Every finding on record at Muncy Place

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 71).Findings include: The facility's medication error rate was 6.67 percent based on 30 medication opportunities with two medication errors. The facility policy entitled, Medication Administration and Charting Guidelines, last reviewed August 3, 2026, listed six recognized standards that included right time and right dose. The, Do's and Dont's, section of the policy included, Do be aware of time window for giving medications, and Do give ACs (before meals) one-half hour before meals and PCs (after meals) within one hour after a meal. Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time, except before and after meals orders, which are administered precisely as ordered. The Medication Pass Observation tool (checklist used to verify staff competency with medication administration) listed points monitored during an observation that included, Follows cautionary messages e.g., don't crush, don't give with antacids, shake well, give with food, give on empty stomach, etc. Clinical record review for Resident 71 revealed active physician orders for staff to administer the following medications: Potassium phosphate-sodium phosphate (K-Phos, a medication containing potassium phosphate used to acidify urine, prevent kidney stones, and support urinary tract health) 305 mg (milligrams) /700 mg per tablet one tablet four times daily before meals and at bedtime (morning, around noon, evening, bedtime) Diclofenac sodium (Voltaren, a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and swelling) one percent gel one application topical three times daily (morning, around noon, evening) four grams left shoulder and bicep Observation of a medication administration pass for Resident 71 on August 10, 2026, at 8:49 AM revealed Employee 2 (licensed practical nurse) prepared one tablet of K-Phos. The labeling on the medication instructed to administer one tablet by mouth four times a day before meals with a full glass of water. Employee 2 also obtained a tube of diclofenac sodium (Voltaren) gel, one percent, for topical application to Resident 71. The label on the medication instructed to apply four grams topically to Resident 71's left shoulder and bicep three times a day. The medication reference Drugs.com instructions regarding the administration of diclofenac sodium gel noted that this medicine comes with a dosing card. Be sure you know how to use it. Employee 2 entered Resident 71's room on August 10, 2026, at 9:10 AM and Resident 71 was eating her breakfast. Employee 2 squeezed a small dollop of Voltaren gel onto her gloved hand and rubbed the gel over Resident 71's left shoulder. Employee 2, then, squeezed another small dollop of Voltaren gel onto her gloved hand and rubbed the gel over Resident 71's left bicep area. Resident 71 declined Employee 2's offer to apply the gel to her hands as she was eating her breakfast. Employee 2 removed her gloves, obtained water from the medication cart in the hallway, returned to Resident 71's bedside, and administered the prepared medication tablets to Resident 71. Interview with Employee 2 on August 10, 2026, at 9:14 AM confirmed that she did not utilize the dosing card to measure the amount of diclofenac sodium gel for an accurate dose of four grams. Observation of the medication packing revealed a plastic dosing card that permitted the user to dispense different amounts for either a two-gram or a four-gram dose. Employee 2 stated that she often finds that someone has discarded the medication packaging including the dosing card; however, Resident 71's diclofenac sodium packaging included a plastic dosing card. The interview also confirmed that Employee 2 was aware that Resident 71 had received and was eating her breakfast at the time of the medication administration. Employee 2 confirmed that her K-Phos medication labeling stipulated that the medication was to be administered before meals; however, trying to get everyone done is the problem. Employee 2 stated that the morning medication administration pass includes medications that are ordered for 7:30 AM but she stated that she has until 11:00 AM to finish. Employee 2 stated that breakfast on the unit is typically served at 8:00 AM. The surveyor reviewed the above two medication error concerns during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2026, at 2:15 PM. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, for three of five residents reviewed for immunization concerns (Residents 39, 49, and 60).Findings include: Current CDC website information notes that there are four pneumococcal vaccines available in the United States. Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20 (Prevnar20), and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). Each of these vaccines helps protect against specific serotypes, or strains, of pneumococcal bacteria. The number at the end of the vaccine name tells how many strains the vaccine includes. CDC Pneumococcal Vaccine Timing for Adults (https://www-new.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf) instructs that a complete series would be a PCV13 (Prevnar 13, pneumococcal conjugate vaccine) at any age, a PPSV23 (Pneumovax 23, pneumococcal polysaccharide vaccine) at greater than or equal to 65 years, and together with the resident, vaccine providers may choose to administer PCV20 (Prevnar 20, 20-valent pneumococcal conjugate vaccine) or PCV21 (CAPVAXIVE, 21-valent conjugate vaccine) to adults greater than or equal to [AGE] years old who have already received the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The CDC stipulates that, Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Current CDC information indicates that for someone greater than [AGE] years old, with no known prior pneumococcal vaccines, the first option is to administer the PCV20 or PCV21; and the second option is to administer the PCV15 followed by the PPSV23 after greater than one year. The facility policy entitled, Infection Control Policy and Procedure, Influenza, Pneumococcal, and COVID-19 Prevention Program, last reviewed August 3, 2026, noted that each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. The facility policies provided did not stipulate the frequency that staff would ensure that residents received education regarding available pneumococcal immunizations during their ongoing admission to the facility (e.g., annually), or that they would be offered appropriate pneumococcal immunizations during their ongoing admission to the facility. Clinical record review for Resident 49 revealed that the facility admitted her on February 14, 2019. Review of Resident 49's immunization record revealed that she received a PPSV23 vaccine on October 20, 2008 (when she was [AGE] years old) and a PPSV23 vaccine on September 16, 2013 (when she was [AGE] years old). Based on CDC guidelines, Resident 49 was eligible to receive either the PCV15, PCV20, or PCV21 vaccine at least one year after the last PPSV23 pneumococcal vaccine (September 16, 2014). Interview with Employee 1 (registered nurse, infection control and prevention coordinator) on August 13, 2026, at 9:42 AM confirmed that Resident 49's clinical record contained no evidence that she received either the PCV15, PCV20, or PCV21 immunizations as recommended by the CDC. The interview indicated that the facility offered Resident 49 a pneumococcal vaccine (unspecified) in 2021; however, she declined. There was no evidence that the facility offered her a pneumococcal vaccine since 2021. Clinical record review for Resident 60 revealed that the facility admitted her on August 28, 2023. Review of Resident 60's immunization record revealed that she received a PPSV23 vaccine on November 15, 2014 (when she was [AGE] years old) and a PCV13 vaccine on January 1, 2020 (when she was [AGE] years old). Based on shared clinical decision-making, Resident 60 was eligible for a PCV20 or PCV21 vaccine five years after her last pneumococcal vaccine (January 1, 2025). Interview with Employee 1 on August 13, 2026, at 10:15 AM confirmed that the facility had no evidence that Resident 60 was offered a pneumococcal vaccine after she became eligible for its administration in January 2025. Clinical record review for Resident 39 revealed that the facility admitted her on April 5, 2024. Review of Resident 39's immunization record revealed that she received a PPSV23 vaccine on January 27, 2000 (when she was [AGE] years old) and a PCV13 vaccine on December 16, 2014 (when she was [AGE] years old). Based on CDC recommendations, Resident 39 was eligible for either the PCV20 or PCV21 vaccine five years after the last pneumococcal vaccine (December 16, 2019). Interview with Employee 1 on August 13, 2026, at 10:22 AM confirmed that Resident 39's clinical record did not contain evidence that she refused a pneumococcal vaccine. The surveyor reviewed the above concerns related to pneumococcal vaccinations for Residents 39, 49, and 60, during an interview with the Nursing Home Administrator and the Director of Nursing on August 13, 2026, at 12:45 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure resident privacy during physician ordered assessments on one of six hallways (First Floor West, Residents 4 and 62).Findings include: The facility policy entitled, Medication Administration and Charting Guidelines, last reviewed August 3, 2026, listed, Do's and Dont's, that included, Do observe resident's privacy. Observation of the First Floor [NAME] hallway on August 10, 2026, at 12:04 PM revealed Employee 3 (licensed practical nurse) obtained a capillary blood glucose assessment (A lancet is used to prick the side of the fingertip, producing a small drop of blood, that is applied to a disposable test strip, that is inserted into a glucometer machine, that provides an assessment of the blood sugar reading) for Resident 4. Employee 3 stated that Resident 4's result was 129; and that he did not need insulin (injected hormone used to lower blood sugar). Employee 3 performed the procedure and announced the finding in the common hallway area that did not afford Resident 4 privacy for the procedure. When Employee 3 completed the above procedure on August 10, 2026, at 12:06 PM Employee 3 requested that staff standing in the hallway bring another resident for, her last blood sugar. Employee 3 observed Resident 62 sitting in his wheelchair in the doorway to his room on August 10, 2026, at 12:08 PM and asked him to come to her at the medication cart which was located in the hallway several rooms away from his room. Employee 3 then went to Resident 62 and took him from his room doorway to the medication cart in the hallway. Employee 3 attempted to obtain a capillary blood sugar assessment in the common hallway area; however, the first attempt failed. Employee 3 announced that the first attempt failed and that she would have to perform the procedure again. Employee 3 performed the procedure again on August 10, 2026, at 12:13 PM and stated, 170, you do not need any insulin sir, you may go to lunch. Employee 3 performed the procedure and announced the finding in the common hallway area that did not afford Resident 62 privacy for the procedure. Interview with Employee 3 on August 10, 2026, at 12:15 PM revealed that she usually performs capillary blood sugar testing in the hallway as residents are going to the dining room for lunch. She stated, some are done in their room, it depends, they don't mind. Employee 3 confirmed that education provided by the facility included that a medical procedure is, best done in the room. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to provide written notice of transfer and bed hold policy that included all the necessary contents to a resident's responsible party at the time of transfer for one of four resident's reviewed for hospitalizations (Resident 3), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for one of four residents reviewed for hospitalizations (Resident 4).Findings include: Clinical record review for Resident 3 revealed profile information that indicated that resident had a resident representative (identified as his sister). Clinical record review that Resident 3 was transferred to the hospital due to a change in condition on May 23, 2026, and July 14, 2026. There was no evidence that Resident 3's representative was notified in writing of the transfer and bed hold policy for either of the transfers noted above. Interview with Nursing Home Administrator on August 13, 2026, at 12:15 PM, confirmed the above findings. Clinical record review for Resident 4 revealed leave of absence documentation that the facility transferred him to the emergency department on April 19, 2026, and he remained in the hospital for eight days. Nursing documentation dated April 27, 2026, at 1:27 PM indicated that Resident 4 returned to the nursing unit from the hospital. Interview with the Nursing Home Administrator on August 12, 2026, at 9:30 AM indicated that the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of Resident 4's transfer to the hospital in April 2026. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 24 residents reviewed (Resident 8).Findings include: Observation of Resident 8 on August 10, 2026, at 12:28 PM revealed her to appear edentulous (no natural teeth). Interview with Resident 8 on the date and time of the observation indicated that she had no natural teeth and had lost her dentures. Clinical record review for Resident 8 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 15, 2025, that assessed her as not edentulous (that she had natural teeth). A significant change MDS dated [DATE], also assessed Resident 8 as not edentulous (that she had natural teeth). A significant change MDS dated [DATE], assessed Resident 8 as edentulous (that she did not have any natural teeth). Resident 8's clinical record did not include evidence that she underwent dental procedures to remove teeth between July 2025 and March 2026. Interview with the Nursing Home Administrator and the Director of Nursing on August 13, 2026, at 12:45 PM confirmed that the July and October MDS assessments for Resident 8 errantly assessed her as having natural teeth. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding resident directed care for one of 24 residents reviewed (Resident 83).Findings include: Clinical record review for Resident 83 revealed a task for thrombo-embolic deterrent (TED) (specialized medical compression garments designed to prevent blood clots) stockings to be applied every AM and removed every PM initiated on February 5, 2026. Observation of Resident 83 on August 11, 2026, at 9:11 AM revealed the resident sitting in her wheelchair at her bedside wearing nonskid socks with no TED stockings. Interview with Resident 83 at this same time revealed she has not been wearing TED stockings since the last time she received physical therapy. Observation of Resident 83 on August 12, 2026, at 9:25 AM revealed the resident sitting in her wheelchair at her bedside wearing nonskid socks with no TED stockings. Interview with Employee 5 (nurse aide) at this same time revealed that she provided morning care for Resident 83 and did not place TED stockings on the resident, and she did not know that the resident was supposed to wear them. Observation of Resident 83 on August 13, 2026, at 12:16 PM revealed the resident sitting in her wheelchair at her bedside wearing nonskid socks with no TED stockings. Interview with Employee 6 (nurse aide) at this same time confirmed that Resident 83 was wearing nonskid socks with no TED stockings. The surveyor reviewed the above findings for Resident 83 with the Director of Nursing on August 13, 2026, at 12:20 PM. 483.25 Quality of CarePreviously cited deficiency 7/25/2025 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of select facility policies and procedures, observation and staff interview, it was determined that the facility failed to properly store resident medications on two of six nursing units reviewed (First Floor South and Second Floor [NAME] Nursing Units, Residents 15 and 70). Findings include: The facility policy titled, Storage of Medications, last reviewed without changes on August 3, 2026, revealed (in part) that medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, or staff members authorized to administer medications. Clinical record review for Resident 15 revealed a diagnosis list that included a Stage 4 pressure ulcer (a full-thickness ulcer with skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer). A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 13, 2026, revealed that facility staff assessed Resident 15 as having a BIMS (Brief Interview for Mental Status) of 11, which indicated some cognitive impairment. A current physician order for Resident 15 included sodium hypochlorite (Dakin's Quarter Strength) 0.125% topical solution (a type of wound cleanser solution), once per day on Tuesday / Wednesday / and Thursday. The order instructed staff to irrigate with normal saline; moisten sterile gauze with Dakin's solution so the gauze is damp; loosely pack the wound cavity; cover with a 2 x2 gauze and medium Allevyn (a type of wound dressing); apply barrier cream. Observation of Resident 15's room on August 11, 2026, at 9:47 AM revealed a yellow and white colored bottle of sodium hypochlorite clearly visible on a shelf behind the resident while conducting an initial interview. A follow-up observation on August 13, 2026, at 11:24 AM revealed the bottle remained on the shelf in Resident 15's room. An interview with Employee 7, licensed practical nurse, on August 13, 2026, at 11:25 AM revealed that the medications was H-Chlor 12 0.125 percent; sodium hypochlorite solution. Employee 7 further noted that the solution should be kept on the wound cart and proceeded to remove it from the room. The above information for Resident 15 was reviewed with the Nursing Home Administrator and Director of Nursing on August 13, 2026, at 11:38 AM. The Director of Nursing further noted there was no self-administration of medications for Resident 15. Observation of Resident 70's room on August 12, 2026, at 9:28 AM revealed a tube of clotrimazole (topical antifungal medication used to treat skin infections 1% cream on his overbed table. Interview with Resident 70 at this time revealed he would apply it himself when he was itchy. Interview with Employee 2 (LPN) on August 12, 2026, at 9:36 AM revealed that the clotrimazole cream should be kept in the treatment cart and proceeded to remove the cream from Resident 70's room. Employee 2 further noted that the resident did not have a current order for the clotrimazole cream. Review of Resident 70's clinical record revealed no active physician order for clotrimazole 1% cream. The above findings were reviewed in a meeting with the Director of Nursing on August 13, 2026, at 12:44 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide dental care for one of nine residents reviewed for dental concerns (Resident 8).Findings include: Interview with Resident 8 on August 10, 2026, at 12:28 PM revealed that she did not have any natural teeth and that she did not have dentures. Resident 8 stated that she would like to have dentures to better chew her food. Observation of Resident 8 on the date and time of the interview indicated that she was edentulous (had no natural teeth). Clinical record review for Resident 8 revealed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 10, 2026, that assessed Resident 8 as edentulous. The significant change MDS dated [DATE], and a quarterly MDS dated [DATE], assessed Resident 8 as needing substantial/maximal assistance of staff for oral hygiene which included the care of dentures. A plan of care developed by the facility on October 26, 2025, to address Resident 8's dental care listed interventions that included assist with dentures/partials as needed. Progress note documentation by the facility's contracted dental provider dated May 29, 2026, noted that Resident 8 was not wearing her dentures. Progress note documentation by the facility's contracted palliative care provider dated August 10, 2026, noted, She (Resident 8) is also frustrated that she does not have her dentures. They are coming to fit her this month for a new set. She feels that makes it difficult for her to eat . The surveyor requested evidence of professional dental services provided in the past year, evidence that staff attested to the daily provision of denture care assistance per Resident 8's plan of care, and any investigation related to Resident 8's report that she lost her dentures, during interviews with the Nursing Home Administrator and the Director of Nursing on August 11, 2026, at 2:30 PM and August 12, 2026, at 2:15 PM. Social services documentation dated August 12, 2026, at 3:26 PM (following the surveyor's questioning) revealed that social services staff spoke with Resident 8's daughter regarding Resident 8's dentures. She confirmed upper dentures in Resident 8's room were Resident 8's; however, she was missing her lower dentures. Interview with the Nursing Home Administrator and the Director of Nursing on August 13, 2026, at 12:45 PM confirmed that information available at the time of the onsite survey indicated that Resident 8 lost her lower dentures at some point, but the facility could not determine when; therefore, the facility could not provide evidence that the facility referred her for dental services promptly (within three days) of losing her dentures. The interview also indicated that the staff caring for Resident 8 do not attest providing assistance with her dentures as per her plan of care (they do not document that care was completed). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15 Dental services

Based on observation and staff interview, it was determined that the facility failed to maintain equipment in a safe and sanitary operating condition, in the facility's main kitchen.Findings include: Observation of the main kitchen dishwashing machine on August 10, 2026, at 9:50 AM revealed that a dietary staff member was using the machine to wash dishes. Initial wash temperature of the machine, per the gauge on the dishwasher, was observed as 148 degrees Fahrenheit. As staff continued to utilize the dishwasher, the observed wash temperature was as low as 142 degrees. An interview with Employee 8, Dietary Manager, on August 10, 2026, at 9:50 AM revealed that the machine was a hot-water sanitizing dishwasher. A review of the temperature documentation sheets for the dishwasher revealed that the temperature range for each cycle should be: Wash: 150-165 degreesRinse: 160-190 degreesFinal Rinse: 180-195 degrees A follow-up observation with Employee 8 of the dishwashing machine within the facility's main kitchen on August 13, 2026, at 11:40 AM revealed that the machine was not currently being used by dietary staff to clean dishes. Employee 8 proceeded to operate the machine which showed an initial wash temperature of 154 degrees per the gauge on the dishwasher. Continued observation revealed that the temperature dropped below 150 degrees. Continued observations revealed wash temperatures that ranged from 144-146 degrees. Employee 8 confirmed that the wash temperature should be a minimum of 150 degrees. During the follow-up observations it was noted that a large volume of water was coming through a gap in the left upper corner of a front access sliding door to the dishwasher. The water was bubbling out and spilling down the front of the machine. A small plastic piece of the edge protector on the sliding door was noted to be missing in the area where the water was coming out. Employee 8 stopped the machine and notified maintenance. This was not observed during the initial visit to the kitchen on August 10, 2026. The dishwasher concerns were discussed with the Nursing Home Administrator on August 13, 2026, at 12:05 PM. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 7/25/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on two of six hallways (First Floor [NAME] and First Floor South, Residents 62, 70 and 71).Findings include: The facility policy entitled, Infection Control Policy and Procedure, last reviewed August 3, 2026, indicated that hand hygiene staff education includes new employee orientation, mandatory annual online learning module, and ongoing instruction through visual cues and in-services. The policy did not stipulate that staff are to perform hand hygiene after removing disposable gloves. The facility policy entitled, Medication Administration and Charting Guidelines, last reviewed August 3, 2026, noted that staff are to wash their hands before starting, between residents, and before and after eye drops. The policy did not stipulate that staff are to perform hand hygiene after removing disposable gloves. The Medication Pass Observation tool (checklist used to verify staff competency with medication administration) listed points monitored during an observation that included to wear gloves during eye medication administration and PEG (Percutaneous Endoscopic Gastrostomy, a small, flexible tube placed through the abdominal wall into the stomach to deliver nutrition, fluids, and medications directly, bypassing the mouth and esophagus) tube administration and perform hand hygiene before and after; however, the tool did not stipulate that staff wear gloves during topical medication treatments (e.g., creams or gels) or perform hand hygiene after removing disposable gloves. Observation of a medication administration pass for Resident 71 on August 10, 2026, at 9:11 AM revealed Employee 2 (licensed practical nurse) donned disposable gloves to apply Voltaren gel (diclofenac sodium, a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, swelling, and inflammation in the joints) to Resident 71's left shoulder and bicep. Employee 2 removed the disposable gloves, went to the medication cart to obtain water for Resident 71's oral medication administration, and returned to Resident 71 to administer the oral medications, without performing hand hygiene. Observation of the First Floor [NAME] hallway on August 10, 2026, at 12:10 PM revealed Employee 3 (licensed practical nurse) obtained a capillary blood glucose assessment (Accu-check, a lancet is used to prick the side of the fingertip, producing a small drop of blood, that is applied to a disposable test strip, that is inserted into a glucometer machine, that provides an assessment of the blood sugar reading) for Resident 62. Employee 3 announced that the first attempt failed and that she would have to perform the procedure again. Employee 3 removed her disposable gloves and donned another pair of disposable gloves to obtain materials needed to repeat the Accu-check without performing hand hygiene between the glove changes. Employee 3 completed the second Accu-check assessment for Resident 62, cleaned the glucometer machine, removed her disposable gloves, used keys to open the medication cart and put the glucometer machine in the medication cart, before completing hand hygiene. Interview with Employee 3 on August 10, 2026, at 12:15 PM revealed that she did not complete hand hygiene when she changed her gloves because the procedure completed was for the same resident and she did not go from one resident to another. Employee 3 was not certain but believed that education provided by the facility included that hand hygiene should be performed after removing gloves and before donning new gloves. Current CDC (Centers for Disease Control and Prevention) Clinical Safety: Hand Hygiene for Healthcare Workers instructs workers to perform hand hygiene immediately after glove removal. The surveyor reviewed the above hand hygiene concerns during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2026, at 2:15 PM. Clinical record review for Resident 70 revealed the resident has a chronic suprapubic catheter (a tube placed directly into the bladder through the abdomen to drain urine) due to obstructive uropathy (a blockage that stops urine from flowing normally). Review of the facility's current policy entitled Catheter-Urinary-Insertion and Care revealed that urine collection bags should not be left in contact with the floor, such as instances when a resident is in a low bed. Observation of Resident 70 on August 10, 2026, at 1:25 PM revealed the resident lying in bed with his urine collection bag directly on the floor next to his bed with no dignity cover. Observation of Resident 70 on August 11, 2026, at 8:51 AM revealed the resident lying in bed with his urine collection bag directly on the floor next to his bed with no dignity cover. Interview with Employee 4 (nurse aide) on August 11, 2026, at 9:17 AM revealed that urine collection bags are usually hung from the holes on the bed frame and covered with a bag. She confirmed Resident 70's urine collection bag was directly on the floor with no dignity cover. Employee 4 also revealed that the resident has removed the dignity bag on occasions in the past. Observation of Resident 70 on August 11, 2026, at 12:03 PM revealed the resident lying in bed with his urine collection bag directly on the floor next to his bed with no dignity cover. The surveyor reviewed the above concerns with Resident 70 during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2026, at 2:25 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 7/25/25 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen and second floor kitchenette.Findings include: Observation of the facility's main kitchen with Employee 6, Dietary Manager, on July 22, 2025, at 8:45 AM revealed the following: A walk-in cooler contained the following: A bag of lunch meat with no dates on it. A container of asiago cheese with a use by date of July 13, 2025. A container of provolone cheese with a use by date of July 5, 2025. A large bag of lettuce opened to the ambient air with a use by date of July 19, 2025. A container labeled, vegetable fresh prep, with a use by date of July 13, 2025.Cooked bacon with a use by date of July 13, 2025. A container of chicken salad with a use by date of July 19, 2025.Feta cheese with a use by date of July 19, 2025. A second walk-in cooler had a damaged single serve milk carton that was leaking onto the adjacent cartons and surrounding area. A hospitality cart in the dry storage area had a snack bag of expired pretzels. A storage rack holding various adaptive equipment had a container of clear, plastic cups with handles. Multiple cups were noted to have a build-up of moisture. Employee 6 was unable to state how long the cups were wet. The dishwashing area contained the following: A black colored, plastic, corner floor shelf that held various housekeeping items with an accumulation of debris underneath it. The debris included food items, a single-use butter container, and a drinking straw. The corner of the dishwashing room where a fan was attached had a significant accumulation of dried splash stains on the walls and ceiling. The fan had a build-up of dust on the protective cover and fan blades. The floor, adjacent to a floor drain under the ice machine, contained various debris, including a plastic cup, and a broken piece of a red colored plate. Observation of the second floor kitchenette on July 23, 2025, at 11:00 AM revealed the resident refrigerator contained a sandwich with no dates or label on it. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 23, 2025, at 2:00 PM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation and staff interview, it was determined that the facility failed to ensure resident dignity during dining for two of two residents reviewed (Residents 94 and 100).Findings include: Observation on July 22, 2025, at 12:21 PM revealed Employee 1, nurse aide, feeding both Resident 94 and Resident 100 their lunch meals. Employee 1 stood between the two residents who were seated next to the dining table while she fed them. During this same time, Employee 1 would leave the table and grab other plates to serve other residents in an adjacent dining room. Observation on July 22, 2025, at 12:26 PM revealed that Employee 1 left Resident 94 and Resident 100, and Employee 2, nurse aide, arrived and finished feeding both Resident 94 and Resident 100. Employee 2 also stood between both Resident 94 and Resident 100 to finish feeding them. Observation on July 23, 2025, at 12:32 PM revealed that the facility served Resident 94 and Resident 100 their lunch meals. Employee 3, nurse aide, began feeding Resident 100 his meal standing up at 12:35 PM. Employee 3 continued feeing Resident 100 for 30 minutes while she stood the entire time. Employee 3 then left with Resident 100 out of the dining area and did not return. There were no observations of nursing staff attempting to feed Resident 94 until 1:00 PM, at which time he was asleep. The above findings were reviewed during an interview with the Administrator and the Director of Nursing on July 24, 2025, at 2:18 PM. 28 Pa. Code 201.29(j) Resident rights

Based on clinical record review and staff interview it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary psychotropic medication for one of five residents reviewed for medication regimen review (Resident 85). Findings include: Clinical record review for Resident 85 revealed an active physician's order dated July 8, 2025, for staff to administer the antianxiety medication, Alprazolam, 1 mg (milligram) as needed (PRN) every eight hours with a stop date of January 3, 2026, (180 days from the order date). Active physician orders for Resident 85 also included instructions for staff to administer 0.5 mg of Alprazolam three times daily (order date November 26, 2024).Per the medication resource Drugs.com, the usual maximum adult dose for anxiety is 4 mg per day. The lowest possible effective dose should be administered and the need for continued treatment reassessed frequently.If administered as often as the active physician orders permitted, Resident 85 could receive 4.5 mg of Alprazolam per day, which exceeds the usual maximum adult dose.Review of Resident 85's medication administration record (MAR, electronic documentation of the administration of medications) dated May 2025, revealed that Resident 85 received the PRN dose of the Alprazolam medication on 16 occasions on the following dates and times:May 1, 2025, at 10:27 AMMay 8, 2025, at 11:00 AMMay 9, 2025, at 10:35 AMMay 12, 2025, at 10:00 AMMay 15, 2025, at 11:49 AMMay 17, 2025, at 12:00 PMMay 18, 2025, at 11:00 AMMay 20, 2025, at 11:00 AMMay 21, 2025, at 10:25 AMMay 23, 2025, at 10:00 AMMay 25, 2025, at 4:04 PMMay 26, 2025, at 4:01 PMMay 27, 2025, at 11:00 AMMay 28, 2025, at 11:04 AMMay 29, 2025, at 10:30 AMMay 31, 2025, at 3:38 PMReview of Resident 85's MAR dated June 2025, revealed that Resident 85 received the PRN dose of the Alprazolam medication on seven occasions on the following dates and times:June 1, 2025, at 10:20 AMJune 4, 2025, at 11:05 AMJune 5, 2025, at 10:00 AMJune 9, 2025, at 11:35 AMJune 12, 2025, at 11:08 AMJune 18, 2025, at 10:00 AMJune 20, 2025, at 11:04 AMReview of Resident 85's MAR dated July 2025, revealed that Resident 85 received the PRN dose of the Alprazolam medication on four occasions from July 1 through 28, 2025, on the following dates and times:July 9, 2025, at 12:00 PMJuly 13, 2025, at 11:00 AMJuly 14, 2025, at 11:00 AMJuly 17, 2025, at 11:01 AMResident 85's documented use of the PRN Alprazolam medication indicated that she did not require the PRN dose daily; nor did she exceed more than one dose in one day. Interview with the Director of Nursing, the Nursing Home Administrator, Employee 4 (assistant director of nursing), and Employee 5 (assistant nursing home administrator), on July 25, 2025, at 12:00 PM confirmed the above findings for Resident 85.The evidence reviewed also indicated that staff consistently administered the PRN Alprazolam between the hours of 10:00 AM and 12:00 PM on 24 of the 27 occasions.Review of Resident 85's plans of care did not provide evidence that the facility identified the pattern of Resident 85's PRN Alprazolam use; or implemented an individualized intervention to address Resident 85's need for PRN antianxiety medication at a consistent time of day. Due to the above documented frequency of the administration of the PRN dose of Alprazolam, there was insufficient evidence that Resident 85 required the Alprazolam dose to exceed the recommended daily maximum, or that the stop date of 180 days met the regulatory requirement for physician review (at 14 days).28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan related to anticoagulant use for one of five residents selected for medication regimen review (Resident 85). Findings include: Clinical record review for Resident 85 revealed an active physician's order dated January 2, 2025, for staff to administer the anticoagulant medication Eliquis (anticoagulants are a family of medications that stop your blood from clotting too easily; they can break down existing clots or prevent clots from forming in the first place) 2.5 mg (milligrams) two times daily. Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2025, assessed Resident 85 as taking an anticoagulant medication. A quarterly MDS assessment dated [DATE], assessed Resident 85 as taking an anticoagulant medication. Review of plans of care developed by the facility to identify and address Resident 85's medical needs did not include a plan of care that noted her use of an anticoagulant medication. The plans of care did not address pertinent associated risks and the prevention of potential complications from the use of an anticoagulant (e.g., bleeding and bruising). Interview with the Director of Nursing, the Nursing Home Administrator, Employee 4 (assistant director of nursing), and Employee 5 (assistant nursing home administrator), on July 25, 2025, at 12:00 PM confirmed the above findings for Resident 85. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of 21 residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a diagnosis list that included hypertension (high blood pressure). A review of the current physician orders for Resident 1 revealed an order dated May 15, 2025, for Metoprolol Tartrate (a medication that is used to treat high blood pressure and/or heartrate) 25 milligrams (mg) give one tablet by gastrostomy tube (a medical tube inserted through the abdomen into the stomach to provide feeding, hydration, and/or medications) every eight hours. The order indicated a blood pressure and/or pulse hold: pulse less than 60; systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100. A review of the Medication Administration Record (MAR) from May, June, and July 2025, for Resident 1 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following dates: May 27 during the midnight administration; the blood pressure was documented as 92/63.June 15 during the midnight administration; the blood pressure was documented as 93/63.June 17 during the midnight administration; the blood pressure was documented as 99/72. July 8, during the midnight administration; the blood pressure was documented as 95/63.July 10, during the midnight administration; the blood pressure was documented as 90/59.July 10, during the 8:00 AM administration; the blood pressure was documented as 94/66. There was no documentation for Resident 1 to indicate a rationale for why the medication was administered outside of the specific stated parameters. The facility provided nursing shift report sheets (sheets used by nursing staff to keep track of important resident information that are not part of the clinical record) with attached dates written on post-it notes of May 27, June 15, June 17, July 8, and July 10 that the facility indicated the doses of Metoprolol were held those dates; however, Resident 1's medication administration record documentation does not reflect that the doses were held. The above information for Resident 1 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 23, 2025, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and family and staff interview, it was determined that the facility failed to implement physician ordered interventions for a resident with limited range of motion for one of nine residents reviewed for range of motion concerns (Resident 85). Findings include: Clinical record review for Resident 85 revealed an active physician's order dated June 4, 2024, that instructed staff to ensure Resident 85 wore a left palm guard with digit separators (splint worn on the hand with cushioning to split the fingers and protect the palm) in the morning for four hours and in the evening for four hours with skin checks every two hours. Review of a plan of care developed by the facility for contracture prevention for Resident 85 revealed a goal that Resident 85 would wear the left palm guard/digit separator for four hours in the morning and four hours in the evening. Interventions included in the plan of care indicated that nursing staff would don (apply) and doff (remove) the splint as scheduled for further contracture prevention. Observation of Resident 85 on July 22, 2025, at 12:14 PM in the common dining area on the nursing unit revealed no splint to her left hand. The fingers of Resident 85's bilateral hands were bent; and it appeared that Resident 85 used her knuckles to grasp beverage cups during her lunch meal. Interview with Resident 85's husband on July 22, 2025, at 2:53 PM confirmed that Resident 85's hands have arthritic changes (stiffness, swelling, and limited mobility of joints). Resident 85's husband stated, you cannot straighten them. Resident 85's husband stated that it depends on what staff are working if Resident 85 has her hand splint on or not. Resident 85's husband stated that the splint use is inconsistent. Observation of Resident 85 on July 23, 2025, at 1:05 PM revealed two nurse aides transferred her back to bed. Resident 85 did not have a splint on her left hand. Interview with Employee 10 (one of the two nurse aides caring for Resident 85) on July 23, 2025, at 1:11 PM revealed that she believed staff from the overnight shift applied Resident 85's splint. Employee 10 stated that Resident 85 wears the splint in the morning from 6:00 AM to 8:00 AM. Employee 10 referred to the electronic kiosk in the hallway that contained resident care instructions and reported that the only instructions for the nurse aides were to, don and doff splint as scheduled. Employee 10 stated that she removed a splint from Resident 85 at 8:00 AM that morning, and she was not sure when Resident 85 should wear it again during her day. Review of nurse aide documentation of the application of Resident 85's hand splint revealed that only day and evening shift staff document the implementation of the device (not overnight shift). No staff initialed the implementation of the hand splint intervention for Resident 85 on either the day or evening shift on July 23, 2025. Observation of Resident 85 in the nursing unit dining room on July 25, 2025, at 9:18 AM revealed she was using her bilateral hands that were formed into fists to drink from a cup. Resident 85's fingers were contracted (bent). Resident 85 was not wearing a hand splint. Observation of Resident 85 on July 25, 2025, at 11:38 AM revealed she was in her room without a hand splint on her left hand. Interview with Employee 11 (nurse aide) on July 25, 2025, at 11:41 AM revealed that she did not know the schedule to follow for Resident 85's hand splint. Employee 11 confirmed that she was assigned to Resident 85's care on this date. Employee 11 located a hand splint device on Resident 85's overbed table and Resident 85 permitted Employee 11 to apply the device to her left hand. The surveyor reviewed the above concerns regarding Resident 85's hand splint use during an interview with the Director of Nursing, the Nursing Home Administrator, Employee 4 (assistant director of nursing), and Employee 5 (assistant nursing home administrator), on July 25, 2025, at 12:00 PM. 483.25(c)(1)-(3) Increase/prevent Decrease in ROM/mobilityPreviously cited deficiency 8/16/2024 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral means to prevent potential complications for one of three residents reviewed for tube feeding concerns (Resident 5). Findings include: The surveyor requested the facility policies and procedures related to bolus feeding (the administration of a limited volume of liquid nutrition formula over a brief period of time) via a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube) during an interview with the Nursing Home Administrator, Director of Nursing, Employee 4 (assistant director of nursing), and Employee 5 (assistant nursing home administrator), on July 25, 2025, at 12:00 PM; and again, during an interview with Employee 5 on July 25, 2025, at 1:00 PM. The facility was only able to provide a policy entitled, Enteral Tube Medication Administration, last reviewed without changes on June 17, 2025, that instructed staff to verify tube placement per facility protocol before administering medications. The policy instructed staff to allow medication to flow down the tube via gravity; give gentle boosts with the plunger (one inch down) if the medication will not flow by gravity, repeat, if necessary, do not push medications through the tube. The facility was unable to provide the facility protocol used to verify tube placement during the onsite survey. Interview with Resident 5 on July 22, 2025, at 1:01 PM revealed that she receives liquid nutrition every four hours through a tube in her abdomen (PEG tube); that she is not allowed food consumption through her mouth. Resident 5 stated that she had surgery to place this abdominal tube three weeks ago. Nursing documentation dated June 19, 2025, at 1:01 PM revealed that the hospital staff gave a report of Resident 5's condition to the writer that included that Resident 5 had a PEG tube placed due to esophageal dysmotility (when the esophagus does not move food and liquid from the mouth to the stomach as it should). Clinical record review for Resident 5 revealed active physician orders dated June 19, 2025, for the following care needs for Resident 5: Nothing by mouth (NPO)One carton of Nutren 2.0 (liquid nutrition) three times a dayCleanse and apply a dressing to a G-tube site daily and as neededTube Feeding - Check placement 3 (three) times dailyTube Feeding - Check residual 3 times dailyTube Feeding - Check placement PRN (as needed)Tube Feeding - Check residual PRN Observation of Resident 5's bolus G-tube feeding on July 25, 2025, at 8:50 AM with Employee 12 (registered nurse) revealed Employee 12 filled a syringe with 50 milliliters of water and flushed Resident 5's tube by pressing the plunger of the syringe. Employee 12 did not allow gravity to instill the water into Resident 5's stomach. Employee 12 did not attempt any intervention to verify the correct placement of Resident 5's G-tube before completing the flush. Employee 12 did not check for any residual feeding in Resident 12's stomach before completing the flush. Employee 12 repeated the process of filling the syringe with Nutren 2.0 liquid nutrition and administering the Nutren 2.0 via Resident 5's G-tube by pushing the plunger four times until the entire 8.45 fluid ounces of liquid nutrition was consumed. Employee 12 did not attempt to allow the liquid nutrition to flow into Resident 5's stomach via gravity. Continued observation of the G-tube feeding on July 25, 2025, at 9:02 AM revealed Employee 12 flushed Resident 5's G-tube with 100 milliliters of water by pushing the plunger of the syringe (not via gravity). Following the completion of the G-tube feeding on July 25, 2025, at 9:04 AM Employee 12 rinsed the used syringe in Resident 5's bathroom, removed her gloves, obtained dressings and saline from Resident 5's in-room cabinet, and donned new gloves without performing hand hygiene (e.g., alcohol hand sanitizer or hand washing with soap and water). Employee 12, then, cleansed Resident 5's G-tube insertion site and applied a new gauze dressing around Resident 5's G-tube. Interview with Employee 12 on July 25, 2025, at 9:12 AM confirmed that she did not complete any G-tube flushes or feedings via a gravity method. Employee 12 denied completing any interventions to confirm the appropriate placement of Resident 5's G-tube. Employee 12 indicated that there were numerical markings visible on Resident 5's G-tube; however, she did not know what number would indicate a correct insertion depth for Resident 5. Employee 12 confirmed that she did not assess for any residual feeding (e.g. aspirate stomach contents) before completing the task. Employee 12 also confirmed that she did not wash her hands or utilize hand sanitizer after removing soiled gloves and donning new gloves. Interview with Employee 5 on July 25, 2025, at 1:00 PM confirmed that the documentation of Employee 12's competency related to G-tube care reviewed a process of care utilizing a gravity method. The procedural steps in the competency did not include using a plunger method to complete the entire process of instillation via a G-tube. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement contact precautions for one of two residents reviewed for isolation concerns (Resident 4), and implement proper hand hygiene practices consistent with accepted standards of practice for two of 21 residents (Residents 5 and 9). Findings include:Review of the facility policy entitled, Hand Hygiene, dated July 18, 2025, revealed that hand hygiene must be performed prior to donning gloves when gloves are being worn for interaction with a patient and/or patient zone. Hand hygiene must be performed after removing gloves when gloves are being worn for interaction with a patient and/or patient zone and patient surroundings. Remove gloves, clean hands, and don a fresh pair of gloves when caring for a patient that requires moving from a dirty site to a clean site. Clinical record review for Resident 9 revealed nursing documentation dated July 21, 2025, at 2:11 PM that Resident 9 had increasing edema (swelling) in both her arms over the weekend. The nurse noted four open areas on Resident 9's arms, and treatment included an oil emulsion dressing (a non-adherent gauze mesh that is impregnated with an oil-based substance, typically white petrolatum or a similar emollient, that allows the dressing to create a protective barrier over the wound, minimizing trauma during dressing changes, and ensuring that the dressing does not stick to the wound surface), gauze, and kerlix wrap (rolled stretchable gauze) daily and as needed. Observation of wound care for Resident 9 with Employee 12 (registered nurse) on July 25, 2025, at 8:27 AM revealed Employee 12 removed the soiled kerlix wrapping, gauze, and oil emulsion dressings from Resident 9's right arm. Employee 12 removed her gloves and donned new gloves without performing hand hygiene (e.g., alcohol hand sanitizer or hand washing with soap and water). Employee 12 used saline-soaked gauze to cleanse two sites on Resident 9's right mid forearm. Employee 12 removed her gloves to open the packaging of the oil emulsion dressings and donned new gloves without performing hand hygiene. Employee 12 applied an oil emulsion dressing over each wound site on Resident 9's right arm, applied sterile gauze, and wrapped Resident 9's right forearm with kerlix dressing. Employee 12 removed her gloves and donned new gloves without performing hand hygiene. Continued observation of Resident 9's wound care on July 25, 2025, at 8:38 AM revealed Employee 12 removed the soiled kerlix wrapping, gauze, and oil emulsion dressings from Resident 9's left arm. Employee 12 removed her gloves and donned new gloves without performing hand hygiene. Employee 12 cleansed two sites on Resident 9's left forearm with saline-soaked gauze, applied oil emulsion dressings and gauze over the two wound sites, and wrapped Resident 9's left arm with kerlix dressing. Employee 12 removed her gloves before documenting the date on Resident 9's dressing. Employee 12 donned new gloves without performing hand hygiene to clean Resident 9's overbed table and remove the garbage from Resident 9's room. Interview with Resident 5 on July 22, 2025, at 1:01 PM revealed that she receives liquid nutrition every four hours through a tube in her abdomen (gastrostomy tube or G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube); that she is not allowed food consumption through her mouth. Resident 5 stated that she had surgery to place this abdominal tube three weeks ago. Nursing documentation dated June 19, 2025, at 1:01 PM revealed that the hospital staff gave a report of Resident 5's condition to the writer that included that Resident 5 had a PEG tube placed due to esophageal dysmotility (when the esophagus does not move food and liquid from the mouth to the stomach as it should). Observation of Resident 5's bolus G-tube feeding (the administration of a limited volume of liquid nutrition formula over a brief period of time) via a PEG tube with Employee 12 on July 25, 2025, at 8:50 AM revealed Employee 12 used gloved hands to flush water and instill liquid nutrition into Resident 5's stomach until 9:04 AM when Employee 12 rinsed the syringe used for the procedure in Resident 5's bathroom sink. Employee 12 removed her gloves, obtained dressings and saline from Resident 5's in-room cabinet, and donned new gloves without performing hand hygiene. Employee 12 then cleansed Resident 5's G-tube insertion site and applied a new gauze dressing around Resident 5's G-tube. Interview with Employee 12 on July 25, 2025, at 9:12 AM confirmed that she did not wash her hands or utilize hand sanitizer after removing soiled gloves and donning new gloves during the care observed for Residents 5 and 9. Review of the facility policy titled, “Transmission Based Precautions in Long Term Care,” last reviewed without changes on June 17, 2025, revealed that “contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment and require the use of appropriate personal protective equipment (PPE), including gowns and gloves before or upon entering (i.e. before making contact with the resident or resident’s environment) the room or cubicle.“ Review of the facility policy titled, Patient and Exam Room Cleaning Procedures, last reviewed without changes on June 17, 2025, revealed a section titled, Before Entering the Room, which instructed staff to look for isolation signs that indicate the need for personal protective equipment and special precautions. Wear required personal protective equipment. Clinical record review for Resident 4 revealed a diagnosis list that included a history of urinary tract infections, hydronephrosis (a swelling of the kidney caused by a build-up of urine), and calculus of the kidney (kidney stone). Current physician orders for Resident 4 revealed orders for an indwelling urinary foley catheter (medical tubing inserted into the bladder to drain urine) and associated care. Clinical record review for Resident 4 revealed a progress note dated July 21, 2025, at 11:25 AM that noted the resident was started on Cipro (an antibiotic medication to help fight bacteria in the body) for a urinary tract infection; asymptomatic urine was tested for pre-operative testing. Lab documentation revealed a urinalysis and associated culture for Resident 4 dated July 16, 2025, that noted various bacteria in the urine: Escherichia coli ESBL, enterococcus faecalis, pseudomonas aeruginosa, and mixed flora. Observation of Resident 4’s room on July 22, 2025, at 10:30 AM revealed a yellow sign on the doorframe outside of the room that indicated the resident was on contact precautions. The sign noted all staff and visitors must follow these precautions, which included hand hygiene, gown, and gloves. Employee 7, housekeeping staff, was observed entering the room with no gown. Continued observation of Resident 4’s room on July 22, 2025, at 10:36 AM revealed Employee 7 proceeded to clean the room and was wiping various surfaces that included the bedside table and wall vent. The employee was then observed sweeping the floor of the room. Employee 7 did not have on a gown as indicated by the isolation sign. Observation of Employee 7 on July 22, 2025, at 10:51 AM revealed the employee left the room with gloves on and entered the hallway. She proceeded to throw something away in the housekeeping cart positioned outside of Resident 4’s room. Employee 7 then returned to the room to finish cleaning. An interview with Employee 7 on July 22, 2025, at 11:00 AM revealed that the employee may have missed seeing the yellow contact isolation sign and should have worn a gown in addition to the gloves to clean Resident 4’s room. An interview with Employee 8, licensed practical nurse, on July 22, 2025, at 2:56 PM confirmed that Resident 4 is on contact isolation due to antibiotics and an upcoming urology appointment procedure. Further review of Resident 4’s clinical record revealed a care plan for enhanced barrier precautions (EBP, gown and glove use during direct care used in nursing homes to prevent the spread of multi-drug resistant organisms which are bacteria that are resistant to some antibiotics). The clinical record did not reveal an existing order or care plan for contact isolation. The new care that was added by the facility on July 23, 2025 (after discussion with the surveyor), noted an infection requiring precautions with the site documented as “urine organism ESBL.” The care plan noted the resident's goal of, “…will comply with contact precautions.” The above information for Resident 4 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 23, 2025, at 2:49 PM. The facility reported that the expectation would be that the cleaning staff utilize a gown and gloves to clean the isolation room. An interview with Employee 9, registered nurse, on July 24, 2025, at 10:05 AM confirmed that Resident 4 is on contact isolation due to ESBL in the urine and pre-operative precautions. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 8/16/24 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to protect residents from staff neglect by implementing interventions to prevent falls for two of four residents reviewed (Residents 1 and 2) resulting in harm to include a fracture for one of two residents reviewed (Resident 2). Findings include: The facility policy entitled, Abuse: Prevention, Investigation, and Reporting, last reviewed without changes on June 4, 2025, revealed that Resident abuse is defined as any act of omission or commission, which may cause or does cause actual physical, psychological, or emotional harm or injury to a resident. Neglect means the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatments and care, including but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Examples cited included the failure to provide safety precautions. Training employees included that all employees would be provided with in-service training following any incident regarding abuse, neglect, mistreatment of residents, or misappropriation of property. Identification of Abuse listed components that included that in the incident report a description of the scene, positioning of the resident, witnesses, time and nature of injury will be included. The staff member completing the investigation will investigate a minimum of eight hours prior to the known injury to determine cause. Protection of resident(s) during the investigation included that residents are protected from harm during the investigation from all involved parties. Components listed under Investigation of Abuse included that all allegations of abuse, neglect, mistreatment of resident, or misappropriation of property will be reported immediately to the supervising nurse. The Director of Nursing is the abuse prevention officer. The Director of Nursing or designee will be notified immediately of any suspected or alleged abuse. Written, signed statements will be obtained from the resident, the alleged offender/offenders, and witnesses. All involved parties will be interviewed by the person conducting the investigation. The Administrator or designee will continue the investigation by gathering information to complete all sections of the PB-22, Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property. Employees suspected of resident abuse, neglect, mistreatment of residents or misappropriation of property will be suspended pending investigation and subject to SH Corrective Action Procedures. Clinical record review for Resident 1 revealed Kardex documentation (electronic documentation available to nurse aide staff that lists resident care needs) that stipulated Resident 1 required Safety/Precautions: Safety Alarms. Review of Resident 1's comprehensive care plan revealed interventions that included, Bed alarm when in bed. Nursing documentation dated May 3, 2025, at 4:15 PM revealed that nurse aide staff found Resident 1 on the floor with bleeding above her left eye. Upon assessment, staff noted Resident 1 had a laceration above her left eye, a bump on her forehead, and a bump above her left eye and on her left cheek. Staff called emergency medical services (EMS, 911) to transport Resident 1 to the hospital emergency room (ER). Nursing documentation dated May 3, 2025, at 7:40 PM noted that Resident 1 returned from the ER; and was assessed to have a black eye and bruising to left check (sic) Laceration of the left eyebrow, traumatic contusion (soft tissue injury of blood vessels resulting in swelling and discoloration) of left periorbital (area around the eye) region. Per report from (ER registered nurse) four or five absorbable sutures placed in the left eyebrow, also she has a small laceration below the left eye, which was not sutured, band aid in place. Review of an Incident/Accident Evaluation (form the facility utilizes to document the outline of an incident investigation) dated May 3, 2025, at 3:25 PM revealed that Resident 1's bed alert was not alarming upon checking alarm was not turned on, resident noted to have bleeding above her left eye, upon assessment resident noted to have a laceration above left eye, bump on forehead and bump above left eye and on left cheek. Review of the PB-22 (Provider Bulletin 22, form electronically submitted to the Department when an event is investigated for potential abuse, neglect, or misappropriation of property) for the incident dated May 3, 2025, at 3:24 PM confirmed that the facility substantiated resident neglect. Employee 3 (registered nurse) provided a statement that Employee 1 (nurse aide) attested that she placed Resident 1 in her bed the afternoon of May 3, 2025, prior to her fall. Resident 1's POC (plan of care) was not followed as Resident 1's fall alarm was not sounding at the time of the fall. Employee 3 stated, (Employee 1) assisted (Resident 1) in bed after lunch, the alarm box was present on the bed, but she did not check to ensure the alarm engaged. The facility's findings were that Employee 1 did not check to ensure Resident 1's safety alarm on her bed was functioning before exiting her room after placing her in bed. The facility's corrective action was to provide education to Employee 1. Employee 4 (assistant director of nursing) documented that the PB-22 was completed on May 6, 2025, at 2:54 PM. The PB-22 did not include information to suggest that the facility suspended Employee 1 pending the outcome of the investigation or provided all employees in-service training following the above incident of substantiated resident neglect. Review of Employee 1's timecard revealed that she worked May 3, 2025, from 10:33 AM to 11:03 PM; May 4, 2025, from 10:32 AM to 11:10 PM; and May 6, 2025, from 10:40 AM to 10:57 PM. Documentation of Supervisor Counseling (form the facility utilizes to record verbal warnings between a staff member and their supervisor) dated May 6, 2025, for the issue/violation that occurred on May 3, 2025, noted a summary of a conversation with Employee 1 and her response. The form indicated that the supervisor (noted as Employee 4) explained to Employee 1 the necessity of always checking fall prevention measures. The counseling documented for Employee 1 was dated three days after the incident with Resident 1, and Employee 1 was permitted to work with a resident assignment without evidence of a suspension per the facility policy. Interview with the Nursing Home Administrator on June 9, 2025, at 9:05 AM revealed that the facility has scheduled in-service training for all staff on June 11, 2025, that includes the topic of abuse prevention, investigation, and reporting. The interview indicated that (other than the scheduled in-service for all staff) individual registered nurse supervisor trainings are provided with an alleged perpetrator as documented in the completed PB-22s. Clinical record review for Resident 2 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident 2 as dependent for rolling left to right, to change from sitting to standing, for personal hygiene, and for toileting hygiene (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of Resident 2's Kardex documentation stipulated that Resident 2 required the assistance of two staff for bed mobility. Nursing documentation dated May 31, 2025, at 1:17 PM that Resident 2 was in bed receiving care from two nurse aides. During care, Resident 2 rolled out of bed and landed on the floor, in a sitting position. Staff heard two loud pops, and assisted Resident 2 to a lying position on the floor. Staff called 911. Resident 2 presented with a bruise on her right knee that staff documented as 3x6 (no unit of measurement provided). A paramedic arrived and assessed Resident 2, straightened her lower extremities, reported that Resident 2's left kneecap was subluxed (partial separation of a joint), and he popped it back into place. Two emergency medical technicians arrived, and Resident 2 was transferred off the floor to a stretcher with the assistance of four people. Review of a witness statement from Employee 5 (nurse aide) relating to Resident 2's fall on May 31, 2025, at 11:50 AM revealed that he was in the bathroom to get washcloths and the wheelchair for Resident 2's care. He heard she's on the floor. He walked out to see Resident 2 sitting against the side of her bed with her legs, almost Indian style. He attempted to help her to the ground softly and (he) heard a pop and immediately called for the nurse. Review of a witness statement from Employee 2 (nurse aide) relating to Resident 2's fall on May 31, 2025, at 11:50 AM revealed that she was rolling Resident 2 to the enabler bar. (Employee 5) was present, but he went to grab the wheelchair. As Employee 2 was proceeding with care her (Resident 2) lower half started sliding along with her upper half. Her upper body was on the bed as she was sitting Indian style. Neither staff statement indicated that the Director of Nursing or Nursing Home Administrator was notified of Resident 2's fall as a result of not following her plan of care (i.e., alarms, level of assistance, gait belt, fall mats). Review of a PB-22 in response to Resident 2's fall on May 31, 2025, at 12:00 PM revealed the facility's description of the incident was that Employee 5 was in the bathroom gathering supplies for care and Resident 2's wheelchair when Employee 2 continued with care. Resident 2 rolled towards the enabler bar, her lower body began sliding off the bed, and her legs were mal aligned on the floor. Staff members heard a pop, 911 transferred Resident 2 to the ER, and at the ER diagnostics completed revealed an acute right distal femoral fracture (break in the lower part of the thigh bone). Resident 2 was admitted to the hospital for planned surgical intervention. The facility substantiated neglect for the failure to utilize two staff members per Resident 2's bed mobility care guidelines. Employee 4 documented that the PB-22 was completed on June 4, 2025, at 1:35 PM. Review of Documentation Supervisor Counseling forms dated May 31, 2025, revealed that the registered nurse supervisor counseled Employees 2 and 5 regarding staying at the bedside when Resident 2 is positioned on her side to prevent falls. Employee 5 reiterated his statement that he was not present at the bedside when Resident 2 was initially rolled on her side in bed. He was in the bathroom gathering supplies to do care to get Resident 2 out of bed when he heard the nurse aide state that she was on the floor. He did not witness the fall. Review of Employee 2's timecard revealed that she worked May 31, 2025, from 11:02 AM to 10:57 PM; June 1, 2025, from 6:47 AM to 7:03 PM; and June 2, 2025, from 2:37 PM to 11:04 PM. There was no evidence that the facility suspended Employee 2 pending the outcome of the investigation of Resident 2's fall (and substantiated neglect) on May 31, 2025. There was no evidence that the facility provided all employees in-service training following Resident 2's incident of substantiated neglect. The surveyor confirmed the above findings regarding the fall incidents for Residents 1 and 2 with the Director of Nursing, the Nursing Home Administrator, and Employee 4 on June 9, 2025, at 5:00 PM. The facility failed to ensure that staff implemented resident interventions identified as necessary in the residents' care plan to avoid accident and injury for Residents 1 and 2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(d) Staff development 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for seven of eight residents reviewed (Residents 18, 42, 58, 59, 60, 71, and 88). Findings include: Clinical record review for Resident 18 revealed a current care plan for staff to provide a restorative nursing program (RNP) to prevent contracture(s) which included: AAROM (active assisted range of motion, movement of the body to maintain a resident's ability) to their BL (bilateral) arms at the shoulders, elbows, wrists, and fingers. Do a slow progressive stretch and monitor for discomfort for up to 30 repetitions by shift. PROM (passive range of motion) to their BLLE (lower legs at the hips, knees, and ankles for flexion, extension, abduction (moving away from the middle of the body), adduction (moving closer to the middle of the body), and ankle pumps, slowly and gently up to 20 repetitions by shift. Review of task documentation for Resident 18 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to their BLUE at the shoulders, elbows, wrists, and fingers. Do a slow progressive stretch and monitor for discomfort for up to 30 repetitions by shift. Evening Shift: July 5, 6, 8, 17, 18, 19, 22, 23, 26, 28, 30, and 31, 2024 August 1, 10, and 12, 2024 PROM to their BL legs at the hips, knees, and ankles for flexion, extension, abduction, adduction, and ankle pumps, slowly and gently up to 20 repetitions by shift. Evening Shift: July 5, 6, 8, 17, 18, 22, 23, 26 28, 30, and 31, 2024 August 1, 10, and 12, 2024 Clinical record review for Resident 42 revealed a current care plan for staff to provide a RNP which included: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. AAROM to BLUE at the shoulders, elbows, wrists, and fingers three times 10 repetitions by shift. Review of task documentation for Resident 42 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. Evening Shift: July 3, 5, 8, 10, 13, 22, 30, and 31, 2024 August 7, 9, 10, 12, and 13, 2024 AAROM to BLUE at the shoulders, elbows, wrists, and fingers three times 10 repetitions by shift. July 3, 5, 8, 10, 13, 22, 30, and 31, 2024 August 7, 9, 10, 12, and 13, 2024 Clinical record review for Resident 58 revealed a current care plan for staff to provide a RNP which included: AROM to BLLE at the hips, knees, and ankles times 10 repetitions by shift. Review of task documentation for Resident 58 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: Evening Shift: July 5, 7, 8, 13, 14, 16, and 18, 2024 August 1, 4, 7, 10, and 13, 2024 Clinical record review for Resident 71 revealed a current care plan for staff to provide a RNP which included: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. AAROM to BLUE at the elbows, wrists, and fingers for flexion and extension three times 10 repetitions by shift. PROM to BL shoulders three times 10 repetitions for gentle flexion and extension by shift. Review of task documentation for Resident 71 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. Day Shift: July 4 and 6, 2024 Evening Shift: July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 AAROM to BLUE at the elbows, wrists, and fingers for flexion and extension three times 10 repetitions by shift. Day Shift: July 4 and 6, 2024 Evening Shift: July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 PROM to BL shoulders three times 10 repetitions for gentle flexion and extension by shift. Day Shift: July 4 and 6, 2024 Evening Shift: July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 Clinical record review for Resident 59 revealed a current care plan for staff to provide a RNP which included: AROM to the right and left hips, right knee, and right ankle for flexion and extension 10 times three repetitions by shift. AROM to BLUE at the elbows, wrists, and hands for flexion and extension three times 10 repetitions by shift. AAROM to shoulders for flexion and extension by shift. Review of task documentation for Resident 59 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AROM to the right and left hips, right knee, and right ankle for flexion and extension 10 times three repetitions by shift. Evening Shift: July 3, 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 AROM to BLUE at the elbows, wrists, and hands for flexion and extension three times 10 repetitions by shift. July 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 AAROM to shoulders for flexion and extension by shift. July 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 Clinical record review for Resident 60 revealed a current care plan for staff to provide a RNP which included: AROM to BLLE at the hips, knees, and ankles for flexion and extension three times 10 repetitions by shift. AAROM to BLUE at the shoulders, elbows, wrists, and fingers, for flexion and extension three times for 10 repetitions by shift. Review of task documentation for Resident 60 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AROM to BLLE at the hips, knees, and ankles for flexion and extension three times 10 repetitions by shift. Day Shift: July 26, 2024 Evening Shift: July 5, 8, 10, 16, 18, 22, 29, 30, and 31, 2024 August 1, 7, 10, 11, 12, and 13, 2024 AAROM to BLUE at the shoulders, elbows, wrists, and fingers, for flexion and extension three times for 10 repetitions by shift. Day Shift: July 26, 2024 Evening Shift: July 5, 8, 10, 16, 18, 22, 29, 30, and 31, 2024 August 1, 7, 10, 11, 12, and 13, 2024 Clinical record review for Resident 88 revealed a current care plan for staff to provide a RNP, which included ambulate with a rolling walker with assist of one and use of a gait belt for mobility up to 300 feet by shift. Review of Resident 88's physical therapy discharge summary date July 17, 2024, revealed that they discharged him to RNP for ambulation and ROM with possible transfers. Review of task documentation for Resident 88 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: Evening Shift: July 5, 8, 14, 16, 18, 22, 23, 28, 29, 30, and 31, 2024 August 1, 7, 9, 10, 11, 12, and 13, 2024 Further review of Resident 88's task documentation revealed that they usually accept staff assistance as needed for care and services, with five refusals to ambulate identified throughout July and August 2024. Observation and interview with Resident 88 on August 13, 2024, and 11:35 AM and August 14, 2024, at 8:59 AM revealed that they were dressed and sitting in a wheelchair in their room. They indicated that they have not received therapy recently, but they would like to walk so they could go home. The surveyor reviewed the above information on August 15, 2024, at 2:15 PM with the Nursing Home Administrator and Director of Nursing. 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 review of facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that one of three residents reviewed was free of neglect regarding providing the care and services necessary to prevent a Stage IV pressure ulcer, which resulted in actual harm (Resident 12). Findings include: The facility policy entitled, Skin Care Prevention, Maintenance, and Wound Management, last approved without changes on July 2020, revealed the purpose is to provide routine monitoring of skin to identify newly developed alterations in integrity, treatment to areas of impaired skin, and to provide a routine evaluation process to monitor treatment effectiveness, prevent, identify, treat wound complications, and promote wound healing. The licensed nurse is responsible to initiate preventative interventions and/or treatment based on the skin inspection, risk evaluation, and presence of any wound. Clinical record review for Resident 12 revealed a comprehensive MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 30, 2020, that indicated the resident had [CONDITION(S)] (a movement disorder characterized by stiff muscles, uncontrollable movements, and poor balance and coordination). The resident was unable to communicate or understand others and was totally dependent on staff for ADL's (activities of daily living are daily care items such as feeding, bathing, dressing, and grooming). The MDS indicated that Resident 12 was at risk to develop pressure ulcers. On admission, a nursing progress note dated June 23, 2020, revealed that Resident 12 had non-blanchable (red area that when pressed does not turn white, Stage 1 of a pressure ulcer) red areas in the antecubital spaces (the crease of the inner arm opposite the elbow) of both arms. Clinical record review of Resident 12's care plan dated June 24, 2020 revealed that the resident had a skin injury, bruises easily, and has sensitive skin. One measure included check my skin with cares check weekly. There was no mention of the antecubital areas on the care plan until August 20, 2020, when pressure injuries were identified in both antecubital areas. Clinical record review of a wound nurse progress note dated June 24, 2020, indicated no reddened areas or skin breakdown were noted on the right or left antecubital areas. Review of Resident 12's treatment record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to address Resident 12's MASD in the skin integrity care plan that indicated treatment or assessments. Review of the clinical record did not indicate when the facility identified the MASD. Clinical record review of Resident 12's nursing progress notes dated July 5, 2020, revealed the resident was readmitted to the facility from the hospital with scattered bruising, excoriation of the inner buttocks, sacrum and coccyx (lower back, and near tail bone), a Stage II pressure ulcer of the mid-back, and wounds on her fingers. A wound nurse progress note dated July 6, 2020, revealed the wounds on the fingers were MASD and the resident sweats frequently. The physician ordered staff to apply [MEDICATION(S)] Rapid Relief on the buttocks, sacrum, coccyx, and groin areas every shift and as needed. There was no documentation to indicate that the antecubital areas had impaired skin integrity. Review of the resident's treatment record revealed this treatment was not reordered on readmission to the facility. Resident 12's treatment record for July 2020, revealed that the LPN (licensed practical nurse) completed weekly skin evaluations for four weeks after readmission to the facility. These were completed on readmission and July 12, 20, and 26, 2020. There was no documentation that indicated impaired skin integrity to the antecubital areas. Resident 12's OT (occupational therapy) discharge summary dated July 27, 2020, revealed the resident exhibited contractures of the upper extremities (abnormal shortening of muscle tissue which can lead to permanent disability, pain, and inability to move a joint) and functional [CONDITION(S)] (the complete inability to move the arms and legs). The OT note included that elbow protectors were removed from the resident's arms and the resident showed good skin integrity with no red marks. The elbow protectors were replaced in position. There was no documentation in the clinical record for the application of elbow protectors until August 19, 2020. A wound nurse progress note written on August 6, 2020, for August 5, 2020, revealed MASD to Resident 12's left antecubital area measuring 0.2 cm (centimeter) long x 1 cm wide x 0 cm deep and MASD to the right antecubital area measuring 0.3 cm long x 1 cm wide x 0 cm deep. The wound nurse documentation included a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review of Resident 12's nurse aide and licensed nurse treatment records for August 2020, revealed that the above physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review of Resident 12's bathing record for August revealed that staff provided bed baths or showers on August 3, 6, 9, 10, 13, 17, and 18, 2020. The bathing record has a section that the nurse aide is to indicate if there is a problem with a skin check that is completed at the time of bathing. The only abnormal finding of the elbow creases by the nurse aide was on August 18, 2020, when a sore was found on the inside of the left elbow. Resident 12's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also indicated that [MEDICATION(S)] was to be discontinued (even though it had never been applied) to the left and right antecubital areas. The new treatment orders were for staff to cleanse the areas with NSS (normal saline solution, salt water solution), apply [MEDICATION(S)] (an antiseptic), apply Promogram AG, apply Allevyn Foam (both are specialized dressings with healing agents used for wound healing), change daily and as needed for soiling or dislodgement, using sterile techniques. The wound nurse progress notes for Resident 12 dated August 19, 2020, written for August 18, 2020, revealed that the resident developed two in-house acquired pressure injuries as follows: 1. Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of the left antecubital area, measuring 1 cm x 0.5 cm wide x 0.5 cm deep; the wound base had 95% granulation tissue, and 5 % tendon (a tough band of connective tissue that connects muscle to bone) exposed. There was no maceration (a moistness or sponginess) and no [CONDITION(S)] (redness) of the peri wound (area surrounding wound), no drainage, no odor, and no infection. 2. Unstageable (when wound cannot be visualized, full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure ulcer of the right antecubital area, measuring 1 cm long x 0.5 cm wide x 0.5 cm deep. The wound base had 100% slough/macerated tissue. There was no maceration, no [CONDITION(S)] of the peri wound, no drainage, and no infection. Clinical record review of Resident 12's nursing notes from August 1 through 18, 2020, revealed the only time the antecubital areas were assessed and documented were on August 6, 2020, when MASD was identified and August 18, 2020, when the MASD became pressure ulcers. Resident 12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 12's August treatment record revealed the treatment that was ordered on August 18, 2020, was discontinued on August 19, 2020. The treatment was changed to the left and right antecubital pressure ulcers as follows: Cleanse the areas with NNS, apply [MEDICATION(S)] AG, apply an ABD pad (large dressing), one roll of cast padding, and one roll of Kerlix (gauze wrap), change daily and as needed for soiling or dislodgement using sterile techniques. Resident 12's wound nurse progress note dated August 20, 2020, written for August 19, 2020, revealed that the general surgeon was in and said he can't close the pressure injury and plastic surgery would have to look at it. Resident 12's nurse aide flowsheet starting August 18, 2020 revealed a head to toe skin check was to be completed every shift and the nurse aide was to notify licensed nursing staff of any skin breakdown. Starting August 19, 2020, the nurse aide was to apply elbow protectors to both arms with the padded sides covering the antecubital areas and not the elbows. The surveyor interviewed Employee 1, OT, on August 20, 2020, at 12:50 PM, to determine if Resident 12's upper arm contractures would inhibit staff to notice skin breakdown at the elbow crease. Employee 1 indicated that an LPN (licensed practical nurse) or RN (registered nurse) would be able to visualize the skin at the elbow crease. Further review of the OT consultation dated August 19, 2020, revealed the OT assessment as follows: The resident is wheelchair bound with BUE (bilateral upper extremity) contractures, which have led to antecubital wounds due to staff not following previous OT recommendations for ROM (range of motion) and off-loading (removing or decreasing pressure) antecubital areas. Resident would benefit from OT services to intervene to address decreased ROM, off-loading pressure areas, and caregiver education regarding RNP (restorative nursing program) programming. Interview with Employee 2, LPN, on August 20, 2020, at 1:10 PM, revealed that the LPN last conducted a skin check in July. Employee 2 reported that skin checks are ordered weekly for four weeks when residents are admitted or readmitted from the hospital. Employee 2 stated that during a skin check she would look at the resident's body from head to toe and would report any abnormalities. When Employee 2 was asked if she applied [MEDICATION(S)] to Resident 12, she said that the nurse aides complete that task. Observation of Resident 12's dressing change to the right and left antecubital areas was completed on August 20, 2020, from 1:15 PM to 2:00 PM. The resident was sitting in her specialized wheelchair with her elbow protectors intact. Employee 3, wound nurse, performed the dressing changes and Employee 4, RN, assisted in holding the resident's arm in position. Employee 5, physician's assistant, was present. Employee 3 reported that the resident had Tylenol for discomfort 30 minutes prior to the dressing changes. The surveyor easily visualized the left and right antecubital areas. The surveyor visualized the tendon in the left antecubital wound. During an interview with Director of Nursing (DON) on August 20, 2020, at 2:00 PM, it was confirmed that there was no documentation that the [MEDICATION(S)] treatment was provided as ordered to the resident's antecubital areas from August 6 through 18, 2020, when the treatment was discontinued. The DON confirmed that there was no assessment of the resident's antecubital areas after August 5, 2020, until August 18, 2020, when the nurse aide found the wound in the left antecubital area. At that time, the areas were assessed as a Stage IV pressure ulcer and an unstageable pressure ulcer. The Director of Nursing indicated that skin assessments are not done routinely on residents without wounds. Weekly assessments are completed on wounds and weekly for four weeks on admission and readmission from the hospital. The nurse aides are to perform a skin check during bathing and report abnormalities to the nurse. Interview with Employee 6, nurse aide, on August 20, 2020, at 2:15 PM, revealed that the night shift gives the resident showers if she is awake in the morning. Employee 6 revealed that she never put [MEDICATION(S)] on the creases of Resident 12's arms and that she leaves the elbow protectors on because there is no reason to take them off. Clinical record review of Resident 12's Wound Center report dated August 24, 2020, revealed that the pressure ulcers on both antecubital areas were changed to atypical wounds. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment recommended was to cleanse the wounds with soap and water, apply [MEDICATION(S)] AG, Kerlix, and cast padding with elbow protectors every other day. The facility failed to prevent neglect by not administering the ordered [MEDICATION(S)] treatments to the antecubital areas and observing the areas during the application of the treatment resulting in wounds requiring treatment from a wound specialist. The above findings for Resident 12 were reviewed with the Nursing Home Administrator on August 20, 2020, at 3:00 PM. 28 Pa. Code 201.18(e)(1) Management Previously cited 4/12/19, 9/13/19 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/12/19, 9/13/19, 1/8/20, 3/5/20 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 4/12/19, 9/13/19, 3/5/20