Every finding on record at Naamans Creek Country Manor

Based upon observation and interview, it was determined that the facility failed to ensure appropriate storage, labeling, and dating was completed for pre-prepared food items in the refrigerator. Observation of the facility refrigerator located in the kitchen on June 24, 2026, at 12:48 p.m. revealed a clear plastic container filled with prepared chicken salad sandwiches. The container was covered with a loose sheet of parchment paper, held in place with a plastic bucket of chicken salad. Interview with the kitchen manager on June 24, 2026, at 12:50 p.m. confirmed that the prepared sandwiches were not properly labeled, dated, or covered. The facility failed to ensure that food was stored properly, labeled, and dated according to professional standards. 28 Pa. Code 201.18(b)(1)

Based on the review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for one of one resident (Residents R27). Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated May 2, 2026, with the diagnoses of aphasia (language disorder that affects communication), vascular dementia, unspecified severity, with agitation (a neurocognitive disorder caused by damage to the brain from reduced or interrupted blood flow due to cerebrovascular disease, resulting in impaired memory, thinking, judgment, and the ability to perform daily activities), muscle weakness, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R27's clinical record revealed a physician's order dated November 25, 2025, for heel boot to right foot when in bed-check placement BID (twice daily), every day and night shift for protections/prevention. Review of Resident R27's care plan includes an intervention dated October 14, 2024, of heel boot to right foot when in bed-check placement BID. During an observation on June 23, 2026, at 9:19 a.m. Resident R27's was resting in bed without heel boot on their right foot.During an additional observation on June 24, 2026, at 10:18 a.m. Resident R27 had no heel protection boots applied while resting in bed. During an additional observation on June 25, at 1:55 p.m. Resident R3 was observed resting in bed without a heel protection boot applied to their right foot. During an interview with Resident R27 he/she could not recall the last time they wore a heel boot or where their heel boot was located. During an interview on June 25, at 2:20 p.m. with the Nursing Home Administrator (NHA) confirmed that the facility failed to implement interventions of a heel protection boot in to ensure that resident received necessary services to prevent pressure ulcers/injuries. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of eight residents reviewed for nutrition (Resident R9). Review of facility policy Weighing of Residents .If the resident exhibits a weight change of 5 lbs. from the previous weight (weights over 100#) in the monthly weight report, the resident shall be re-weighed within 24 hours and the re-weight shall be recorded, The licensed nurse or designee should then strike out the previous weight to identify that a re-weight was obtained and verified. Review of Resident R9's clinical record revealed recorded weights of:February 4, 2026: 191.2 lbsFebruary 5, 2026: 191.2 lbsMarch 13, 2026: 168.2 lbsApril 2, 2026: 240.0 lbsApril 4, 2026: 191.0 lbsFurther review of Resident R9's clinical record revealed a dietary note dated March 19, 2026, indicating the resident's weight. Further review of the same dietary note revealed a recommendation of reweight requested for the March 13, 2026, weight.Interview with Registered Dietitian on June 25, 2026, at 1:10 p.m. confirmed that Resident R9 should have been reweighed within 24 hours of March 13, 2026, weight.The facility failed to obtain and monitor weights for Resident R9. 28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in freezer was properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety. (Main Kitchen) Findings include: Observations in the kitchen on April 13, 2026, at 10:10 a.m. in the presence of the Assistant Food Service Director (AFSD) revealed a large accumulation of ice on the ceiling of the freezer with some ice extending on to the boxes on the top shelf labelled; pancakes; Portico seafood and Vegetable blend. Interview with AFSD on April 13, 2026, at 10:15am confirmed that the ice build up should not be there The above findings were conveyed with the Nursing Home Administrator (NHA) on April 13, 2026, at 11:30am and confirmed the above findings. 28 Pa. Code 211.6(f) Dietary services.

Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units). Findings include: Review of the facility policy, Dry Food Storage dated [DATE], revealed, dry food storage is necessary for foods that do not require refrigeration or freezing and requires proper guidelines. All food items must be dated, labeled and sealed. Rotate products to ensure that the oldest inventory is used first. Observation on [DATE], at 9:45 a.m. of the second-floor kitchen dry food storage area revealed expired used by dates for multiple loaves of bread and packages of buns. This included, 1 package of hot dog buns use by dated [DATE], 1 loaf of wheat bread use by dated [DATE], 1 loaf of raisin bread use by dated [DATE], 5 packages of hamburger buns use by dated [DATE], of which 2 packages revealed black and green spots on the buns, and 9 loaves of rye bread with no visible received or use by dates. Interview with Director of Dietary Services, Employee E3, on [DATE], at 9:45 a.m. confirmed that items were not properly labeled or dated, items were expired, and the 2 packages of hamburger buns had visible black and green spots on them. The facility failed to ensure that food was stored properly, labeled and dated according to professional standards. 28 Pa Code 201.18(b)(1) Management

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined the facility failed to ensure physician's orders were followed for three of the 18 residents reviewed (Residents 13, 14, and 66). Findings include: A review of the facility's policy titled Weighing of Residents, undated revealed that residents requiring daily weights due to clinical conditions warranting strict monitoring will be weighed in the same procedures as stated above. Documentation of the daily weight will be recorded in the electronic medical record (EMR). If the resident experiences a weight gain of three (3) pounds in a 24-hour period or a weight gain of greater than five (5) pounds in a week, the licensed nurse will notify the physician. Clinical records review revealed Resident 13 was admitted to the facility on [DATE], with a diagnosis of Congestive Heart Failure (CHF weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 13's physician's order dated April 2, 2025, revealed an order to weigh the resident one time a day for monitoring. Clinical records review revealed Resident 13's daily weight monitoring was not done on the following dates: April 4, 5, 8, 10, 11, 13, 14, 15, 19, 21, 22, and 28, 2025. An interview was conducted with the Assistant Director of Nursing (ADON) on May 1, 2025, at 10:00 a.m. The ADON confirmed that Resident 13's daily weight monitoring was not done on the dates mentioned above. The ADON was unable to provide an explanation as to why Resident 13's weights were taken as ordered by the physician. An observation conducted on May 2, 2025, at 10:00 a.m., revealed Resident 14 was sitted in a wheelchair. Further observation revealed Resident 14's bilateral lower legs were swollen. Clinical records review revealed Resident 14 was admitted to the facility on [DATE], with a diagnosis of CHF. A review of Resident 14's physician's order dated April 10, 2025, revealed an order to weigh the resident one time for monitoring. Clinical records review revealed Resident 14's daily weight monitoring was not done on the following dates: April 13, 14, 15, 23, and 24, 2025. Further review revealed Resident 14's weight taken on April 22, 2025, was 130.4 pounds, Resdient refused his weight on April 25, 2025 and the weight taken on April 26, 2025, was 136.4, a six-pound weight gain in four days. The record review failed to reveal that the physician was notified of the six-pound weight gain in four days. A review of the physician's note dated April 30, 2025, revealed Resident 14 was seen in bed with an increased lower extremity edema. The physician ordered Lasix (A medication that treats fluid retention and swelling caused by CHF, liver disease, kidney disease, and other medical conditions) 40 mg for one dose. An interview was conducted with the ADON on May 1, 2025, at 10:00 a.m. The ADON confirmed that Resident 14's daily weight order was not done on the dates mentioned above. The ADON also confirmed that the physician was not notified of the six-pound weight gain on the four days between obtained weights identified on April 26, 2025. The facility failed to ensure Resident 13's and 14's daily weight monitoring orders were followed as ordered. Review of resident 66's diagnosis list includes Orthostatic Hypotension (significant drop in blood pressure due to standing up.) Review of Resident 66's physician orders dated April 1, 2025, revealed an order for Midodrine (used to treat low blood pressure) HCL 2.5 milligrams (MG), Give 1 tablet by mouth three times a day for orthostatic hypotension Hold for SBP (Systolic Blood Pressure) above 120mmHG. Review of Resident 66's medication administration record (MAR) for the month of April 2025 revealed that from April 1, 2025, until April 7, 2025, facility administered Midodrine to the resident 20 times without checking blood pressure for parameters. Further review revealed that from April 8, 2025, until April 26, 2025, resident was given Midodrine medication four times outside ordered parameter. An interview with the Interim Director of Nursing conducted on May 2, 2025, at 11:00 a.m., confirmed that parameters for Midodrine medication was not followed. The facility failed to ensure Resident 66's Midodrine medication order was followed 28 Pa Code 211.10(c)Resident Care Policies Previously cited 5/17/24 28 Pa Code 211.12(c)(d)(3) Nursing Services Previously cited 5/17/24

Based on review of facility's policy, clinical records review and staff interviews, it was determine that the facility failed to appropriately monitor the weights and timely address identified significant weight changes for three of 18 Residents reviewed (Resident 63, 66 and 175). Findings include: A review of the facility's policy titled Weighing of Residents, undated, revealed that the facility must monitor the resident's weight to detect significant weight loss or gain to ensure that the resident maintains acceptable parameters of nutritional status. The same policy revealed that upon admission and readmission, the resident is weighed weekly for one month. An assigned licensed nurse or designee should review resident weights after they are entered or recorded. If the resident exhibits a change of five (5) pounds from the previous month's weight report and three (3) pounds from the previous weight report, the resident shall be reweighed within 24 hours and the re-weight shall be recorded. If the weight change falls into the significant category- 5% in one month or 10% in six months, the dietitian will complete an assessment to investigate the cause of the weight change. The charge nurse will notify the dietitian, the physician, and the family of the significant weight changes. Review of Resident 66's diagnosis includes Type 2 Diabetes (DM- failure of the body to effectively use insulin produced in the body, insulin regulates blood sure to pass from blood stream to cells) and Gastroesophageal reflux disease (Gerd- failure of the body to stop stomach acid from flowing back into the esophagus causing irritation to the lining of the esophagus.) A review of Resident 66's clinical records weight and vitals revealed, on March 29, 2025, Resident 66 weighed 192.4 and on April 16, 2025, the resident weighed 172.4 pounds a 10.40% weight loss in 18 days. Clinical record review revealed a re-weight was not completed until 2 days later revealing residents' weight was 172.4 Pounds. Clinical records review failed to reveal that the physician was notified of the significant weight loss and that an intervention was put in place. The facility failed to ensure physician was notified of Resident 66's significant weight loss and further intervention were put in place to prevent further weight loss An interview with the Interim Director of Nursing conducted on May 2, 2025, at 10:00 a.m., confirmed that the resident's physician was not notified of the significant weight loss and interventions were not put in place to prevent further weight loss. A review of Resident 175's diagnosis list includes Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and dysphagia (Difficulty swallowing). A review of Resident 175's Weights and vitals, revealed a weight of 150.2 pounds on April 16, 2025, and 139.4 pounds on April 23, 2025, a 10.8 (7.19%) significant weight loss in seven days. Clinical records review revealed reweight was not done until two days after which revealed a weight of 140.2 on April 25, 2025, a 6.66% weight loss in a week. The clinical records review failed to reveal that the resident was assessed after identifying the significant weight loss. The records also failed to reveal that the physician was notified of the significant weight change and that an intervention was put in place to prevent further weight changes. An interview with the Dietitian, Employee E4 was conducted on May 1, 2025, at 1:00 p.m. Employee E4 reported that she/he was not notified of the resident's weight loss identified on April 23, 2025. An interview with the Interim Director of Nursing conducted on May 2, 2025, at 10:00 a.m., confirmed that the resident was not assessed when significant weight loss was identified and that the physician was not notified of the significant weight change. The facility failed to ensure Resident 175's significant weight loss was assessed and addressed in a timely manner. 28 Pa Code 211.10(c)Resident Care Policies Previously cited 5/17/24 28 Pa Code 211.12(c)(d)(3) Nursing Services Previously cited 5/17/24

Based on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 24 sampled was free of chemical restraints (Resident 63). Findings include: A review of Resident 63's clinical record revealed admission to the facility on [DATE], with diagnoses to include cerebral infraction (pathologic process that results in an area of necrotic tissue in the brain), cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated January 24, 2025, indicated that the resident is moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8-12 represents moderate cognitive impairment). A review of resident 63's clinical record revealed that the resident was prescribed Xanax (antianxiety, used to treat anxiety disorders and anxiety caused by depression) Oral Tablet 0.25 MG (milligrams) PRN (as needed) every 8 hours for 30 days, with a start date of February 14, 2025. Additional review of the resident's clinal record revealed an order to administer Nonpharmacological Intervention(s) used before PRN Pain Medication or before PRN antidepressant, antianxiety, antipsychotic or sedative/hypnotic medication Document by number:1 Reposition for comfort 2 massage 3 involve in activity/alt. activity to divert 4 provide quiet setting with reduced stimuli as needed 5 relaxation technique 6 music 7 remove from area 8 direction/distraction with a start date of January 24, 2025. Review of Resident 63's medication administration record (MAR) for the month of March 2025, revealed the facility administered the Xanax to Resident 63 on March 5th 2025, March 12, 2025 and March 14, 2025. Further review of Resdient 63's MAR for March 2025 revealed the facility did not attempt any Nonpharmacological Interventions prior to administering Xanax to Resident 63. Review of Resident 63's progress notes failed to reveal any documentation of nonpharmacological Intervention being attempted prior to the administration of Xanax. An interview conducted with the Nursing Home Administrator (NHA) on May 2nd, 2025, at 11:25 a.m. confirmed the facility failed to attempt nonpharmacological Intervention prior to administering antianxiety medication to Resident 63. 28 Pa. Code 211.8 (c.1)(1)(e) Use of Restraints. 28 Pa. Code 211.5 (f) Medical records

Based on clinical record review and staff interviews, it was determined that the pharmacy failed to ensure medication for wound care was available for one of the four residents reviewed (Resident 175). Findings include: A review of Resident 175's physician order dated April 29, 2025, revealed an order for Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) ointment, apply nickel thick layer to the sacrum (The triangular bone just below the lumbar vertebrae) wound bed after cleansing with normal saline solution, cover with foam dressing once a day and as needed. May use Medihoney (A dressing that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns.) until Santyl arrives. An observation of the wound care treatment conducted on May 1, 2025, at 9:45 a.m., revealed that Medihoney treatment was used for the sacral wound instead of the Santyl. An interview with licensed nurse Employee E4 conducted on May 1, 2025, at 9:50 a.m., revealed that the facility was still using Medihoney instead of Santyl because the pharmacy had not delivered the medication yet. An interview conducted with the Assistant Director of Nursing on May 1, 2025, at 1:00 p.m., revealed that the medication order was sent to the pharmacy on April 29, 2025. A medication follow-up was made on April 30, 2025, and was informed that the medication would be delivered. On May 1, 2025, after another follow-up call, pharmacy representative [name of the pharmacist] reported that the medication delay was due to the absence of wound dimension documents. Records revealed order sent had dimension documents but was missed by the pharmacy. The pharmacy failed to ensure Santyl's medication for Resident 175's sacral wound was made available timely. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa Code 211.12(c)(d)(3) Nursing Services Previously cites 5/17/25

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions and failed to prevent cross-contamination for one of 12 resident observed during lunch (Resident R7). Findings include: Observations conducted on September 24, 2024 at 12:15 p.m. in the main dining area on the second floor during the lunch meal tray line, revealed Licensed (LPN) Employee E1 removed R7's tray from the tray cart which revealed a soiled cloth towel on the tray touching the plate containing R7's meal. Further observation on September 24, 2024 revealed licensed Employee E1 returned from the kitchen at 12:18 p.m. with a new tray and meal for R7. Interview conducted with the Dietary Manager, on September 24, 2024, at 12:45 p.m. confirmed the soiled towel should not have been on R7's tray and reported that it was an accident. Interview conducted with the Director of Nursing (DON) on September 24, 2024, at 12:55 p.m. confirmed that all resident trays should be free of soiled cloth towels. 28 Pa. Code 211.6(f) Dietary Services.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain dish machine water temperatures by manufacturer recommendations for food service safety in the main kitchen. Findings include: A review of the facility's policy titled Machine Ware Washing undated, revealed that dining services will properly clean and sanitize all service ware to destroy foodborne pathogens. The same policy revealed that the staff will monitor/document water temperatures routinely in the Mechanical ware washer water temperature log. Monitoring schedule: at least one time every meal (mid-morning - breakfast clean-up, mid-afternoon - lunch clean-up, and evening - supper clean-up). Standard temperature = Wash = > 150 F. Final Rinse = > 180 F. A kitchen tour was conducted on May 14, 2024, at 9:34 a.m., with the presence of the Food Director Employee E4. An observation of the dish machine was conducted and revealed drinking cups and plates were being washed. An observation of the Wash temperature gauge revealed a temperature of 140F. The Rinse temperature gauge was observed not moving and was kept to 0 F. A review of the dishwater temperature log revealed that the water temperature was last checked on the evening of May 13, 2024. The temperature log for the morning of May 14, 2024, was blank. An interview was conducted with Employee E4 on May 14, 2024, at 9:45 a.m., who reported that the dish machine was recently serviced/checked by Ecolab and was functioning well until today. The above was conveyed to the Nursing Home Administrator on May 14, 2024, at 9:50 a.m. The facility failed to ensure dish machine water temperature in the main kitchen was maintained according to the manufacturer's recommendations for food service safety. 42 CFR 483.60(i)(2) Food Procurement, Store/Prepare/Serve-Sanitary 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based upon observation, it was determined the facility failed to ensure residents were treated with dignity and failed to ensure private health information was secure for one of 24 residents observed (Resident 56). Findings include: Observation of Resident 56's room on May 16, 2024, at 11:00 a.m. revealed the presence of two white boards. One board was located on the wall next to Resident 56's bed and the other board was located on the wall directly below Resident 56's television. Further observation of these white boards revealed the following information Dietary restrictions - Mildly thick/nectar thick liquids only. No ice, room temp liquids via teaspoon. Further observation of Resident 56's room revealed a paper sign located above the head of Resident 56's bed. The sign indicated no straws. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on May 17, 2024, at 10:00 a.m. 28 Pa. Code 201.18(b)(2) Management

Based on clinical records review and staff interview, it was determined that the facility failed to monitor a fluid restriction order for one of the 18 residents reviewed (Resident 235). Findings include: Review of Resident 235's diagnosis list includes Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Kidney Failure, and Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of Resident 235's physician's order dated May 9, 2024, revealed an order for 2000 ml (milliliter) fluid restriction, and heart-healthy modification. The clinical records review failed to reveal evidence that Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed. Interview was conducted with the Director of Nursing on May 17, 2024, at 11:00 a.m. The Director of Nursing confirmed that nursing does not have documented evidence that Resident 235 ' s 2000 ml fluid restriction order was monitored and followed. The facility failed to ensure Resident 235's fluid intake was monitored to ensure the 2000 ml fluid restriction ordered by the physician was followed. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure skin impairment identified upon admission was comprehensively assessed for two of the six residents reviewed (Resident 57 and 235). Findings include: Review of the facility's policy titled Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, and Monitoring, last reviewed in October 2021, revealed that residents admitted with pressure ulcers receive the care and services necessary to promote healing. A review of the same policy revealed that an evaluation of the pressure ulcer should be documented. At a minimum, documentation must include the date observed and the following: location, size, exudate if present, pain, wound bed, and description of wound edges and surrounding tissue as appropriate. Review of Resident 57's clinical records revealed Resident 57 was admitted to the facility on [DATE], with a diagnosis of Pneumonia. Review of Resident 57's admission skin assessment completed on January 26, 2024, revealed, the resident was admitted with a pressure ulcer (open wound caused by unrelieved pressure that results in damage to the underlying tissue) to the sacrum (tailbone). A review of the same assessment revealed no information regarding the wound's size, and description. Review of Resident 57's clinical records revealed Resident 57 sacral wound was not comprehensively assessed until evaluated by the wound nurse practitioner (NP) on February 5, 2024, 10 days after a wound was identified on admission. Review of Resident 235's clinical records revealed Resident 235 was admitted to the facility on [DATE], with a diagnosis of Dementia and Urinary Tract Infection. Review of Resident 235's admission skin assessment completed in May 2024, revealed the resident was admitted with a pressure ulcer to the right heel. Further review of the same assessment revealed no information regarding the wound's size and description. Review of Resident 235's clinical records revealed Resident 235's right heel wound was not comprehensively assessed until evaluated by the wound Nurse Practitioner on May 13, 2024. Interview was conducted with licensed nurse Employee E5 on May 17, 2024, at 9:30 a.m. Employee E5 reported that the admitting nurse is responsible for assessing the resident's skin for any impairment. Employee E5 added that although nurses don't initially document the stage of the wound, measurements, description of the wound, and the surrounding area should be assessed and documented. An interview with the Director of Nursing conducted on May 17, 2024, confirmed Resident 57 and Resident 235's pressure ulcers should have been comprehensively assessed on admission. The facility failed to ensure Resident 57 and Resident 235's pressure wounds identified upon admission were comprehensively assessed. 28 Pa Code 211.5 (f) Clinical records Previously cited 7/20/23. 28 Pa code 211.10 (c) Resident care policies Previously cited 7/20/23. 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 7/20/23.

Based on clinical record review and staff interview, it was determined that the facility failed to notify hospice services and the resident's responsible party of a change in condition for one of three residents reviewed (Resident CL1). Findings Include: Review of facility policy titled Change in Resident Condition/Notification with a review date of March 2022 indicated it is the policy of this facility to notify the resident's responsible party/family when there is a significant change in the resident's condition. Additional review of facility policy indicated the licensed nurse or administrator will notify the designated person for notification as soon as possible following a significant change in a resident's condition. Documentation of the time and person notified, or message left, will be noted in the resident's record. Review of Resident CL1's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including but not limited to following Endocarditis (Inflammation of the inner lining of the heart chambers and valves), Cerebral Infraction (aka Stroke), and Displaced Intertrochanteric Fracture of Left Femur. Review of Resident CL1's October 2023, physician orders revealed an order dated October 29, 2023, indicating [Resident]'s end of life care will be coordinated with the facility and [name] hospice. Review of Resident CL1's clinical record including nursing progress notes revealed note dated November 28, 2023, indicating This nurse called to resident's room by assigned nurse to pronounce resident passing. Resident noted to be absent of pulse and respirations, pronounced at 5:20 am by this nurse. Further review of Resident CL1's clinical record failed to reveal documented evidence of notification to the hospice provider or the resident's responsible party. Interview on December 19, 2023, at 3:20 p.m. with the Nursing Home Administrator confirmed that there is no documented evidence that neither resident's hospice provider or resident's responsible party was notified of Resident CL1's change in condition. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observations, and interviews with residents and staff, the facility failed to post pertinent State regulatory information, including State licensure office contact information and how to file a complaint with the State Survey Agency as required for two of two nursing units observed (First Floor and Second Floor nursing units). Findings include: During an interview, on July 18, 2023, at 10:30 a.m. a group of five alert and oriented residents (Residents 27, 36, 1, 28, 31) stated that they did not know how to contact or how to file a complaint with the State Survey Agency. Observation, on July 18, 2023, at 11:02 a.m. of the main lobby and first floor nursing unit areas revealed that there was no information posted regarding the State licensure office contact information and how to file a complaint with the State Survey Agency. Continued observation, on July 18, 2023, at 11:10 a.m. of the second floor nursing unit revealed that there was no information posted regarding the State licensure office contact information and how to file a complaint with the State Survey Agency. Further observation on July 18, 2023, at 11:15 a.m. and interview with the Nursing Home Administrator confirmed that there was no information posted regarding the State licensure office contact information and how to file a complaint with the State Survey Agency as required. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide residents with the opportunity to file grievances anonymously for two of two nursing units observed (First Floor and Second Floor nursing units). Findings include: During an interview, on July 18, 2023, at 10:30 a.m. a group of five alert and oriented residents (Residents 27, 36, 1, 28, 31) stated that they did not know who the grievance official was at the facility and they did not know where the grievance process was posted. Observation, on July 18, 2023, at 11:02 a.m. of the main lobby and first floor nursing unit areas revealed that there was no information posted regarding the facility's grievance process, the grievance officer or how to file a grievance. Continued observation, on July 18, 2023, at 11:10 a.m. of the second floor nursing unit revealed that the facility Grievance/Complaint Procedure was posted in the hallway near the elevator. Review of the Grievance/Complaint Procedure undated, revealed, Please fill in this form and submit to the Charge Nurse who will see that it is forwarded to the Social Worker, who will assign a facility representative to investigate. The Grievance/Complaint Procedure listed the social worker's name and contact information as the grievance official. Further observation revealed that there were no grievance forms available and that there was no box to place grievance forms anonymously. Observation on July 18, 2023, at 11:15 a.m. and interview with the Nursing Home Administrator confirmed that no grievance information was posted on the first floor nursing unit, that there were no grievance forms available and that there was no box to place grievance forms anonymously. Interview on July 18, 2023, at 11:24 a.m. Employee E3, Director of Social Worker, stated that grievance forms were located at the nurses station and the residents could ask staff for a grievance form. Employee E3, Director of Social Worker, confirmed that there were no grievance forms available or a box for residents to be able to file grievances anonymously. The facility failed to provide residents the opportunity to file grievances anonymously. 28 Pa Code 201.29 (b) Resident rights

Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to administer as needed pain medications for appropriate pain levels for two of five residents reviewed. (Residents 2 and 42) Findings include: Review of facility policy and procedure titled Pain Management, revised March 2022, revealed PRN (as needed) pain medication orders should include name of medication, strength, frequency, pain indication or location and pain scale (mild, moderate, severe). If there are multiple prn pain medication orders the orders must contain the necessary, pain scale clearly defining the level of pain for each use. Review of Resident 2's physician orders revealed an order dated April 26, 2023 for Oxycodone (narcotic pain reliever) with Acetaminophen (Tylenol) Tablet 5-325 MG (milligrams); Give 1 tablet by mouth every 6 hours as needed for moderate pain. Review of Resident 2's Medication administration Record for July and June 2023 revealed the resident received the medication for a pain level other than moderate a total of eight times. Review of Resident 42's physician orders revealed an order dated July 14, 2022 for Acetaminophen tablet 325 MG give two tablets by mouth every four hours as needed for mild pain; and an order dated May 20, 2023 for oxycodone HCL tablet 5 MG give one tablet by mouth every 6 hours as needed for pain, this ordered did not specify a pain level for the medication to be administered. Review of Resident 42's MAR for June and July 2023 revealed the Acetaminophen was administered 19 times for a pain rating other than mild. Further review of Resident 42's June and July 2023 MAR revealed the Oxycodone was given for a mild pain level totaling 25 times when the acetaminophen should have been administered. Interview with the Director of Nursing and the Nursing Home Administrator on July 20, 2023 at 9:30 a.m. confirmed prn pain medications were not administered as ordered and the prn pain medications for Resident 42 did not include a pain level per policy. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety for two of two nursing units (First Floor and Second Floor nursing units). Findings include: Review of the facility policy, Food Safety-Resident Food dated [DATE], revealed, the facility will be responsible for safe storage of food and beverage items. Resident food items will be labeled with the resident's name. The item will also be dated. The item will only be safe for three days. Observation on [DATE], at 9:17 a.m. of the second-floor kitchen dry food storage area revealed a box that was open and left open to air of food thickener. Interview, at the time of the observation, Employee E4, Dietary Manager, confirmed that the box of thickener was left open to air and then proceeded to close the box. Observation on [DATE], at 9:56 a.m. of the second-floor pantry, revealed the following: A container of cream cheese for Resident 42 that expired [DATE]; Two bags full of containers of food brought in by family for Resident R42 that were undated; An opened quart sized container of iced tea that expired [DATE], and did not contain a resident name label; An opened quart-sized container of strawberry lemonade that expired [DATE], and did not contain a resident name label; An opened two-liter bottle of soda that was undated and did not contain a resident name label; An opened container of pastries that was undated and did not contain a resident name label; An opened carton of prune juice that was undated; Four pint-sized containers of ice cream that were undated, three of which did not contain a resident name label; An opened bag of potato chips that was undated; An opened bag of cheese crackers that was undated; A loaf of bread that expired on [DATE]; Four one-liter bottles of Glucerna 1.5 (nutritional supplement) that expired February 1, 2023; Two one-liter bottles of Glucerna 1.5 that expired [DATE]; Twelve eight-ounce bottles of Jevity 1.5 (nutritional supplement) that expired on [DATE]; Eight eight-ounce bottles of Glucerna 1.5 that expired on [DATE]; and two eight-ounce bottles of Glucerna that expired on [DATE]. Observation on [DATE], at 10:21 a.m. of the first-floor pantry, revealed thirty-three eight-ounce bottles of Nepro (nutritional supplement) that expired on [DATE]. Interview with Employee E5, Chef, on [DATE], at 10:24 a.m. confirmed that food was not stored properly in the pantries. Further it was confirmed by Employee E5, chef, that items were not properly labeled or dated, and the items were expired. The facility failed to ensure that food was stored properly, labeled and dated according to professional standards. 28 Pa Code 201.18(b)(1) Management

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor weight loss for one of three residents reviewed for nutrition (Resident 18). Findings include: Review of facility policy, Weighing of Residents, undated, revealed that if the resident exhibits a weight change of 3 lbs. from the previous weight (weights under 100 lbs.), the resident shall be re-weighed within 24 hours and the re-weight shall be recorded. Review of Resident 18's weights revealed on April 5, 2023, the resident was recorded as weighing 79 lbs. On April 7, 2023, the resident was recorded as weighing 73.4 lbs., which is a 7.09% loss in two days. Further review of Resident 18's weights revealed the resident was not weighed again until April 14, 2023. Further review of Resident 18's weights revealed on May 10, 2023, the resident was recorded as weighing 78.2 lbs. On June 12, 2023, the resident was recorded as weighing 71.6 lbs., which is an 8.06% loss in one month. Further review of Resident 18's weights revealed the resident was not weighed again until July 6, 2023. Interview with the Registered Dietitian, Employee E6, on July 20, 2023, at 10:30 a.m. confirmed that the facility should have obtained reweights on Resident 18 within 24 hours. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on a review of the facility's policy, clinical records, and staff interviews, it was determined that the facility failed to follow physician's order to monitor the resident's vital signs and to timely notify the physician of an abnormal blood pressure reading resulting in actual harm of hospitalization for one of three residents reviewed (Resident 1). Findings include: Review of the facility's policy titled Vital Signs, Frequency, May 2022, revealed that upon admission or readmission of a resident to the facility, vital signs will be obtained every shift for 72 hours to establish baseline vital signs. Vital signs will be obtained and documented per physician's orders, as a nursing measure and/or pharmacy recommendations. Review of the facility's policy titled Change in Resident Condition/Notification, dated March 2022, revealed that the facility must evaluate each resident's significant change in condition and notify the attending physician appropriately of the evaluation on time. Review of Resident 1's diagnosis list revealed Chronic Obstructive Pulmonary Disease (COPD-group of lung diseases that blocks airflow and make it difficult to breathe), Acute Respiratory Failure, Pneumonia (infection that inflames the air sacs in one or both lungs), and Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of Resident 1's clinical records revealed Admission/Readmission nursing documentation dated April 18, 2023, revealed resident was readmitted to the facility from the hospital on April 18, 2023, at 6:50 p.m., with a diagnosis of Pneumonia (infection of the air sacs in one or both the lungs. Characterized by severe cough with phlegm, fever, chills and difficulty in breathing). Vital signs documented as follows: Blood Pressure (B/P) was 140/73 mm Hg; heart rate (HR) was 81 BPM; respirations 18/min.; and oxygen saturation was 95%. Review of the physician's order dated April 19, 2023, at 7:00 a.m., revealed an order for vital signs every shift x 72 hours then monthly everyday shift for three days; to start on April 19, 2023, at 7:00 a.m. Review of the resident's clinical records revealed that the resident's B/P was not taken on the morning shift (April 19, 2023 7a.m.-7p.m) and night shift (7p.m.-7a.m. on April 19th into April 20, 2023). Heart Rate (HR), respirations, and temperature were not taken on the morning shift. Interview with the licensed nurse Employee E3 conducted on May 4, 2023, at 11:00 a.m., revealed that vitals which include B/P, HR, RR (Respiratory Rate), and temperature should have been checked every shift as ordered and the result should be documented on the resident's clinical records. Employee E3 confirmed that there was no documentation of Resident 1's blood pressure from April 19, 2023, at 7:00 a.m., until April 20, 2023, at 4: 22 p.m. Review of Resident 1's nursing progress notes by licensed Employee E4 dated April 20, 2023, at 4:59 p.m., revealed at 4:00 p.m., the resident's oxygen via nasal cannula was not on while the resident was sleeping, V/S normal, Spo2 100%. The daughter reported that she forgot to put it back on after readjusting her, daughter was educated. Review of the vitals and weights dated April 20, 2023, at 4:22 p.m., documented by Employee E4 revealed a blood pressure of 83/55 mm Hg (normal B/P range from 90/60-120/80 mm Hg), Pulse Rate (PR) -82, Respiration Rate (RR)-18, Temperature (T)-97.4 F, and Oxygen level (Spo2) was 100%) Review of Resident 1's clinical records failed to reveal the resident was comprehensively assessed after noting a blood pressure of 83/55 mm Hg at 4:22 p.m. Further review of the clinical records failed to reveal the physician was notified of the resident's low blood pressure. Review of the nursing progress notes dated April 20, 2023, at 7:21 p.m., revealed the resident's granddaughter requested the resident be transferred to the hospital for evaluation because the resident had decreased responsiveness and was not talking or interacting with the family. The physician was notified. Review of the progress notes dated April 20, 2023, at 8:00 p.m., revealed resident physician ordered the transfer of the resident to the hospital for evaluation due to a change in mental status, and lethargy. Review of the progress notes dated April 21, 2023, at 2:46 a.m., revealed staff spoke to the ER (emergency room ) nurse and reported that the resident was admitted with hypotension (low blood pressure) and that they were having a difficult time trying to keep the patient's blood pressure up. Review of the hospital records dated April 21, 2023, revealed the resident was transferred to the hospital for hypotension and was, in fact, hypotensive upon arrival and received sepsis (blood infection) fluid challenge with the improvement of blood pressure. The resident was admitted to PCU (Progressive Care Unit) with a diagnosis of Sepsis. Interview with Employee E4 conducted on May 4, 2023, at 1:00 p.m. revealed Employee E4was not able to answer any questions asked by the surveyor. Employee E4 reported that she/he was an agency. Employee E4 stated, I do not know what you are talking about. I don't remember at the top of my head. I'm sorry, I can't speak on it. Interview with licensed nurse Employee E5 conducted on May 4, 2023, at 1:15 p.m. Employee E5 reported that she/he was the nursing supervisor from 3:00 p.m., until 11:00 p.m., on April 20, 2023. Employee E5 reported not getting any concerns/reports regarding the resident's condition until around 7:00 p.m., when staff notified her/him that Resident 1's granddaughter wanted to talk to the nursing supervisor, or she will call 911 herself for the resident to be transferred to the hospital. Employee E5 reported that the resident was noted to be very sleepy, the family requested for the resident to be transferred to the hospital for evaluation, so she/he called the on-call physician and prepared paper work for transfer. Employee E5 reported that Employee E6 handed her Resident 1's vital sign list but she/he did not get to ask when it was taken. Employee E5 reported that the blood pressure noted was in the 80's. Employee E5 reported that the physician called back and gave orders to transfer the resident to the hospital, 911 was called, the resident left, and the family followed. Review of the transfer form completed by Employee E5 on April 20, 2023, at 7:32 p.m., revealed the same vital signs taken on April 20, 2023, at 4: 22 p.m. There was no record that Resident 1's vitals were re-checked after 4:22 p.m. An interview with licensed nurse Employee E6 was conducted on May 4, 2023, at 1:45 p.m. Employee E6 reported that she/he was the nurse on April 20, 2023, from 7:00 p.m., until 7:00 a.m., the next day. Employee E6 reported that her/his shift starts at 7:00 p.m., and during the report, the morning (agency) nurse reported that the family was requesting for the resident to be transferred to the hospital, that vital signs were taken, and it was fine, and the nursing supervisor was already notified. Employee E6 was unable to remember the resident's vital signs reported by the morning nurse and reported that she/he might have written it on her/his report paper, but it was already thrown out. Employee E6 reported checking the resident and noted that the resident was gazing and not talking. Employee E6 reported that she/he did not check the resident's vitals, and the nursing supervisor sent the resident to the hospital. Interview with the Nurse Practitioner was conducted on May 4, 2023, at 2:00 p.m. The Nurse Practitioner (NP) reported that she was present on April 20, 2023, and was on-call until 5:00 p.m. The NP confirmed not getting a call regarding Resident 1's low blood pressure taken at 4:22 p.m., the NP reported that an order would have been made if she/he was notified regarding the resident's low blood pressure. The facility was unable to determine how long the resident had been having low blood pressure since the order to monitor the resident's blood pressure (vitals) ordered on April 19, 2023, at 7:00 a.m., was not followed. The facility was unable to provide an explanation why the physician was not notified of Resident 1's blood pressure of 83/55 mm Hg on April 20, 2023, at 4:22 p.m., and no documentation that the resident was comprehensively assessed. The physician was only notified of the resident's condition upon the family's request to transfer the resident to the hospital. The facility failed to follow the physician's order to monitor blood pressure/vitals and failed to timely notify the physician of the resident's low blood pressure which resulted in harm to Resident 1 of hospitalization . 28 Pa. Code 211.5(f) Clinical records Previously cited 7/22/22, 6/28/21 28 Pa. Code 211.10 (c) Resident care policies Previously cited 7/22/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/22/22, 6/28/21 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 6/28/21

Based on observation, review of the facility policy and clinical records, and staff interview, it was determined that the facility failed to timely assess and provide wound treatment to a sacral wound resulting in actual harm of advanced stage pressure ulcer from a Stage two (an ulcer involving loss of the top layers of the skin) to a Stage three (ulcer involving the full thickness of skin loss, exposing tissue) to one of 19 residents reviewed (Resident 46). Findings include: A review of the facility's policy entitled, Skin Integrity Management, with a revision date of December 20, 2019, revealed that a complete comprehensive evaluation of the patient upon admission/re-admission to the center is a practice standard. Complete risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through a review of all appropriate assessment information. Perform skin inspection on admission/re-admission and weekly. Perform daily monitoring of wounds or dressings for the presence of complications or declines and document. A review of Resident 46's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 46's nursing documentation dated March 25, 2021, at 3:28 p.m. revealed that the resident was admitted to the facility for therapy post-fall. The same documentation revealed that the resident's skin was intact. A Braden risk assessment for skin breakdown was completed on April 1, 2021, that identified Resident 46 as being not at risk for skin breakdown. A review of Resident 46's current care plan initiated on March 25, 2021, revealed that the, resident requires assistance/is dependent for mobility. An intervention of ¼ bed rails was developed as a mobility enabler. A review of the resident's care plan revealed that there was no skin care plan developed for the resident. A review of the Minimum Data Set assessment (MDS-an assessment tool used to facilitate the management of care) dated March 31, 2021, revealed that the resident had severe cognitive impairment. A review of the same MDS revealed that the resident required extensive assistance with two-person assistance with bed mobility and was occasionally incontinent of the bladder. A review of Resident 46's skin checks dated April 3, 2021, at 9:00 a.m. revealed that the resident had no identified skin injury/wound. A review of the daily, Nursing Documentation, which was a check list, revealed a daily review of the integumentary (skin) system. The documentation on the following dates: April 4, 2021, April 5, 2021, and April 6, 2021, revealed that the review of the integumentary system was not completed. A review of the, Nursing Documentation, on April 7, 2021, at 3:37 a.m. revealed that the integumentary system was reviewed but no indication of the outcome of the review. A review of the, Assessment Note, dated April 7, 2021, at 3:37 p.m. revealed that a new pressure wound, of the sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), Stage two in-house acquired was identified and the practitioner was notified. An interview with Licensed Employee E3 on June 28, 2021, at 1:00 p.m. was conducted and revealed that any new identified wounds are assessed by the nurse on duty. Licensed Employee E3 stated that pictures of the wounds are taken, and the wounds are measured electronically. A review of the wound evaluation completed on April 7, 2021, at 3:51 p.m. revealed a new wound on the sacrum, with a measurement of 1.45 centimeters (cm) x 0.73 cm., with 100% epithelization (a process where epithelial cells migrate upwards and repair wounded area). A review of the Nurse Practitioner's (NP) note dated April 7, 2021, at 4:18 p.m. revealed that the resident was transferred to the hospital due to a change in mental status, and increased heart rate. The note also revealed that the resident had a sacral ulcer. A review of the hospital records dated April 8, 2021, revealed a wound consult with the following information: incontinence-associated [CONDITION(S)] (skin rash); pressure injury Stage two to the sacrum, reddened, pink, with a measurement of 4.0 cm x 4.0 cm, with a wound surface area of 16 cm; pressure injury to right and left heel, both Stage one (the skin appears reddened and does not blanch), and both measuring 3.0 cm x 3.0 cm, with a wound surface area of 9.0 cm. A review of the hospital records dated April 9, 2021, revealed a problem list as follows: [CONDITION(S)] (an abnormal heart rhythm characterized by the rapid and irregular beating of the heart), acute kidney injury, and pressure ulcer, non-hospital. A review of the, Nursing Documentation, dated April 9, 2021, at 7:23 p.m. revealed that Resident 46 was readmitted to the facility. The note indicated that the resident was incontinent of both bowel and bladder. A review of the integumentary system section revealed that a review was done but there was no information found regarding the resident's skin condition upon readmission to the facility. A review of Resident 46's care plan failed to reveal that a skin and/or wound care plan was developed upon readmission on April 9, 2021. During an interview on June 28, 2021, at 1:00 p.m. Licensed Employee E3 confirmed that there was no readmission skin assessment completed on April 9, 2021. Licensed Employee E3 also confirmed that there was no skin and/or wound care plan developed for Resident 46 when readmitted to the facility on [DATE]. A review of post readmission, Nursing Documentation, dated April 10, 2021, at 12:02 a.m., April 10, 2021, at 8:02 p.m., April 11, 2021, at 4:02 p.m., April 11, 2021, at 12:02 p.m., and April 12, 2021, at 4:02 a.m., revealed that a review of the integumentary system was not conducted. A review of the April 2021 Treatment Administration Record (TAR) did not reveal any wound/skin treatment from the time the resident was readmitted to the facility on [DATE], until April 12, 2021. A review of an assessment note dated April 12, 2021, at 10:54 a.m. revealed, A deteriorating pressure wound Stage three, in-house acquired to sacrum was assessed today, the practitioner had been notified. A review of the electronic wound evaluation dated April 12, 2021, revealed a deteriorating Stage three to the sacrum, with a measurement of 0.62 cm x 0.72 cm. A review of the April 2021 TAR revealed that a wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 46's clinical records, electronic wound evaluation revealed that from April 12, 2021, the sacral wound was monitored weekly. The wound remained stable at Stage three. A review of the electronic wound evaluation dated June 22, 2021, revealed a stable Stage three to sacrum with a measurement of 1.95 cm x 1.34 cm. The [MEDICATION(S)] wound treatment was continued. A wound observation on June 28, 2021, at 1:30 p.m. revealed Resident 46's sacral wound was clean, with no drainage. A review of Resident 46's care plan revealed that a skin/wound care plan was developed on June 28, 2021. The above was conveyed to the Director of Nursing on June 28, 2021, at 2:30 p.m. The facility failed to timely assess and provide wound treatment to Resident 46's sacral wound which resulted in actual harm of an advanced stage pressure ulcer from Stage two to a Stage three. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services

Based on a review of clinical record and staff interview, it was determined that the facility failed to ensure that residents were free of significant medication errors which resulted in actual harm to Resident R1 experiencing a hypoglycemic episode, requiring two doses of [MEDICATION NAME] injection, one dose of [MEDICATION NAME] intravenously and transfer to the hospital via emergency services for one of four residents reviewed. (Resident R1) Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of (MONTH) 2019 physician's orders [REDACTED]. A review of nursing notes dated (MONTH) 25, 2019, at 6:25 p.m. revealed Patient ordered [MEDICATION NAME] U-500 25 units with meals. Patient given incorrect dose of insulin. BS (blood sugar) at 4:30 p.m. was 77. New orders to do accuchecks q (every)1 hr for 6 hrs (hours), given one dose of [MEDICATION NAME], house supplements and orange juice with sugar. Observe for [DIAGNOSES REDACTED] and alert MD (physician) with any changes. Review of nursing note dated (MONTH) 26, 2019, at 5:12 a.m. noted, Resident request to use the bathroom at 0200 (2:00 a.m.) while in the bathroom (10 min) resident began perspiring, tensing up and speech became unclear/blood sugar was taken BS decrease to 47 resident was transferred from toilet to bed with maximal assist; at this time MD was called via charge nurse, while assigned nurse made several attempts to bring sugar to normal range. BS 40 resident was given [MEDICATION NAME] with negative results/ MD states send pt to emergency room (ER) while awaiting for Emergency Medical Transport (EMT) resident received second [MEDICATION NAME] injection BS when obtain BS 41/ resident continues with non responsive behavior nurse remained with resident to keep resident alert/EMT arrived assessed resident placed IV with [MEDICATION NAME] due to BS continuing to decrease/once IV was placed and medication received resident alert with clear speech and able to make needs known/resident take to (hospital) for observation/management; POA (Power of Attorney) made aware. A review of Statement via phone conversation by the Director of Nursing (DON) with licensed nursing staff, Employee E2 revealed I read the order, it was for insulin U-500 25 units, I did not see anything in the MAR (Medication Administration Record) to tell me about it being a high dose or that I had to use another syringe. DON proceeded to ask Employee E2 during interview, when you read her name did you not see the red warning signs right above where pharmacy placed her name sticker? Licensed nursing staff Employee E2 responded that she in error did not see or read the warning labels on box and bottle to administer with U-500 syringe that was available. She never knew there were different syringes for the U-500 insulin. She has only ever used a U-100 (syringe) for everything. Regular insulin U-500 is 5 times more potent than the Regular insulin U-100. The use of the U-100 syringe with the insulin [MEDICATION NAME] R-500 resulted in more insulin medication being delivered. Observation of the [MEDICATION NAME] R U-500 box on (MONTH) 15, 2019, at approximately 1:30 p.m. confirmed that a warning label was placed on the medication's box indicating Warning- Highly Concentrated IMPORTANT: Use only with a U-500 syringe. A review of the Medication Safety Alert Sheet Focus on U-500 Insulin provided by the pharmacy stated that U-500 insulin is only available as regular insulin in a concentration of 500 units/ml (milliliters) Due to the potential confusion in the volume of insulin ordered, directions for injection should include the insulin volume to be administered in milliliters. A TB ([MEDICATION NAME]) syringe is recommended for administration. It should be noted this highly concentrated solution of insulin has a prolonged duration of therapy and patients should be continually monitored for [DIAGNOSES REDACTED]. Recommendations for safe prescribing, dispensing and administration include: Two nurses should check the dose and volume when drawing and administering this medication. Review of Resident R1's (MONTH) 2019 Medication Administration Record [REDACTED]. A review of the facility investigation into the medication error involving Resident R1 dated (MONTH) 25, 2019, concluded that the incorrect syringe was used during the administration of the insulin medication [MEDICATION NAME] R U-500 to Resident R1. The nurse did not follow the pharmacy warning box label or the warning in red on the bottle to use a U-500 syringe and the nurse did not follow drug warning on three occasions therefore did not follow 5 rights of drug information (right patient, right time and frequency of administration, right dose, right route and right drug). The facility failed to ensure that the correct syringe was utilized in the administration of insulin medication to Resident R1 which resulted in actual harm to Resident R1 experiencing a hypoglycemic episodes, requiring two doses of [MEDICATION NAME] injection, 1 dose of [MEDICATION NAME] intravenously and transfer to the hospital via emergency services. 28 Pa. Code 211.5(f) Clinical records Previously cited 08/24/18, 09/15/17 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 08/24/18, 09/15/17 28 Pa Code 211.10(c) Resident care policies Previously cited 08/24/18, 09/15/17 28 Pa Code 211.12(c)(d)(1)(5) Nursing services Previously cited 08/24/18, 09/15/17

Based on review of a closed clinical record, facility documentation and review of hospital records, observation, and staff interviews, it was determined that the facility failed to ensure that safety measures were in place during the transport of two residents in a van for a facility sponsored activity, and one of the two residents fell out of a wheelchair and sustained multiple injuries causing actual harm to the resident. (Resident R1). Findings include: Review of Resident R1's current [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated [DATE], revealed that the resident had short term memory problems, required total assistance with transfer and attended activities 1/3 to 2/3 of the time. Review of a facility reported event dated May 3, 2011, revealed that the resident was in a wheelchair in the facility van on a facility sponsored trip and slid out of the wheelchair when the van stopped at a red light. Staff transferred the resident into a seat and returned to the facility. The nurses' note dated May 3, 2011 at 3:18 p.m., indicated that the resident slid out of the wheelchair when the driver put on the brakes and the resident's knees hit the floor. The nurses' note dated May 3, 2011 at 3:29 p.m., indicated the resident was complaining of pain in the bilateral (both) knees, the physician and the family were called and the physician ordered a STAT (immediate) X-ray of the bilateral knees and legs. The nurses' note dated May 3, 2011 at 3:42 p.m. indicated that the resident was placed into bed and was assessed to have bruising to the bilateral (both) lower extremities right below the knees. Review of the X-ray report electronically signed and dated by the radiologist on May 3, 2011 at 7:11 p.m., indicated there were multiple fractures of the right and left tibia (inner larger lower leg bone extending from the knee to the ankle) and left proximal (near the center) fibula fracture (outer lower leg bone). The report also indicated that osteoporosis (condition in which the bones become brittle and fragile) was present. The nurses' note dated May 3, 2011 at 10:05 p.m., indicated that the physician was called with results and that the family stayed with the resident most of the shift. During an interview on May 11, 2011, the Administrator indicated that the family wanted the resident to remain in the facility until May 4, 2011. An interview with the Administrator by telephone on May 19, 2011, confirmed that the administrator spoke with the family several times on May 3, 2011, and the family wanted the resident to remain in the facility until the following morning and the family was aware of the X-ray results. Review of a statement from licensed nursing Employee E7, indicated that the physician was called on May 3, 2011, and agreed that the resident would not have treatment until May 4, 2011. Licensed nursing Employee E7 also documented that the physician was comfortable with keeping the resident at the facility until the morning. Review of the physician's verbal order dated May 4, 2011 at 6:30 a.m., indicated to transfer the resident to the hospital emergency room via an ambulance. The nurses' note dated May 4, 2011 at 7:52 a.m., indicated that the resident was transferred to the hospital emergency room by ambulance with multiple fractures of the tibia and fibular. The family was aware of the transfer. The hospital record dated May 4, 2011, indicated that the resident was admitted with multiple fractures. The right leg had extensive osteopenia (a decrease in bone tissue), fracture of the proximal tibia (inner and large bone of the leg), comminuted fracture of the fibula (fracture where there are several breaks in the bone resulting in two or more fragments in the long thin bone of the leg), knee joint effusion (escape of fluid into a body cavity), and possible fracture versus tissue derangement (disruption of the normal relationship between the joint structures). The left leg showed a fracture of the proximal tibia (inner and large bone of the leg), comminuted fracture of the fibula and knee joint effusion Review of the facility investigation report dated May 3, 2011, indicated that the resident had no seat belt applied when in the van during the transport. During an interview on May 11, 2011 at 10:30 a.m., Activity staff Employee E4, who was the individual responsible for securing the safety devices, confirmed locking the wheelchair in the van but the seat belt was not in place at the time of the incident. Employee E4 did not recall the educational training for seat belts for residents while in wheelchairs during transport in the van. Observation of the van safety devices on May 11, 2011 at 11:30 a.m., with the Administrator, the Maintenance Director and nursing Employee E5, revealed there was right and left side shoulder/lap belts to be used to ensure resident safety during van transport when in a wheelchair and anchor floor locks to secure the wheelchair in the van. Review of the training program for staff regarding resident van transport indicated there was no documentation of staff education prior to the incident of May 3, 2011. Review of the training program's procedures for resident van transport safety written after the May 3, 2011 incident, indicated there was no information regarding seat belt application for wheelchairs in the van. During an interview on May 11, 2011 at 11:00 a.m., the Administrator confirmed the above review of facility documentation and that the facility staff failed to apply the seat belt during the van transport. This interview also revealed that the facility staff no longer transport residents in the van. The facility failed to provide safety measures to Resident R1 while on a van trip causing actual harm evidenced by pain and injury to the resident. This resulted in the hospitalization of the resident due to injuries of multiple fractures to both legs. CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 08/18/09 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/18/09 28 Pa. Code 201.18(b)(1) Management Previously cited 08/18/09, 10/19/10 28 Pa. Code 201.18(e)(1) Management Previously cited 10/19/10 28 Pa. Code 201.20(a)(c) Staff development 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/18/09 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 08/18/09, 10/19/10

Based on review of facility documentation, clinical record review and interview with facility staff, the facility failed to provide a safe environment for two of two residents during a van transport causing actual harm to one resident which sustained multiple fractures of both legs. (Resident R1, R2). Findings include: Review of a facility reported incident dated May 3, 2011, indicated that Resident R1 was in a wheelchair on a van trip and slid out of the wheelchair in the van and sustained bilateral fractures of his/her legs. Review of the facility's investigation report dated May 3, 2011, indicated that no seatbelt was applied to Resident R1 during the van transport. Review of Resident R1's nurses' notes dated May 3, 2011 at 3:18 p.m., related that when the driver put on the brakes, the resident slid out of the wheelchair and the resident's knees hit the floor. The resident complained of knee pain and medication was given for the pain. The nurses' note at 3:29 p.m. indicated that the physician ordered STAT (immediate) X-rays of the knees and legs. Review of the X-ray report dated May 3, 2011 at 7:11 p.m., indicated there were multiple fractures of the right and left tibia (inner larger lower leg bone extending from the knee to the ankle) and left proximal (near the center) fibula fracture (outer lower leg bone). The X-ray report also stated the resident had [MEDICAL CONDITION] (a condition when the bones become brittle and fragile). The nurses' note dated May 4, 2011 at 7:52 a.m., indicated that the resident was transferred to the hospital emergency room and admitted for treatment of [REDACTED]. The nurses' note written on May 18, 2011 at 11:23 a.m., indicated a late entry nurses' note for Resident R2 for the date of May 3, 2011, which stated that the resident returned from an activity with the recreation department without incident. Interview with activity staff Employee E4 on May 11, 2011 at 10:30 a.m., related that the two residents, Resident R1 and Resident R2, were in wheelchairs in the van. Neither of the two residents were secured by seatbelts while in the van during transport to an activity outing. One of the two residents, Resident R1, fell out of the wheelchair. The facility's staff failed to provide a safe environment for wheelchair bound residents while traveling in a van. The facility failed to apply seat belts to the residents, which caused actual harm to one resident that fell out of the wheelchair and sustained bilateral fractures of both legs and suffered pain. CFR 483.70(h) Safe/Functional/Sanitary/Comfortable Environment Previously cited 8/19/09 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/18/09 28 Pa. Code 201.18(b)(1) Management Previously cited 08/18/09, 10/19/10 28 Pa. Code 201.18(e)(1) Management Previously cited 10/19/10 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/18/09