACTED]. A review of readmission physician orders [REDACTED]. A corresponding nurse's notes dated April 28, 2013 at 3:49 AM revealed "as needed [MEDICATION NAME] given for complaints of back pain with desired effect." The next nurse's note dated April 28, 2013 at 12:22 PM revealed "resident complained of pain and discomfort, observed crying and restless in room. Stated the [MEDICATION NAME] every 4 hours not working, needs it sooner." Nurses notes and physician's orders [REDACTED]. A nurses note dated April 29, 2013 at 10:55 PM revealed "resident complaining that current pain management not working stating he wants to talk to administration. Social services made aware of verbal outbursts, MD made aware, he refused treatments to pressure areas stated he will start cooperating with treatments when he gets stronger pain medication, he will not give staff a hard time." A review of the April 2013 MAR indicated [REDACTED]. A physician's orders [REDACTED]. There was no corresponding nurses or pain assessment to explain the need for the additional narcotic pain medication at this time. Nurses notes dated from May 29, 2013 through June 10, 2013 indicated that Resident 90 received the IV [MEDICATION NAME] and the [MEDICATION NAME] 5-325 mg by mouth at the maximum amounts daily. There was no indication in the nurse's notes or pain assessment during that time period to support the resident's clinical need for increased pain medication. A review of a nurse's note June 11, 2013 revealed that as needed pain medication was given for complaints of back pain and bilateral leg pain with effectiveness. The resident was pleasant and cooperative. New physician's orders [REDACTED].{long-term} pain), 12 mcg, change every 72 hours. There was no pain assessment noted for this change in this resident's pain regimen. A review of monthly MARs and narcotic pain sign out records for April 2013, May 2013 and June 2013 revealed that almost daily Resident 90 received the maximum ordered doses of the [MEDICATION NAME], both IV and by mouth. A review of the resident's pain rating evaluation flow sheet dated from April 27, 2013 through June 25, 2013 indicated that Resident 90 stated that he had a pain rating of 10 (1 being mild pain and 10 being severe) daily. A review of monthly physicians and physicians assistant's progress notes dated from December 31, 2012 through June 7, 2013 revealed no reference to the this resident's long standing opioid dependence, his current and ongoing pain management program or documentation of the clinical justification to support the multiple pain medication adjustments made. There was no evidence that the facility conducted a comprehensive physical and psychological assessment of the resident's clinical and mental health needs for pain management to promote maximum functional status and psychosocial well-being. Aside from the resident's admission and readmission pain assessments, there was no evidence at the time of the survey that the facility conducted ongoing and accurate pain assessments for this resident to demonstrate that an appropriate and necessary pain management was developed, implemented and consistently monitored. There was no new assessment of the resident's status and needs with the continued pain rating voiced at a 10. A review of the resident's meal intake records from admission to June 2013 revealed that he ate 25 to 50 % of his meals daily. He was also provided multiple nutritional supplements, but only consumed a portion of the drinks. A review of lab work dated April 7, 2013 revealed his total protein at 5.3 GM\DL (normal 6.1 - 8 GM\DL), [MEDICATION NAME] 1.7 G\DL ( normal 3.5\4.8 G/Dl) and [MEDICATION NAME] 4.8 MG/DL ( normal- 45 MG\DL) all measures of protein stores in the body, which support wound healing. During an interview June 27, 2013 at 11:30 AM Resident 90 stated that he has been on narcotic pain killers since he was [AGE] years old. He stated that he has chronic pancreatitis and is always in pain. The resident stated that he can' t eat or sleep because his belly constantly hurts and he needs his pain meds. He stated that he understood his need for good nutrition, but that he needed more [MEDICATION NAME]. He stated that he hated his physician and wanted to fire him because the physician would not give him more IV [MEDICATION NAME]. He also stated that he has taken larger amounts of that pain medication in the past. During this interview the resident was fixated on his need for more narcotic pain medication. During an interview June 26, 2013 at 9:30AM the Director of Nursing stated that Resident 90's attending physician managed the resident's pain medications. She confirmed that there were no pain assessments available to correspond with the multiple adjustments in the resident's pain medication nor any clinical consultations conducted or requested specifically for pain management/opioid dependency expertise to prevent the resident's physical and psychological status from being further compromised by his continued requests for increased narcotic pain medications. 483.25 Quality of Care previously cited 12/07/12 28 Pa Code 211.12 (a)(c)(1)(3)(5) Nursing services previously cited 12/7/12, 5/24/13 28 Pa. Code 211.2(a) Physician services 28 Pa Code 211.10(a)(d) Resident care policies previously cited 12/7/12 28 Pa. Code 211.5(f)(g)(h) Clinical records

Based on clinical record and select policy review, staff and resident interview and observation, it was determined that the facility failed to thoroughly and accurately assess pressure sores and consistently monitor wound status to promote healing and to timely identify decline for one resident out of 21 sampled (Resident 90). Findings include: A review of the facility policy for Pressure Sore Prevention/Wound Protocol, reviewed by the facility January 2013 revealed that if the resident is identified through the assessment process as having a current pressure ulcer or a history of pressure ulcers, the resident will be identified as high risk for pressure ulcers from that point forward. The facility will complete an incident/accident form for any alterations in skin integrity, evaluating the resident's current care plan and current interventions. The resident's plan of care will be updated to reflect curative and preventative measures as indicated based on the facility investigation and assessment. The policy further stated if the resident develops a wound after admission the licensed staff will assess/evaluate the wound and document findings on the weekly skin tool, documenting the following: date of onset, date physician and responsible party notified, type of wound and original stage. Nursing will notify the physician if a lack of healing progress is observed for two weeks, or if a wound is deteriorating, for further assessment and or change in treatment order. A review of the clinical record revealed that Resident 90 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was admitted to the facility with an unstageable, necrotic (dead skin) open area on his coccyx, measuring 3.8 cm x 1.5 cm. An admission Minimum Data Set assessment dated [DATE], revealed that Resident 90 was cognitively intact, required the assistance of two persons for bed mobility and was admitted with an unstageable area on his sacrum. Preventative measures ordered by the physician monthly since admission to prevent skin breakdown of the lower extremities included turn and reposition in bed every 2 hours, apply skin prep to bilateral heels and bilateral mafo boots (a hard molded orthotic device) on at all times and to remove for care. A review of a resident care event report dated March 13, 2013, at 8:30 PM revealed that "while doing treatment to resident, left heel observed with dried blood on Mafo boot. Observed open area on left lower extremity. No complaints of pain. Examined by RN." The anatomical drawing on the event report indicted the opened area was on the calf portion of the resident's leg. The report also indicated that this resident often refuses repositioning in bed. The physician was contacted and ordered that staff discontinue the use of the Mafo boot and to wash the area, back lower extremity, with normal saline, apply solosite (a hydrogel wound dressing to rehydrate non-viable tissue) wound gel and apply dry sterile dressing twice a day. Corrective actions planned by the facility and noted on the care event report included a dietary screen, physician order for [REDACTED]. The was no documentation of any measurements of the open area and description of the wound at the time it was identified. Further review of the care event report, under "additional comments" on the form was the notation "resident seen by wound care specialist, area noted to be an abrasion." A review of a corresponding nurses note dated March 13, 2013, 3 PM to 11 PM shift revealed that the physician was notified of an open area to the left lower extremity, new was order noted. This nursing entry also failed to include measurements or description of the open area. A weekly skin alteration measurement tool indicated that the area was found on March 13, 2013. The first noted measurement of the skin breakdown was dated March 26, 2013, describing the area on his left posterior calf measuring 2 cm x 0.3 cm x 0.1 with a small amount of bloody drainage, the wound bed was pale and 100% granulating skin (healing) with no noted staging of the wound noted. A review of a wound care specialist evaluation dated March 19, 2013, revealed no reference to the open area on the left calf area. The wound specialist saw this resident six days after the open area on the resident's left lower extremity was discovered by the facility. The next wound care specialist report dated March 26, 2013, noted that the left calf area measured as 2 cm x 0.3 cm x 0.1 cm, with light serous drainage and 100% granulation tissue with recommendations to the facility of triple antibiotic solution, dry protective dressing daily and to off load the wound and to reposition per facility protocol. The wound care specialist report did not refer to the area as an abrasion. There were no new orders noted at that time. On April 2, 2013, the left calf wound area was now noted as 3.5 cm x 3 cm x 0.2 cm with a small amount of serous (bloody) drainage. The wound bed now was noted as 50% granulation and 50% slough (dead tissue) and the wound bed described as both pale and dark. The form noted the wound evaluation as "no change," although the size and description of the wound reflected a marked decline. This wound was not staged at this time. A review of a wound care specialist evaluation dated April 2, 2013 revealed that the measurements were as noted above (on April 2, 2013) with 50 % necrotic tissue and 50% granulation tissue. The wound was debrided at that time. A nurses note dated April 2, 2013, evening shift, indicated that the physician was made aware the resident's 3 plus [MEDICAL CONDITION] (swelling due to fluid accumulation when the skin is touched, it leaves an indent in the skin) of the bilateral feet and a new order was received. A review of a corresponding physician's order revealed [MEDICATION NAME] 25 mg (a diuretic medication) by mouth every morning. The decline in the left calf area noted on this same date was not included in the nurses note. A review of a weekly skin alteration record revealed that Resident 90 had also developed a facility acquired area of skin breakdown on the left heel on March 23, 2013. The first notation of the description of this impaired area was dated March 26, 2013, which indicated that this area was a suspected deep tissue injury, measuring 3.5 cm x 3.5 cm with a dark wound bed. Corresponding nurses notes dated March 23 through March 27, 2013 revealed no reference to an open area on the resident's left heel. There was no evidence at the time of the survey that the facility evaluated potential causative factors for the skin breakdown on the resident's heel or evidence that the physician was notified of the open area on the resident's left heel. On April 2, 2013, the left heel wound measured the same (3.5 cm x 3.5 cm) with the same assessment as noted above dated on the initial weekly record of March 26, 2013. A review of physician progress notes [REDACTED]." with no mention of the left heel open area or the worsened left calf pressure area. The prior physician's progress note was dated March 8, 2013. A review of a treatment administration record for March 2013 revealed that mafo boots, right and left, were signed out as applied to the resident for the entire month of March 2013, although the physician order on March 13, 2013, discontinued their use and prescribed a soft boot. There was no evidence at the time of the survey that the left mafo boot was discontinued and the soft boot was applied as ordered. A review of a nurses note dated April 5, 2013 revealed "went to do treatment to left lower extremity. Noted to have sero/sanguineous drainage, leg swollen and red, warm to touch. physician called. Resident sent to the hospital." The resident's left calf and heel areas were surgically derided (the areas of dead skin are surgically removed) during this hospital stay. The resident was readmitted to the facility on [DATE]. The weekly wound sheet dated April 29, 2013 revealed that the pressure sore on the resident's left heel measured 12 cm x 8 cm x 0.1 cm moderate bloody drainage, a dark wound bed with the wound bed 100% granulating tissue. The weekly measurements and description dated May 5, 2013, through June 6, 2013, remained essentially the same. Resident 90's weekly wound assessment dated [DATE] revealed that the left heel wound measured 11.4 cm x 8 cm x 0.1 cm with no drainage and the wound bed was now 100% necrotic (dead tissue, black in color). The evaluation of the wound by the facility's assistant Director of Nursing/wound nurse indicated that the wound area was "improved," although the wound bed went from 100% granulating (healing) to 100% necrotic (dead) tissue. There was no evidence at the time of the survey, June 27, 2013, that the physician was contacted on June 10, 2013, with this change in the status of the left heel pressure area. A review of a treatment administration record for June 2013 revealed that Resident 90 refused to have his leg treatments performed on June 3, 4, 10 and 19, 2013. The physician was contacted June 19, 2013 at 10:16 PM concerning that day's treatment refusal, but there was no evidence at the time of the survey that the physician was informed of the other dates of treatment refusals. A review of the weekly wound sheet dated June 17, 2013 revealed that the left heel unstageable wound measured 11.4 cm x 8 cm x 0.1 cm with no drainage and the wound bed was 100% necrotic. The next entry on the wound sheet dated June 24, 2013 revealed that the area measured 10 cm x 6 cm x 0.1 cm with moderate drainage (no description of the drainage noted) and the wound bed was 100% necrotic. A nurses note dated June 24, 2013, at 5:03 PM revealed "new orders received for treatments to areas." A corresponding physician's order dated June 24, 2013, at 5 PM revealed "discontinue all previous treatments to legs and buttocks. Skin prep (a protective coating for the skin) to necrotic areas on left and right heels and apply Santyl (an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level) to open areas on left and right heels daily." A review of monthly physician's progress dated from May 1, 2013 through June 7, 2013 revealed no mention of the condition of the resident's left leg and left heel wounds. An observation June 26, 2013 at 2:15 PM of the resident's left heel wound area revealed measurements of 9 cm x 6.1 cm with an open area in the middle of the wound measuring 2 cm x 2.3 cm x 0.8 cm. The open wound area was observed to be red with bloody drainage with granulating tissue. The surrounding area was noted to be 100% necrotic. Review of a wound care physician's progress note dated May 7, 2013 revealed "signing off on patient (Resident 90) who remains in the facility. Patient non-compliant with wound care and chooses not to be followed by wound team at this time." During an interview June 26, 2013 at 2 PM the assistant Director of Nursing/wound nurse stated that Resident 90 "fired" the wound specialist. She stated that he refused to be seen by him and that the facility's nursing staff was taking care of this resident's wounds. She confirmed that the physician was not timely informed of the changes in the resident's wounds. The ADON was unable to explain why Resident 90's wounds were not timely and accurately assessed or why the physician was not consulted promptly regarding changes in the resident's wounds and repeated treatment refusals. CFR 483.25(c) Pressure sores previously cited 12/7/12 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services previously cited 12/7/12, 5/24/13 28 Pa Code 211.10 (a)(c)(d) Resident care policies previously cited 12/7/12