Every finding on record at Neffsville Nursing and Rehabilitation

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents. Specifically, the facility utilized radiant space heaters in resident rooms and in a hallway of the rehabilitation unit following loss of heat, placing residents, including residents with cognitive impairment, at risk for serious injury or death. This failure constituted Immediate Jeopardy for the 22 residents on the Rehab unit.Findings include:During an interview conducted with the Nursing Home Administrator (NHA) on February 3, 2026, at approximately 8:20 a.m., the NHA reported one hallway in the rehabilitation unit lost heat on the evening of January 31, 2026. In response, the facility placed three radiant space heaters in resident rooms and two radiant space heaters in the rehabilitation unit hallway.Observations conducted February 3, 2026, at 8:24 a.m., during the survey revealed radiant space heaters actively in use in resident rooms and in a hallway accessible to residents. The heaters were positioned in locations where residents could come into direct contact with hot surfaces and electrical components.The Maintenance Director was contacted on February 3, 2026, at 8:25 a.m., and the surveyor accompanied the Maintenance Director while temperature readings of the space heaters were obtained.Temperature measurements of the space heaters located in resident rooms were as follows:Space Heater #2 located in Resident R1's and R2's room measured 138.5 FSpace Heater #3 located in Resident R3's room measured 153 FSpace Heater #4 located in Resident R4's and R5's room measured 123 FTemperature measurements of the space heaters located in the affected hallway were as follows:Space Heater #1 located at the entrance of the hallway measured 139 FSpace Heater #5 located at the end of the hallway measured 136 FInterview conducted with the Maintenance Director and the NHA on February 3, 2026, at approximately 8:42 a.m., NHA confirmed the facility was aware of the temperatures of the radiant space heaters located in resident rooms and the hallway. The NHA reported that space heaters were placed in the rooms of Residents R1, R2, R4, and R5 because those residents were dependent on staff for transfers. The NHA further indicated a space heater was placed in Resident R3's room because the resident had a BIMS score of 15, indicating intact cognition. The Maintenance Director reported placing orange caution cones around the space heaters located in the hallway to prevent residents from walking into them.Observations conducted in the affected hallway at approximately 8:58 a.m. revealed a resident in a wheelchair independently ambulating using handrails to pull themselves forward. The resident maneuvered around Space Heater #5 by moving to the opposite side of the hallway and continued down the hallway until reaching Space Heater #1, where the resident again had to maneuver around the heater to continue ambulation.Review of Resident R1's Minimum Data Set (MDS) revealed the resident was independent with chair-to-bed and bed-to-chair transfers and able to ambulate independently. The MDS further revealed a BIMS score of 12, indicating moderate cognitive impairment.Review of Resident R2's MDS assessment revealed the resident was dependent on staff for transfers and ambulation and had a BIMS score of 12, indicating moderate cognitive impairment.Review of Resident R3's MDS assessment revealed the resident was independent with transfers and ambulation and had a BIMS score of 15, indicating intact cognition.Review of Resident R4's MDS assessment revealed the resident was dependent on staff for transfers and ambulation and had a BIMS score of 3, indicating severe cognitive impairment.Review of Resident R5's MDS assessment revealed the resident was dependent on staff for transfers and ambulation and had a BIMS score of 14.Interview conducted with the NHA on February 3, 2026, at approximately 9:20 a.m., the NHA reported the facility did not have any policies or procedures providing guidance for the use of radiant space heaters in resident care areas.Interviews conducted with Certified Nursing Assistants (CNA) Employees E1, E2, and E3 revealed inconsistent understanding of the risks associated with radiant space heaters, including risks of burns, fire, and electrical hazards.An Immediate Jeopardy situation was identified and communicated to the Nursing Home Administrator on February 3, 2026, at 2:21 p.m., and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility.On February 3, 2026, at 4:25 p.m., the facility submitted an acceptable Immediate Jeopardy action plan, which included:Space heaters in use were taken out of the rooms and in the hallways.Room temperatures remained at 71 degrees and above.Residents in affected rooms were interviewed to ensure they are warm enough, extra blankets offered.Residents continued to be monitored q15 minutes.Vendor was contacted to provide p-tac units that will be used to provide heat in the residents' rooms as the facility waits for vendor to repair heat source.Space heaters will be removed from the facility.Maintenance staff will be educated by the NHA/Designee to ensure no space heaters are in use in resident rooms and hallwaysHourly audits of resident rooms temps and hallway temps in the affected area will be completed until the heat source is repaired.The audits will also include observation of the affected areas to ensure no space heaters in use with results to QAPI committee for further action and recommendations.During an interview conducted with the NHA on February 4, 2026, at approximately 8:15 a.m., the NHA reported the vendor provided 12 PTAC (self-contained heating and cooling unit) units, six of which were actively in use with six maintained as backups.Observations conducted of the Rehabilitation unit on February 4, 2026, at approximately 8:20 a.m., revealed all radiant space heaters had been removed.Review of facility temperature logs revealed room temperature checks were conducted and documented every 15 minutes. Temperature readings obtained with the NHA at approximately 8:22 a.m. revealed all rooms were within acceptable temperature ranges.Interviews conducted with Licensed Practical Nurses Employees E4, E5, and E6 and Certified Nursing Assistants Employees E7 through E11 confirmed staff education regarding prohibition of space heater use and required temperature monitoring.Interviews conducted with Residents R1, R2, R3, and R5 confirmed their rooms were warm and staff frequently checked on them and offered blankets.Immediate Jeopardy began on the evening of January 31, 2026, when the facility lost heat in the Rehabilitation unit and implemented the use of radiant space heaters in resident rooms and hallways, and continued until February 4, 2026, at 9:20 a.m., when the facility removed all space heaters, implemented alternative heating measures, and demonstrated corrective actions were sufficient to remove the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services28 Pa. Code 211.12(d)(2) Nursing services

Based on review of employee job descriptions, as well as observations, record review, and staff interviews, it was determined that the facility's administration, including the Nursing Home Administrator and Director of Nursing, failed to effectively utilize available resources to promote resident safety and maintain the highest practicable physical well-being of residents. Specifically, the facility failed to ensure the environment was free from accident hazards by permitting the use of radiant space heaters in resident rooms and hallways, including areas accessible to residents with cognitive impairment. This failure placed residents at risk for serious injury or death and resulted in an Immediate Jeopardy situation.Findings include: The job description for the Nursing Home Administrator (NHA), dated October 06, 2025, indicated the NHA's primary purpose is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times.The position description for the Director of Nursing (DON), dated august 11, 2022, revealed the DON is responsible to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Medical Director, to ensure that the highest degree of quality care is maintained at all times.The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F689) revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that the residents' environment remained free of accident hazards. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observations, staff interview, and resdient interview it was determined the facility failed to maintain a clean, comfortable, and homelike environment in four of four resident bathrooms. (Apple, Rosemont, [NAME] and Rehab units)Findings Include:Observation of the Apple unit bathroom on October 17, 2025 at 11:15 a.m. revealed the floor of the shower was missing approximately 8 tiles and the corner of the wall separating the bathtub and the shower had broken and missing tiles.Observations of the Rosemont unit bathroom on October 17, 2025 at 11:20 a.m. revealed a soiled Band-Aid lying on the floor of the shower. The wall of the entrance to the shower was broken at the floor with missing tiles and the metal covering bent and sticking out. The wall next to the entrance to the bathroom was missing tiles and had broken tiles.Observations of the [NAME] unit bathroom on October 17, 2025 at 11:25 a.m. revealed a plastic light cover was broken and lying on the floor by the entrance door of the bathroom.Observation of the Rehab unit bathroom on October 17, 2025 at 11:30 a.m. revealed on the bottom of the wall separating the two showers were broken and missing tiles.Interview with the Nursing Home Administrator at the time of all the above observations confirmed each area needed repair and the facility was currently planning the repairs.Interview with Resident 1 on October 17, 2025 at 11:50 a.m. revealed the bathrooms have had broken tiles for a while now and there have been instances when they were taken to the bathroom for a shower and the floor was soiled with bandages and dirty wash rags.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) (e)(3) Management.28 Pa. Code 207.2(a) Administrator's responsibility

Based on facility policy and procedure review, staff interview, clinical record review, and facility documentation review it was determine the facility failed to ensure that one of three residents reviewed was free from free from accidents and provided adequate supervision resulting in actual harm of a distal femur fracture of Resident 1. Findings include: Review of Resident 1's diagnosis list revealed a diagnosis of Obesity, history of falling, hip fracture, Muscle Weakness, CVA (Cerebral Vascular Accident- Stroke) and Dementia (group of conditions that cause a decline in cognitive function, including memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life). Review of Resident 1's Minimum Data Set (MDS-periodic assessment of resident needs) dated May 5, 2025, revealed the resident was cognitively intact. Review of Resident 1's Care Plan revealed a care plan for ADL (Activities of Daily Living- basic self-care tasks that individuals perform on a regular basis to maintain their health and independence) self-care performance deficit r/t (related/to) impaired mobility and CVA revealed an intervention initiated on October 22, 2024 indicating the resident requires extensive assistance of 2 staff participation to reposition in bed. Review of Resident 1's Care Cardex for bed mobility revealed the resident required extensive assistance of 2 staff participation to reposition and turn in bed. Resident 1's cardex was located in the room on the door of the closet. Review of Resident 1's Progress Notes revealed an Incident Note date September 1, 2025, at 7:47 a.m. indicating CNA (Certified Nursing Assistant) notified this nurse that the resident was on the floor around 0450 (4:50 a.m.). the resident was noted sitting on the floor besides (his/her) bed with (his/her) back towards the wheelchair. CNA provided care to the resident and left (him/her) in a lateral (side laying) position to look for a drop sheet 10 minutes before. The resident complained of pain in (his/her) right knee. The resident said: I slipped out of bed and hit my knee, and I can't reposition it.the resident was transferred to (his/her) bed with three assistants by mechanical lift. Further review of Resident 1's progress notes revealed an entry dated September 2, 2025 at 9:35 a.m. indicating IDT (Interdisciplinary Team - group of diverse professionals with different areas of expertise who collaborate to achieve a common goal, often to provide coordinated, holistic care for complex needs, particularly in healthcare) reviewed residents fall from bed on 9/1/25. Resident reported (he/she) had moved (his/her) leg too far off of the bed when (his/her) was lying on (his/her) side and the slid out of bed onto the floor. Resident c/o (complained of) pain in right knee and had limited mobility, noted to be externally rotated (indicative of a fracture of the femur) Resident admitted to the hospital with distal femur fracture (knee). Review of facility documentation into the investigation of the cause of the fall revealed a statement from Nursing Assistant Employee E3, dated September 1, 2025. I went into the residents room about 0435 to clean and wash and dress resident. After washing and dressing (him/her), (he/she) began to have a bowel movement. Resident was on (his/her) side in the middle facing the window and I asked if (he/she) was ok while I went to grab more towels. I lowered the bed and went to grab the linen off the cart in the hallway I could hear (him/her) yelling help. I went into the resident's room, and (he/she) was on the floor in the sitting position. I asked (him/her) what happened, and (he/she) stated (his/her) leg went too far over (the edge of the mattress) and (he/she) slipped out of bed. Interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:00 p.m. confirmed Resident 1 was not provided appropriate staff supervision during care while Employee E3 left the bedside to get more towels while providing incontinence care which resulted in actual harm to Resident 1 who was admitted to the hospital for a fractured femur. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on facility documentation, clinical records review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards when the facility failed to notify the physician of recommendations following a specialist consultation for one out of 1 resident reviewed (Resident 2). Review of Resident 2's clinical records reveal medical diagnoses that include: Spina bifida (a birth defect that mainly affects the spine), hydrocephalus (a complication that can be associated with spina bifida causing the abnormal buildup of the fluid that surrounds the brain), neurogenic bladder (a problem with the brain, nerves, or spinal column that causes loss of control of the bladder that can be associated with spina bifida), and neurogenic bowel (difficulty moving or controlling the bowels because of nerve damage that can be associated with spina bifida).Review of Resident 2's clinical record revealed an after-visit summary dated January 3, 2025 from a Spina bifida specialist to the attention of the Nursing Supervisor stating: Please see attached order for daily SS enema (soap suds enema: a medical procedure that involves administering fluid with soap or mild detergent into the rectum to flush out the contents of the bowel.)Review of Resident 2's clinical record revealed the following order recommendation from the provider at Spina Bifida Specialist: Perform a rectal soap suds enema daily with 300-500mL warm, soapy water, with a diagnosis of Neurogenic bowel to be started on 1/24/25.Review of Resident 2's facility record reveals no progress note reflecting Resident 2's consultation with the Spina Bifida clinic.Review of Resident 2's facility record reveals no contact with Resident 2's primary care provider communicating these new orders.Review of Resident 2's physician's history and physical note dated 2/26/2025 does not reflect being informed of any consultation recommendations.Review of resident 2's medication administration record (MAR) reveal that no order was entered for a soap suds enema to be started on January 24, 2025.During an interview on September 10, 2025 at approximately 2:00 p.m. with the DON, it was confirmed that there is no evidence that the consultation recommendations were addressed with the primary care provider for Resident 2.28 Pa Code 211.12(d)(5) Nursing Services

Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to maintain a sanitary environment in the kitchen. Findings Include: Review of facility policy and procedure titled Cleaning and Sanitation of Food Service Area, last revised July 2023 revealed the food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Observation of the dishwashing area on March 25, 2025 at 2:45 p.m. revealed a large brown colored substance covering the wall behind the dishwashing machine. Interview with Dietary Employee E3 on March 25, 2025 at 3:10 p.m. confirmed that the walls were dirty and that there had been a buildup of debris behind the dish washing machine. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on a clinical records review and staff interview, it was determined that the facility failed to ensure that the wound care order was consistently followed for one of the three residents reviewed (Resident CL1). Findings include: A review of Resident CL1's diagnosis list includes Cerebrovascular Disease (an interruption in the flow of blood to cells in the brain) and Dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life). A review of the physician's wound consult dated November 11, 2024, revealed Resident CL1 had a worsening Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) to the right gluteus (buttock) measuring 10.0 x 9.0 x 0.3 cm. with 40% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture that may be adherent to the base of the wound or present in clumps throughout the wound bed) and 50% eschar ( Is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like). A review of the physician's order dated November 17, 2024, revealed a wound care order to cleanse the wound with normal saline solution, apply Santyl (a topical medication used to remove damaged or burned skin to allow for wound healing and growth of healthy skin), and cover with bordered gauze two times a day and as needed. A review of the November 2024, Treatment Administration Record revealed that from November 18, 2024, until November 22, 2024, wound treatment was not provided in the morning of the following dates: November 19, 20, and 22, 2024. An interview with the Director of Nursing on January 2, 2024, at 11:00 a.m., revealed no explanation as to why ordered wound treatment were not provided on the above dates. The facility failed to consistently follow the physician's wound care treatment for a worsening wound of Resident CL1. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for ten of ten residents reviewed (Residents 2, 21, 24, 28, 66, 70, 78, 123, 161, 170). Findings include: A review of the facility's policy titled Enhanced Barrier Precautions (EBP), dated August 2022, revealed EBP's employees targeted gown and gloves use during high contact resident care activities when contact precautions do not otherwise apply. EBP's are indicated for residents with wounds and indwelling medical devices regardless of MDRO (Multi Resistance Drug Organisms) colonization. Communication related to EBP precautions will be via signage, Kardex, or assignment sheets. PPE (Personal Protective equipment) is available in the resident's room for use. Review of Resident 2's clinical record revealed Resident 2 has a cholecystostomy tube (tube inserted into gallbladder to drain fluid) in place. Observation of Resident 2's room failed to reveal evidence of Personal Protective Equipment (PPE) or any evidence that Enhanced Barrier Precautions were in place for staff during direct care and emptying of the cholecystostomy drainage. Review of Resident 21's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated August 29, 2024, revealed that the resident had an in-dwelling catheter (a flexible tube inserted into the bladder for removing fluid). Observations on all days of the survey of Resident 21's room failed to reveal evidence of EBP signage/communication or PPE. Review of Resident 24's clinical record revealed Resident 24 with a diagnosis of Retention of Urine (accumulation of urine within the bladder because of the inability to urinate). Review of MDS-significant change in status assessment dated [DATE], revealed that the resident had an in-dwelling catheter. Observation of Resident 24 and 28's room revealed indwelling catheters draining to gravity and failed to reveal evidence of PPE or EBP signage/communication for staff providing direct care. A review of Resident 66's clinical records revealed a surgical wound to the left foot. An observation on November 13, 2024, at 12:26 p.m., revealed that licensed Employee E4 was performing wound care on Resident 66's left foot. Further observation revealed Employee E4 was only wearing gloves on both hands without wearing a gown while performing a wound care. The room does not have an EBP sign/communication and no PPE is available in the room. An interview with Employee E4 was conducted on November 13, 2024, at 12:30 p.m. Employee E4 reported that she/he was not told what PPE to use (during wound care) and that there was no PPE available so she/he just used the gloves. Review of Resident 78's clinical record revealed Resident 78 had a foley catheter in place for urinary drainage. Observation of Resident 78's room failed to reveal evidence of PPE or any evidence that EBP were in place for staff during direct care of the foley catheter and emptying of the foley catheter drainage bag. Review of Resident 70's clinical record revealed Resident 70 has a pressure wound in the right gluteal area. Observation of Resident 70's room during interview failed to reveal evidence of PPE or any evidence that EBP were in place for staff during wound dressing changes. A review of Resident 123's clinical records revealed resident had a right above-knee amputation with the presence of a surgical wound. An observation conducted on November 12, 2024, at 11:00 a.m., revealed Resident 123 had a wound vacuum machine (A device that uses negative pressure to help wounds heal) on the right thigh stump. Further observation failed to reveal the presence of EBP signs/communication and PPEs in the room. A review of Resident 161's clinical records revealed resident had a PICC line (Peripherally Inserted Central Catheter- a thin, flexible tube inserted into a vein in the vein near the arm and threaded into a large near the heart) and a surgical wound to the left foot. An observation conducted on November 13, 2024, at noon, revealed a PICC line on Resident 161's left upper arm and a wound dressing to the left foot. Further observation failed to reveal the presence of EBP sign/communication and PPEs in Resident 161's room. Review of Resident 170's clinical record revealed Resident 170 had a Percutaneous Endoscopic Gastrostomy tube (feeding tube that is inserted through the abdomen wall and into the stomach). Resident 170 required EBP due to tube feedings. Observation of Resident 170 revealed a PEG tube and foley catheter. Resident 170's room failed to reveal evidence of PPE or EBP were in place for staff providing direct care to PEG tube or foley catheter. An interview with the Infection Preventionist, licensed Employee E5 conducted on November 13, 2024, at 12:35 p.m., revealed that for residents requiring an EBP, signage/communication are placed by the door and assignment sheets and PPEs are placed by the door. Employee E5 reported that none of the residents on the Rehab unit required EBP's. The above was discussed with the Director of Nursing on November 15, 2024, at 10:00 a.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy, clinical record review, and staff interview, it was determined the facility failed to monitor weights and notify the physician of significant weight changes for six of 10 residents reviewed for nutrition (Residents 2, 6, 43, 161, 173, and 174). Findings include: Review of facility policy, Weight Assessment and Intervention, dated March 2019, indicated that any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation, if the weight is verified, nursing will notify the Physician and Dietitian. Further review of the policy indicated that The Dietitian and /or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. Negative trends will be evaluated for whether or not the criteria for significant weight change has been met. Review of Resident 2's Weight Summary revealed Resident 2 weighed 217 pounds on October 5, 2024. Further review of Resident 2's Weight Summary revealed Resident 2 weighed 184 pounds on November 4, 2024. Review of Resident 2's dietitian progress notes dated November 6, 2024, revealed the dietitian requested Resident 2 be re-weighed to verify weight changes. Review of Resident 2's clinical record revealed Resident 2 was reweighed on November 8, 2024, four days after the original weight loss was noted. Further review of Resident 2's clinical record failed to reveal evidence that interventions were put into place to correct Resident 2's weight loss. Review of Resident 6's Weight Summary revealed on August 23, 2024, Resident 6 weighed 110.7 pounds. Further review of Resident 6's Weight Summary revealed on August 30, 2024, Resident 6 weighed 94.4 pounds which represented a 14.72 percent weight loss in one week. Review of Resident 6's dietitian progress notes on August 30, 2024, revealed a reweight was requested to confirm the 16-pound weight loss in 7 days. Review of Resident 6's Weight Summary revealed a reweight was not completed until September 3, 2024. Review of Resident 6's dietitian progress notes dated September 6, 2024, revealed Resident 6's weight loss was confirmed. Interventions were not put into placed until September 6, 2024, two weeks after Resident 6's original weight loss was noted. Interview with the Director of Nursing (DON) on November 15, 2024, at 11:00 a.m. confirmed the above-mentioned weight losses and the lack of timely reweights and interventions. Review of Resident 43's weight summary revealed a weight of 121.6 pounds on July 10, 2024. Resident's weight was 114.4 pounds on August 1. 2024 (loss of 7.2 pounds or 5.9%). Weight loss was confirmed on August 4, 2024, at 114.0 pounds. Review of the clinical record revealed that the weight loss was not addressed until August 25, 2024 (21 days after the confirmed weight loss). Interview with the DON on November 15, 2024, at 11:45 a.m. confirmed that Resident 43's significant weight loss was not addressed in a timely manner. A review of Resident 161's weights and vitals dated October 21, 2024, revealed a weight of 285 pounds and 252.5 pounds on November 11, 2024, a 32.5 (11.40 %) significant weight loss in three weeks. The clinical records review failed to reveal that Resident 161 was re-weighed to confirm a significant weight change. The clinical records review failed to reveal dietitian and physician were notified of Resident 161's significant weight change. Clinical records failed to reveal that significant weight loss was addressed. Review of Resident 173's clinical record revealed an admission weight on September 5, 2024, of 206.4 pounds. Resident's weight was recorded as 227.5 pounds on October 4, 2024, a gain of 21.1 pounds or 10.22%. Further review of the clinical record revealed that a re-weight was obtained on October 11, 2024, with a weight of 227.5 pounds. Resident's weight was recorded as 232.8 pounds on November 4, 2024. Further review of the clinical record revealed that there was no documentation of the Resident 173's physician being notified of the resident's weight gain. Interview with the DON on November 15, 2024, at 10:30 a.m. revealed that Resident 173's physician should have been notified of the weight gain and the Dietitian should have made recommendations to prevent further weight gain. A review of Resident 174's weights and vitals dated October 21, 2024, revealed a weight of 101.2 pounds and 94.2 pounds on October 31, 2024, a seven-pound (6.92%) significant weight loss in ten days. Clinical records review failed to reveal Resident 174 was reweighed to confirm the significant weight loss identified on October 31, 2024. A review of the Dietitian's notes dated November 3, 2024, revealed weight change, re weight requested. Clinical records review failed to reveal resident was reweighed despite the Dietitian's request for a reweight. Clinical records also failed to reveal that the physician was notified of the significant weight loss. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations, and staff interviews, it was determined that the facility failed to properly store frozen food in the main kitchen, and properly serve meals on one of five units observed (Rehab unit). Findings include: An observation of the walk-in freezer in the main kitchen was conducted on November 12, 2025, at 9:38 a.m., in the presence of the Assistant Food Service Director Employee E3. The observation revealed the following: Three boxes of frozen cookie dough in plastic bags, all were opened and unsealed; Unsealed frozen potatoes in a plastic bag; Unsealed frozen hamburger patties in a plastic bag; Unsealed frozen carrots in a plastic bag; and two plastic bags of chopped frozen chicken meat, both were opened and unsealed. An interview with Employee E3 conducted on November 12, 2024, confirmed that frozen food in a plastic bag should have been re-sealed after use. An observation of the meal pass was conducted on November 12, 2024, at 12:56 p.m., in the front hall Rehab Unit. The meal tray observation revealed peaches placed on a small bowl were uncovered. Apple juice poured on small Styrofoam cups were also uncovered. The observation revealed food cart was stationed at the end of the hallway, the staff took each resident's meal tray from the cart and then delivered it to residents' rooms with uncovered dessert and juice drinks. A meal observation was conducted on November 13, 2024, at 12:50 p.m., at the front hall Rehab Unit. The coleslaw and apple juice in the meal tray were uncovered. Observation revealed that while the food cart was stationed at the end of the hallway, staff took residents' meal trays from the cart and delivered them to their rooms with uncovered coleslaw and apple juice. An interview with Nursing Assistant, Employee E6 conducted on November 13, 2024, confirmed that the food served to the residents should have been covered. The above was discussed with the Nursing Home Administrator on November 15, 2024, at 11:00 a.m. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services

Based on observation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure assessments accurately reflected the resident's status for three of the 35 residents reviewed (Residents 2, 67, and 123). Findings include: Review of Resident 2's Quarterly Minimum Data Set (MDS - A standardized assessment tool that measures health status in long-term care residents) dated September 10, 2024 revealed Resident 2 had an indwelling urinary catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body). Review of Resident 2's clinical record failed to reveal evidence of an indwelling urinary catheter. Interview with Licensed Employee E7 on November 15, 2024 at 11:00 confirmed Resident 2 did not have a urinary catheter and also confirmed Resident 2's Quarterly MDS dated [DATE] did not accurately reflect Resident 2's status and was completed incorrectly. A review of Resident 67's Quarterly Minimum Data Set, dated dated dated [DATE], revealed resident was on Dialysis (A process of purifying the blood of a person whose kidneys are not working normally) while a resident (in the facility). A review of Resident 67's clinical records failed to reveal documentation that resident was on Dialysis. An interview with licensed nurse Employee E7 was conducted on November 14, 2024, at 1:48 p.m. Employee E7 confirmed Resident 67 was not on dialysis and that MDS was coded in error. A review of Resident 123's Quarterly MDS dated [DATE], revealed that the resident had other restraints. An observation conducted on November 12, 2024, at 12:30 p.m., revealed Resident 123 did not have any form of restraints. An interview with Employee E7 conducted on November 14, 2024, at 1:50 p.m., confirmed Resident 123 was not on any kind of restraints and that MDS was coded in error. The above was conveyed to the Director of Nursing on November 15, 2024, at 10:00 a.m. The facility failed to ensure residents' assessments were completed accurately. 28 Pa. Code 211.5(f) Clinical Records 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 ensure a baseline care plan for pressure ulcers was developed timely for one of seven residents reviewed (Resident 85). Findings include: A review of Resident 85's clinical records revealed resident was admitted to the facility on [DATE], with a right heel Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) measuring 3.8 x 3.2 x 0.2 cm. Clinical records review revealed Resident 85's pressure ulcer baseline care plan was not developed until July 2, 2024, a week after a resident was admitted and assessed with the presence of an unstageable pressure ulcer to the right heel. An interview conducted with the Director of Nursing (DON) on November 15, 2024, at 11:00 a.m., confirmed that Resident 85's baseline care plan for unstageable pressure ulcers was not developed until a week after it was identified. The facility failed to ensure Resident 85's unstageable pressure ulcer baseline care plan was developed timely. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to develop comprehensive care plans for a foley catheter and a wound vac for two of eighteen residents reviewed (Resident 78 and Resident 123) . Findings include: Review of Resident 78's diagnosis list revealed diagnoses including a history of prostate cancer and an enlarged prostate (gland in men encompasing the urethra when enlarged can restrict the flow of urine from the bladder out of the body). Review of Resident 78's clinical record revealed Resident 78 had a urinary catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body). Further review of Resident 78's clinical record failed to reveal evidence of a care plan for the urinary catheter. Interview with the Nursing Home Administrator on November 15, 2024 at 10:00 a.m. confirmed that Resident 78 did not have a comprehensive care plan for the foley catheter. A review of Resident 123's physician order dated October 3, 2024, revealed an order for a Wound vac (A device that uses negative pressure to help wounds heal) to the right AKA (above the knee amputation) stump. An observation conducted on December 12, 2024, at 10:58 a.m., revealed the presence of a wound vac machine attached to Resident 123's right AKA stump. Clinical records review failed to reveal that a comprehensive care plan was developed for the resident's wound vac treatment to the right AKA stump surgical wound. An interview with the Director of Nursing (DON) conducted on November 15, 2024, at 11:00 a.m., confirmed that a comprehensive care plan for Resident 123's wound vac treatment was not developed until November 14, 2024, after the surveyor had asked for it. The facility failed to ensure Resident 123's wound vac treatment for the right AKA stump surgical wound care plan was developed timely. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.11(c)(d) Resident care plans

Based on a review of the facility's policy, observation, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of a change in condition and follow a medication order for two of 35 residents reviewed (Residents 67 and 345). Findings include: A review of the facility's policy titled Weight Assessment and Intervention, dated March 2019, revealed any weight change of five pounds or more since the last weight assessment will be retaken for confirmation. Nurses will notify the Physician and dietitian. A review of Resident 67's diagnosis list includes Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain) and Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). An observation conducted on November 12, 2024, at 1:50 p.m., revealed Resident 67 was lying in bed, the left arm was observed swollen from the hands to the upper arm. An interview conducted with Resident 67 revealed left arm had been swollen but was unsure when it started. The resident denied pain. A review of weights and vitals revealed a weight of 165.8 pounds on October 6, 2024, and 184.4 pounds on November 6, 2024, an 18.5 pounds (11.22%) significant weight gain in a month period. A review of the dietitian's progress notes dated November 7, 2024, at 6:39 p.m., revealed + 5 changes over 30 days, reweight requested. Clinical records review failed to reveal that Resident 67 was reweighed despite the dietitian's request for a reweight to confirm the significant weight change. Clinical records also failed to reveal that the physician was notified of the significant weight change. A review of the Dietitian's progress notes dated November 13, 2024, at 7:15 p.m., revealed the weight was obtained, 184 pounds showing significant weight gain. Will notify nursing of the significant weight gain. A review of the nursing progress notes dated November 14, 2024, at 11:45 a.m., revealed Nurse Practitioner (NP) was aware and gave new verbal orders: Lymphedema (A swelling most often in an arm or leg, caused by a lymphatic system blockage) clinic appointment; Ultrasound of the left arm due to increased edema; Chest x-ray 2 views. An interview conducted with the Director of Nursing on November 15, 2024, at 10:20 a.m., revealed that the resident's significant weight change should have been rechecked within 48 hours for confirmation. The DON also reported that nursing should have notified the physician of the significant weight change identified on November 6, 2024. Clinical records review revealed Resident 67's change in condition was not addressed until November 14, 2024, eight days after a significant weight change was identified on November 6, 2024. A review of Resident 345's diagnosis list includes Osteomyelitis (Bone infection) of the left foot. A review of Resident 345's physician order dated November 2, 2024, revealed an order for Meropenem Intravenous Solution (Antibiotic) 1 gram intravenously (Administer into the vein) every 12 hours for Bacteremia (Infections of blood caused by blood-borne pathogens) until November 29, 2024. Start date: November 2, 2024, 8:00 p.m. A review of November 2024, Medication Administration Record (MAR) revealed Meropenem medication was not administered on the following dates: November 2, 2024, at 8:00 p.m., November 3, 2024, at 8:00 a.m., and November 3, 2024, at 8:00 p.m. A review of the nursing progress notes dated November 2, 2024, at 9:02 p.m., revealed Meropenem medication was not available yet. A review of the pharmacy documentation, and emergency medication list, revealed Meropenem medication was available in the facility. An interview with the Director of Nursing (DON) conducted on November 15, 2024, confirmed that Meropenem medication was available in the facility but the agency nurse working at that time reported not seeing it since the medication was not premixed (In-stock medication comes in a vial that needed to be mixed with an IV solution). Clinical records review revealed physician was not notified of the missed Meropenem medication until November 4, 2024. On November 7, 2024, at 8:00 p.m., Meropenem medication was not administered. The nursing progress notes dated November 7, 2024, at 8:45 p.m., revealed that medication was unavailable, awaiting pharmacy delivery. An interview with the DON conducted on November 15, 2024, confirmed Meropenem was available as an In-stock facility medication. The DON confirmed physician should have been notified of the missed medications timely. The facility failed to ensure Resident 67's change in condition was timely addressed and Resident 345's medication order was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review and staff and resident interview it was determined the facility failed to obtain informed consent prior to laboratory studies for five of 40 residents reviewed (Residents 6, 79, 90, 100, and 107). Findings include: Review of Resident 6's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident is severely cognitively impaired. Review of Resident 6's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing , gave verbal consent to be screened for pharmacogenomic testing through gene ID lab for medication management with a date written of September 20, 2023 and a signature. Review of Resident 79's Significant Change MDS dated [DATE], revealed a BIMS of 15, indicating the resident has no cognitive impairment. Interview with Resident 79 on December 19, 2023, at approximately 12:40 p.m. revealed the resident recalled getting a cheek swab for laboratory studies in September 2023, but did not understand why the test was done or what the results of the test were. Review of Resident 79's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing , gave verbal consent to be screened for pharmacogenomic testing through gene ID lab for medication management with a date written of September 20, 2023 and a signature. Review of Resident 90's Quarterly MDS dated [DATE], revealed a BIMS of 15, indicating the resident had no cognitive impairment at the time of the assessment. Review of Resident 90's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing, obtained verbal consent from next of kin/responsible party for patient to be screened for pharmacogenomic testing through gene ID lab for medication management, with a date written of September 20, 2023 and a signature. Review of resident 100's admission MDS dated [DATE] revealed a BIMS of 8 indicating the resident is moderately cognitively impaired. Review of Resident 100's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing, gave verbal consent to be screened for pharmacogenomic testing through gene ID lab for medication management with a date written of September 20, 2023 and a signature. Review of Resident 107's Significant Change MDS, dated [DATE] revealed a BIMS of 5 indicating the resident is severely cognitively impaired. Review of Resident 107's clinical record revealed an informed consent for pharmacogenomics testing. There was a stamp by the signature line stating patient incapable of signing, gave verbal consent to be screened for pharmacogenomic testing through gene ID lab for medication management with a date written of September 20, 2023 and a signature. Interview with the Nursing Home administrator and the Director of Nursing on December 21, 2023 at 11:45 a.m. confirmed Residents 6, 100, and 107 were unable to give verbal consent and the designated responsible parties should have been contacted and given consent for the testing and provided no explanation as to why Residents 79 and 90 were not given informed consent. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on review of facility's policy, clinical record review and staff interview it was determined the facility failed to assess, monitor and treat pressure ulcers for two of eight residents reviewed. (Residents 82 and 106) Findings Include: Review of the facility's policy titled Skin and Wound Management System, undated, revealed Residents identified with skin impairments will have appropriate interventions, treatment, and services implemented to promote healing and impede infection. Wound location, characteristics, and a physician's order for treatment are documented in the medical record. Review of Resident 82's weekly skin review dated August 21, 2023 revealed the resident had a wound on the right heel that was pending treatment. Further review of the clinical record revealed there was no other documentation of this wound or notification to the physician of this new wound. Review of Resident 82's progress notes revealed a skin and wound note by the wound CRNP, dated September 7, 2023 at 8:53 a.m. which documents two wounds to Resident 82's right foot. Right lateral (outside) mid foot pressure ulcer, 1.8cm (centimeters) x 4.4cm x 0.3 cm and a right heel pressure ulcer 1.6cm x 1.3cm x 0.2 cm. Further review of the clinical record revealed these areas were not documented and assessed or treated until found by the wound CRNP on September 7, 2023. Interview with the Director of Nursing on December 20, 2023 at 1:30 p.m. confirmed the documentation of Resident 82's wound on the weekly skin reviews were inaccurate and incomplete and there should have been documentation and treatment of a wound prior to being accessed by the wound CRNP on September 9, 2023. Clinical records review revealed Resident 106 was admitted to the facility on [DATE], with diagnosis of Respiratory Failure. Review of Resident 106's skin admission assessment revealed resident had a wound on the coccyx (tailbone). Clinical records review revealed that the coccyx wound identified upon admission on October 10, 2023, was not assessed. Clinical records review failed to reveal that a wound treatment for Resident 106 ' s coccyx was initiated. Review of a wound consult assessment dated [DATE], revealed an unstageable wound (Obscured full-thickness skin and tissue loss) to sacrum/coccyx measuring 3.2 x 0.8 x 0.2 cm., with 100% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Review of the physician order dated October 12, 2023, revealed a wound treatment order to cleanse the coccyx wound with normal saline, apply Medi honey (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), apply border gauze daily every evening shift. Review of the October 2023, Treatment Administration Record (TAR) revealed that the wound treatment ordered on October 12, 2023, was not done until October 15, 2023, three days after the physician's order was made. Interview with the Director of Nursing (DON) on December 21, 2023, at 11:00 a.m., was conducted. The DON confirmed that Resident 106 ' s identified coccyx/sacrum wound was not assessed upon admission on October 10, 2023. The DON reported that the wound treatment order made by the physician on October 12, 2023, was improperly transcribed to the Electronic Medical Records until corrected on October 15, 2023. The facility failed to ensure Resident 106's identified wound was assessed and treated timely. 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 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy, observation, interview, and clinical record review, it was determined that the facility failed to ensure residents were free of accident hazards for three of 35 residents reviewed (Residents 12, 77, and 98) and failed to ensure residents had appropriate interventions in place to prevent falls for one of 35 residents reviewed (Resident 90). Findings include: Review of facility policy, Medication Administration - General Guidelines, undated, revealed that the resident is always observed after administration to ensure that the dose was completely ingested. Additionally, residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of Resident 12's nursing progress note of May 14, 2023, revealed that When this nurse went in to give morning meds[medications] she found cup full of pills in garbage at residents bedside. When resident was asked when were they from she responded from last night. I reinforced with resident the need to take medications that Physician has prescribed to her. Review of Resident 12's psychiatry progress note of December 8, 2023, revealed Pt [patient] is agitated about how many pills she takes as she is looking at a cup of pills they brought her-says it used to be 10 pills and now its 20 (of note it looks more like 10 or less). Review of Resident 12's clinical record revealed no physician's order or assessment for self administration of medications. Observation on December 18, 2023, at 1:50 p.m. revealed licensed staff, E6, bring medication to Resident 77 and leave room. Resident 77 then observed sitting on the bed with pill cup containing three pills on seat of rolling walker. Resident 77 indicated that he/she had to take medicine before going to the facility store. Review of Resident 77's clinical record revealed no physician's order or assessment for self administration of medications. Observation on December 19, 2023, at 9:01 a.m during interview with Resident 98, revealed licensed staff, E7, placing pill cup containing multiple pills and Spiriva inhaler (relaxes muscles in the airways and increases air flow to the lungs) on the resident's overbed table. Interview with the resident revealed that staff do not usually leave medications. Resident then proceeded to use inhaler. Review of Resident 98's clinical record revealed no physician's order or assessment for self administration of medications, except for voltaren gel (topical medication for joint pain). Interview with the Nursing Home Administrator (NHA) on December 21, 2023, at 10:30 a.m. confirmed that the above residents do not have orders or assessments to self administer medications. The NHA also confirmed that medications should not be left at the bedside. Review of Resident 90's clinical record revealed a nursing progress note on November 29, 2023, which stated that the resident was found on the floor next to the bed at approximately 3:30 a.m. Further review of Resident 90's progress notes revealed an interdisciplinary team note on November 29, 2023, which stated: reviewed resident's fall from this AM at 0330. Resident tends to sleep close to the edge of the bed. [Social services] to reach out to [Hospice company] to request a full scoop mattress for resident's bed. Further review of Resident 90's progress notes revealed a nurse's note on December 14, 2023, which stated that the resident was found on the floor next to the bed and sustained a small skin tear to the left elbow. Observation of Resident 90 on December 19, 2023, at 10:30 a.m. revealed the resident was lying in bed on a regular mattress. Interview with the Nursing Home Administrator on December 20, 2023, at approximately 2:00 p.m. revealed the resident would be receiving a scoop mattress the following day. Interview with the Social Services Director, Employee E3, on December 21, 2023, at 10:20 a.m. revealed the employee did not contact Hospice regarding getting Resident 90 getting a scoop mattress until the day before on December 20, 2023. The above findings were discussed with the Nursing Home Administrator and Director of Nursing on December 21, 2023, at approximately 10:50 a.m. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the provider of a resident change in condition in a timely manner for two of 35 residents reviewed (Residents 28 and 45). Findings include: Review of Resident 28's clinical record revealed a diagnosis of Type 1 Diabetes (insulin dependent). Review of Resident 28's November 2023 physician's orders revealed an order dated April 3, 2023, for Glucagon HCl Injection Solution Reconstituted 1 MG subcutaneously every 15 minutes as needed for as need it related to blood sugar bellow 70 and patient unresponsive turn on side, administer injection. Check BS every 15 minutes until BS reaches 70, offer a protein snack if PT responsive, call DR if nonresponsive. Review of the clinical record revealed a nursing note dated November 26, 2023, at 6:00 p.m. Resident 28 was found not responding and snoring heavily. Blood Sugar 42. IM Glucagon given. After 15 minutes, BS 62 but resident continues to not respond. Second dose of IM Glucagon given. After 15 minutes, BS 94, Resident w/ opened eyes but continues to sleep. Will continue to check BS & monitor level of consciousness. There is no further documentation that the physician was called until 8:00p.m. when staff gave a third dose of Glucagon due to BS of 43. Resident 28's blood sugar then was 84. When staff returned the residents blood sugar was 503. Resident remained lethargic with snoring respirations. On call provider called. Interview with the Nursing Home Administrator on December 21, 2023, at 11:00 a.m. revealed that there was no further documentation of the physician being called until 8:00 p.m. Review of facility policy Weight Assessment and Intervention, last revised March 2019, revealed: Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If weight is verified, nursing will notify the Physician and Dietitian. Review of Resident 45's clinical record revealed diagnoses including liver cancer with metastasis to the lungs (cancer that has spread to the lungs) and malignant ascites (condition where fluid with cancer cells accumulates in the abdomen). Review of Resident 45's weights revealed on November 10, 2023, the resident was recorded as weighing 127 pounds (lbs.) On December 5, 2023, the resident was recorded as weighing 147.6 lbs., a 20.6 lb. weight gain in less than a month. Review of Resident 45's progress notes revealed the dietitian was made aware of the resident's weight gain and requested a reweight. Further review of Resident 45's weights revealed the resident was documented as weighing 147.6 lbs. on December 6, 2023, and December 10, 2023. Further review of Resident 45's progress notes failed to reveal evidence that the physician or provider were notified of Resident 45's weight gain. Review of Resident 45's Hospice notes revealed a nurse s note on December 12, 2023, which stated that the resident had increased dyspnea (difficulty breathing), moist nonproductive cough, wheezing, pain all over, and edema (swelling) up to the resident s hips and thighs. Further review of Resident 45's progress notes revealed a nurse s note on December 12, 2023, which stated: Hospice recommendation to begin Lasix [(water pill used to reduce fluid build up in body)] 40mg Po QD x 3 days [(by mouth daily for three days)] approved by [provider.] The delay in notifying the provider and addressing Resident 45's weight gain was discussed with the Nursing Home Administrator and Director of Nursing on December 21, 2023, at approximately 10:50 a.m. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy, interviews with residents, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agency for one of 35 residents reviewed (Resident 91). Findings include: Review of facility policy, Abuse Policy, revised January 2020 revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee. Interview with Resident 91 on December 19, 2023, at 9:03 a.m. revealed that she had reported $300 dollars missing approximately six months ago. Review of facility concern form completed June 9, 2023, revealed that Resident 91 had reported missing money and an investigation had been completed. Interview with the Nursing Home Administrator on December 21, 2023, at 12:30 p.m. confirmed that the allegation of misappropriation had not been reported to the appropriate state agency. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa Code 211.10(a)(d) Resident Care Policies

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 28 residents reviewed (Resident 73). Findings include: Review of Resident 73's admission orders of September 12, 2023, included an order for hemodialysis (process to filter wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work) every Tuesday, Thursday, and Saturday. Further review of the clinical record revealed no care plan regarding dialysis. Interview with the Nursing Home Administrator on December 21, 2023, at 10:30 a.m. confirmed that there was no care plan in place to address the hemodialysis. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/3/23 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/3/23

Based on clinical record review, facility policy and facility documentation review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect when they failed to provide treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy including life sustaining medications for 18 of 36 residents on the secure dementia unit (Rosemont). The failure resulted in 133 missed medication doses including insulin, antipsychotic, and heart medications. This placed the residents on the Rosemont unit in an Immediate Jeopardy situation. (Residents R1, R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19). Findings Include: Review of facility policy titled Abuse Policy with a revision date of January 2020 revealed under Definitions: Neglect is defined as 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident R1's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] =5 units; 201-349=8 units; subcutaneously before meals for DM 2 (Diabetes Mellitus Type 2). Review of Resident R1's clinical record including June 2022 MAR (Medication Administration Record) revealed that on June 5, 2022, the resident did not receive 9 am dose for [MEDICATION(S)]; 9 am and 1300 (1 p.m.) dose of [MEDICATION(S)]; and 7:30 a.m. and 11:30 a.m. dose of [MEDICATION(S)] insulin. Review of Resident R1's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:17/2:17 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of R2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R2's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R2's June 2022 MARs revealed that on June 5, 2022; [MEDICATION(S)] Tablet 1 GM (used to prevent urinary tract infections) dose was not administered at 9 a.m. Further review of Resident R2's June 2022 MARs revealed on June 5, 2022; [MEDICATION(S)] HCI 50 mg dosage at 9 a.m. was not administered. Review of Resident R2's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:20/2:20 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of Resident R3's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's clinical record revealed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] =0 (units); 151-200=4; 201-250=6; 251-300=8; 301-350=10; 351-400=12 call if blood sugar greater than 400. Subcutaneously three times a day for Type I Diabetes Mellitus. Additional review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's clinical record including June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications not administered were [MEDICATION(S)] 2 doses (8 a.m. sliding scale measurement and 4 units); [MEDICATION(S)] (8 a.m. dose); [MEDICATION(S)] (8 a.m.); and [MEDICATION(S)] (8 a.m.). Review of Resident R3's clinical record failed to reveal a documentation regarding reason the medications were not administered on June 5, 2022. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:24/2:24 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of Resident R4's clinical record revealed that on June 5, 2022, resident was not administered [MEDICATION(S)] 500 mg (medication used to treat Diabetes) and [MEDICATION(S)] 125 mg (used to treat either psychological disorder or [CONDITION(S)] disorder). Further review of Resident's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's clinical revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's clinical record including June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R6's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Review of Resident R7's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R7's clinical record including June 2022 MARs revealed the resident was not administered [MEDICATION(S)] (2.5 mg); [MEDICATION(S)] (80 mg) and Hydroxycholoroquine (used to treat [CONDITION(S)]). Further review of June 2022 MARs revealed the resident was not administered additional 10 doses of prescribed medications. Review of Resident R7's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Review of facility documentation titled Medication Administration Count Summary Report revealed total number of missed medication administration doses for each resident of Rosemont (dementia unit). Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R8 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R9 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R10 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R11 was not administered five doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R12 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R13 was not administered 14 doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R14 was not administered four doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R15 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R16 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R17 was not administered six doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R18 was not administered 10 doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R19 was not administered six doses of medications on June 5, 2022. Further review of the Residents' clinical records failed to reveal nursing notes dated June 5, 2022, indicating reason for the missed medications. Interview on June 6, 2022, at approximately 5:00 pm with the evening receptionist revealed, the nurse supervisor was detained due to managing a medication cart. The employee stated that the facility has been significantly short staffed for several weeks including this date (June 6, 2022); which was the reason for the nursing supervisor to coordinate multiple tasks including managing a nursing unit and administering medications on the dementia unit. Interview with RN Supervisor, Employee E3 on June 6, 2022, at approximately 5:20 p.m. revealed she was managing a medication cart on the Rosemont unit due to staff shortage. Interview conducted June 6, 2022, at approximately 6:52 p.m. with Nursing Home Administrator revealed that on June 6, 2022, in the morning the administration learned that 18 residents on the dementia unit (Rosemont) were not given their morning medications, totaling 133 doses on June 5, 2022. Nursing Home Administrator indicated during interview that during the investigative process, the licensed staff was interviewed who neglected to administer the 133 doses to 18 residents. Licensed staff did not provide a written statement only verbal statement indicating she refused to place nursing license in jeopardy due to staffing situation on the dementia unit June 5, 2022. Licensed employee was terminated due to neglectful actions, effective June 6, 2022. Interview conducted on June 7, 2022, at approximately 12:30 p.m. with licensed Employee E9 revealed that the facility has been significantly short staffed recently. I have been the only nurse on the floor before. When questioned regarding this statement, Employee E9 responded that he/she prioritizes the medications to administer but did agree that medications may have been late or missed entirely. Review of facility nursing schedules for June 5, 2022, revealed that there was only one licensed nurse scheduled to work on the Rosemont unit. The resident census for the Rosemont unit was 36 for a ratio of 1 nurse to 36 residents on June 5, 2022. The nurse failed to notify administration of staffing issue on the dementia unit including alerting the Nursing Home Administrator and Director of Nursing who were in the building during the time of the medication errors. An Immediate Jeopardy situation was identified on June 7, 2022, at 3:26 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, the Director of Nursing, and the Executive Director at 3:30 p.m. on June 7, 2022, regarding the facility's failure to ensure the residents were free from neglect when licensed staff failed to provide treatment and care of administering life sustaining medications. The facility submitted and completed an immediate action plan which included maintaining sufficient staffing by offering incentives, additional shifts, utilizing agency to provide nursing related services to ensure resident safety and non- licensed staff are appropriately supervised by a licensed nurse by holding staffing huddles each shift seven days a week. The action plan included assessments of all 18 residents for signs and symptoms of adverse reactions to missed medications. Attending physicians were notified of the missed dosages. The facility conducting a full house audit of all residents' MAR/TAR (Medication Administration Record/Treatment Administration Record). The NHA, DON, and scheduler were educated on June 6, 2022, on sufficient staff levels to ensure nursing services are provided timely. Licensed staff were educated on timely medication administration and procedures for sufficient staff. New Staff will be educated prior to the start of shift. The Nursing Home Administrator, Director of Nursing, or designee will do audits every shift for two weeks and then daily for four weeks to ensure that residents medications are administered. The audits will be reviewed by QAPI committee for further action plan. The action plan was accepted on June 7, 2022, at 6:22 p.m. On June 8, 2022, a review of audits, documentation of completed employee education, and interviews with 7 licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on June 8, 2022, at 2:24 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy Review conducted of the clinical records affected by the neglectful act of not administering medications June 5, 2022; revealed medications not administered included but not limited to [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and skin treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of Licensee Previously cited on 1/28/22 and 10/8/20 28 Pa Code 201.18(b)(1) Management Previously cited on 1/28/22 28 Pa Code 211.12(c) Nursing Services 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services Previously cited on 1/28/22 and 4/8/21

Based on clinical record review, facility policy and facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate and sufficient staff to ensure residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and comprehensive person-centered policy including life sustaining medications for 18 residents on the secure dementia unit (Rosemont). The staffing failure resulted in 133 missed medication doses including insulin, antipsychotic, and heart medications but had the potential to adversely affect all 36 residents who require supervision. The failure to adequately staff the dementia unit placed the residents on the Rosemont unit in an Immediate Jeopardy situation. Findings Include: Review of Resident R1's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] =5 units; 201-349=8 units; subcutaneously before meals for DM 2 (Diabetes Mellitus Type 2). Review of Resident R1's clinical record including June 2022 MAR (Medication Administration Record) revealed that on June 5, 2022, the resident did not receive 9 am dose for [MEDICATION(S)]; 9 am and 1300 (1 p.m.) dose of [MEDICATION(S)]; and 7:30 a.m. and 11:30 a.m. dose of [MEDICATION(S)] insulin. Review of Resident R1's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:17/2:17 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of R2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R2's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R2's June 2022 MARs revealed that on June 5, 2022; [MEDICATION(S)] Tablet 1 GM (used to prevent urinary tract infections) dose was not administered at 9 a.m. Further review of Resident R2's June 2022 MARs revealed on June 5, 2022; [MEDICATION(S)] HCI 50 mg dosage at 9 a.m. was not administered. Review of Resident R2's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:20/2:20 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of Resident R3's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's clinical record revealed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] =0 (units); 151-200=4; 201-250=6; 251-300=8; 301-350=10; 351-400=12 call if blood sugar greater than 400. Subcutaneously three times a day for Type I Diabetes Mellitus. Additional review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's clinical record including June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications not administered were [MEDICATION(S)] 2 doses (8 a.m. sliding scale measurement and 4 units); [MEDICATION(S)] (8 a.m. dose); [MEDICATION(S)] (8 a.m.); and [MEDICATION(S)] (8 a.m.). Review of Resident R3's clinical record failed to reveal a documentation regarding reason the medications were not administered on June 5, 2022. Further review of the clinical record revealed an interdisciplinary note dated June 6, 2022 (14:24/2:24 p.m.) Physician notified of medication error on 6/5/2022. Nursing assessment completed, no findings. Review of Resident R4's clinical record revealed that on June 5, 2022, resident was not administered [MEDICATION(S)] 500 mg (medication used to treat Diabetes) and [MEDICATION(S)] 125 mg (used to treat either psychological disorder or [CONDITION(S)] disorder). Further review of Resident's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's clinical revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's clinical record including June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of Resident R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R6's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Review of Resident R7's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R7's clinical record including June 2022 MARs revealed the resident was not administered [MEDICATION(S)] (2.5 mg); [MEDICATION(S)] (80 mg) and Hydroxycholoroquine (used to treat [CONDITION(S)]). Further review of June 2022 MARs revealed the resident was not administered additional 10 doses of prescribed medications. Review of Resident R7's clinical record failed to reveal a nursing note dated June 5, 2022, indicating reason for the missed medications. Review of facility documentation titled Medication Administration Count Summary Report revealed total number of missed medication administration doses for each resident of Rosemont (dementia unit). Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R8 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R9 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R10 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R11 was not administered five doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R12 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R13 was not administered 14 doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R14 was not administered four doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R15 was not administered seven doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R16 was not administered three doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R17 was not administered six doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R18 was not administered 10 doses of medications on June 5, 2022. Review of facility documentation noted on the Medication Administration Count Summary Report revealed that Resident R19 was not administered six doses of medications on June 5, 2022. Further review of the residents' clinical records failed to reveal nursing notes dated June 5, 2022, indicating reason for the missed medications. Review of clinical records revealed medications not administered on June 5, 2022, during the dayshift included [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The medications not administered are used to treat Diabetes, heart conditions, or [CONDITION(S)]. The failure to provide sufficient staff to oversee the administration of medications as well as monitor and supervisor residents on the dementia unit (Rosemont) potentially placing their safety and wellbeing in jeopardy. Interview on June 6, 2022, at approximately 5:00 pm with the evening receptionist revealed, the nurse supervisor was detained due to managing a medication cart. The employee indicated the facility has been significantly short staffed for several weeks, which was the reason the nursing supervisor was struggling to coordinate multiple tasks including managing a nursing unit and administering medications on the dementia unit (Rosemont). Interview with RN Supervisor, Employee E3 on June 6, 2022, at approximately 5:20 p.m. revealed she was managing a medication cart on the Rosemont unit due to staff shortage. Employee E3 indicated the facility has been experiencing staffing shortages. Interview conducted June 6, 2022, at approximately 6:52 p.m. with the Nursing Home Administrator revealed that on June 6, 2022, in the morning the administration learned that 18 residents on the dementia unit (Rosemont) were not provided their morning medications, totaling 133 doses on June 5, 2022. Attending physicians and responsible parties were notified June 6, 2022. Each resident had an assessment per recommendation and facility procedure. The Nursing Home Administrator indicated that the licensed employee who failed to administer 133 doses of medication to 18 residents was terminated June 6, 2022. The Nursing Home Administrator stated that both herself/himself and the Director of Nursing worked on June 5, 2022 as housekeeping staff due to staffing shortage. Interview conducted on June 7, 2022 at approximately 12:30 p.m. with licensed Employee E9 revealed that the facility has been significantly short staffed recently. I have been the only nurse on the floor before. When questioned regarding this statement, Employee E9 responded that he/she prioritizes the medications to administer but did confirm, medications may have been late or missed entirely when the unit is short staffed. Review of facility nursing schedules for June 5, 2022 revealed that there was only one licensed nurse scheduled to work on the Rosemont unit. The resident census for the Rosemont unit was 36 which is 1 licensed staff to monitor, supervise, and care for 36 residents. An Immediate Jeopardy situation was identified on June 7, 2022, at 3:26 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, the Director of Nursing, and the Executive Director at 3:30 p.m. on June 7, 2022, regarding the facility's failure to ensure the residents were free from neglect when licensed staff failed to provide treatment and care of administering life sustaining medications. The facility submitted and completed an immediate action plan which included maintaining sufficient staffing by offering incentives, additional shifts, utilitizing agency to provide nursing related services to ensure resident safety and non licensed staff are appropriately supervised by a licensed nurse by holding staffing huddles each shift seven days a week. The action plan included assessments of all 18 residents for signs and symptoms of adverse reactions to missed medications. Attending physicians were notified of the missed dosages. The facility conducted a full house audit of all residents' MAR/TAR (Medication Administration Record/Treatment Administration Record). The NHA, DON, and facility scheduler were educated on June 6, 2022 on sufficient staff levels to ensure nursing services are provided timely. Licensed staff were educated on timely medication administration and procedures for sufficient staff. New Staff will be educated prior to the start of shift. The Nursing Home Administrator, Director of Nursing, or designee will do audits every shift for two weeks and then daily for four weeks to ensure that residents medications are administered. The audits will be reviewed by QAPI committee for further action plan. The action plan was accepted on June 7, 2022, at 6:22 p.m. On June 8, 2022, a review of audits, documentation of completed employee education, and interviews with 9 licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on June 8, 2022, at 2:24 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 28 Pa Code 211.12(a)(c)(d)(1)(3)(4)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to provide appropriate interventions following the administration of oxygen with the use of a nasal cannula, resulting in harm with the development a pressure ulcer for one of 6 residents reviewed (Resident R81). Findings include: Review of facility policy, Oxygen Administration, revised in January 2021, stated, securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Review of facility policy, Pressure Ulcer/Injury Treatment, revised in January 2021, revealed interventions and care strategies for prevention of pressure ulcers includes, but not limited to determine cause of pressure and relieve and implement pressure-reliving devices in accordance with residents assessed needs. Review of clinical documentation for Resident R81 revealed a Braden scale (an evaluation of a person's risks for developing a pressure score) completed on February 17, 2021, with a score of 13, indicating a moderate risk of developing a pressure ulcer. Further review of clinical records for Resident R81 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils) for comfort every shift. Review of clinical documentation for Resident R81 revealed a nursing note written by a Employee E8, the Wound Nurse, Registered Nurse (RN) on March 26, 2021, at 8:05 a.m. related to an area on left cheekbone that stated, The area appears to be in the shape of oxygen tubing and most likely device related pressure injury, Stage 2, (2.5cm x 4.5cm x 0.1cm). Further review of clinical documentation failed to reveal that interventions were in place prior to the detection of the pressure ulcer on Resident R81 left cheek on March 26, 2021. Review of clinical documentation revealed a care plan initiated March 29, 2021, for foam padding to oxygen tubing while in use. Review of a Wound Nurse note dated April 6, 2021, at 10:50 a.m. revealed, F/U (follow up) today for resident with a pressure injury to his left cheekbone from the oxygen tubing. Area today is completely epithelialized (healed). Padding to tubing to prevent re-occurrence. Observation of Resident R81 on April 5, 2021, at 11:35 a.m. and April 6, 2021, at 9:05 a.m. failed to reveal foam padding in place on the oxygen tubing and observations on 4/5, 4/6 and 4/7/2021, revealed no evidence of an open wound on the resident's cheek bone. Interview with Employee E6, Director of Staff Development (RN), on April 7, 2021, at 1:45 p.m. confirmed foam padding was not used on the oxygen tubing for Resident R81 prior to April 7, 2021. Employee E6 stated that the foam padding is not used on all residents receiving oxygen. Interview of Licensed Employee E7 on April 8, 2021, at 9:45 a.m. revealed staff are encouraged to put foam padding on all residents receiving oxygen. Interview with Employee E5, Registered Nurse, on April 8, 2021, at 10:15 a.m. Employee E5 stated we can use the Braden scale to assess the need for padding, but are supposed to put them on any resident receiving oxygen if possible. Confirmed above with the Nursing Home Administrator on April 8, 2021, at 12:05 p.m. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(3) Nursing Services 28 Pa. Code 211.12(d)(5) Nursing Services

Based on clinical record review, interviews with staff, and review of documentation provided by the facility, it was determined that the facility failed to ensure adequate supervision was provided to prevent accidents, for one of three residents reviewed (Resident R3). This failure resulted in a fall out of a bed that was in a high position and caused harm from a large, 6-7 inch laceration to the back of the left side of the head. Resident R3 was transferred to the hospital and received seven staples to close the laceration. Findings include: Review of Resident R3's clinical record revealed diagnoses that included dementia, (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and lack of coordination. Review of the March 3, 2020, Quarterly Minimum Data Set (an assessment tool for resident care) revealed that Resident R3 required extensive assist of two people for bed mobility. Resident R3's care plan, dated December 10, 2019, also stated that all care during bed mobility is to be provided by two staff. Review of Resident R3's clinical record revealed a nursing note stating that on June 2, 2020, at 6:05 a.m. Registered Nurse (RN) supervisor was called to the room and found the resident on the floor. It was reported to the RN supervisor Employee E4, that while the Nurse Aide (NA) was performing morning care, the resident rolled out of bed onto the floor. With a large amount of blood surrounding the head. Resident R3 sustained a large 6-7 inch laceration to the back of head, left side. Resident R3 was sent to the hospital and received seven staples. Review of facility documentation revealed that on June 2, 2020, a staff member was providing care alone, and the resident was care planned for two caregivers to provide care. Further documentation revealed that the staff member was disciplined for providing care alone. An interview conducted with the Nurse Aide, Employee E3, on June 23, 2020, at 12:40 p.m., revealed that after Resident R3's bed bath, Employee E3 was changing the bed sheets. The resident was rolled onto her side and as Employee E3 adjusted the sheets, the resident continued to roll forward and rolled off of the bed. Employee E3 was asked if it was known that the resident required 2 people for bed mobility/care, and it was stated not at that time. Upon further interview, Employee E3 revealed to the surveyor that the information for the resident's care was kept on a paper behind the door and the employee knew it was there, but it was not reviewed (by the employee) before care was given. During an interview with the Director of Nursing on June 23, 2020, at 1:15 p.m., the Director of Nursing confirmed that Resident R3 did not receive adequate supervision to prevent a fall, which resulted in harm to the resident from a head laceration that required 7 staples. 28 Pa. Code 201.18(a)(b)(3) Management 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(a)(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on review of facility documentation, clinical record review, staff interview and the coroner's report it was determined that the facility failed to ensure that residents were free from neglect as indicated by the improper transfer of a resident resulting in a fall and failure to report the fall to the nurse, for one out of three residents reviewed, resulting in harm when the resident sustained [REDACTED]. Findings include: Review of facility documentation on education provided for new hires during orientation revealed that all staff must call for the nurse immediately if a resident has fallen or is found on the floor. Review of Resident R1's clinical record revealed the resident was admitted on (MONTH) 18, (YEAR), with the [DIAGNOSES REDACTED]. Review of Resident R1's clinical record revealed a Quarterly MDS (Minimum Data Set- A resident assessment for care) dated (MONTH) 28, 2019, which indicated in Section G-Transfer Status, that the resident was a 3 (extensive assist) and a 3 (two persons physical assist). Review of Resident R1's care plan identified the resident had a transfer status of 2 people. Review of Resident R1's clinical records revealed a nurse's note dated (MONTH) 1, 2019, at 8:00 a.m. indicating that the resident was found by Employee E2 (a nurse aide), shortly after change of shift (shortly after 7:00 a.m.). The resident was found with a laceration to the forehead. The resident was assessed by the nurse and the resident was found undressed from the waist up, laying on her back, in her bed with approximately a 1 mm puncture wound above the right eyebrow and an approximately 1cm skin tear below the puncture wound. Pressure was applied, the wounds were cleansed with NSS (Normal Saline Solution), and a pressure dressing was applied. Review of a Nurse Practitioner's note for date of service (MONTH) 1, 2019 with no time given, revealed upon examination the resident was resting in bed. The resident was unable to verbalize what happened or if she was in pain. She did appear to have some facial grimacing. Wound on right side of forehead appeared to be approximately the size of a pencil point with some mild ecchymosis (bruising) surrounding the wound. No active bleeding noted on examination. Nursing reports the resident was found in bed bleeding from the forehead with no known cause of injury. Review of the facility documentation revealed interviews by the Nursing Home Administrator with Employee E2 (a nurse aide) on (MONTH) 1, 2019. Employee E2 gave a written statement that I walked in to the resident's room to get her ready for breakfast and saw blood on her head and called the nurse. Review of a written statement from a Registered Nurse stated that when called to the room, Resident R1 was naked from the waist up, laying on her back, wearing shorts and socks. There was a large hematoma on her forehead with blood draining down the back of her scalp onto the mattress. Further review of the clinical record revealed that at around 4:00 p.m. on (MONTH) 1, 2019, Resident R1 was found unresponsive and the Unit Manager was notified and pronounced her deceased at this time. Further review of facility documentation revealed that a second written statement was obtained from Employee E2, dated (MONTH) 6, 2019, 5 days after the incident, in which Employee E2 stated, I walked into the Residents room and started to give her care. I started with putting on her pants. After care I went to transfer her, and she dropped. I put her back on the bed and started cleaning her and called the nurse. The reason I did not say anything was I was afraid. Review of the final coroner's report, received by the Department on (MONTH) 11, 2019, dated (MONTH) 5, 2019, listed a cause of death as traumatic neck injury. An interview with the Nursing Home Administrator on (MONTH) 11, 2019 at approximately 1:35 p.m. revealed that Employee E2 did not transfer the resident according to her care plan and did not report the fall to the nurse. An interview with the Nursing Home Administrator on (MONTH) 29, 2019, at approximately 1:30 p.m. revealed that Employee E2 was provided new hire orientation education on reporting falls (MONTH) (YEAR). Review of Employee E2's Clinical Competency Listing showed that on (MONTH) 30, (YEAR), Employee E2 was trained on care plans and using lifts. The Nursing Home Administrator also revealed that Employee E2 was questioned on (MONTH) 6, 2019, and confirmed knowledge that Resident R1's transfer status was to be with two people. Employee E2 also stated that a transfer was attempted by herself with Resident R1 from the bed to the wheelchair and the resident fell on the wheelchair and onto the floor. Employee E2 scooped the resident back up and placed her on the bed. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa Code 201.18(b)(1)(3) (e)(1) Management Previously cited [DATE], [DATE], [DATE]

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for two of 35 residents reviewed (Resident #142, Resident #104 and Resident #206) resulting in actual harm to Resident #142's surgical site reopening, becoming infected and requiring intravenous antibiotic treatment. Findings include: Review of Resident #142's [DIAGNOSES REDACTED]. Review of Resident #142's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 6, (YEAR) revealed that Resident #142 had a Brief Interview for Mental Status Score (BIMS a tool used to asses a residents cognitive status) of 12 which indicated moderate cognitive impairment. Further review of Resident #142's Quarterly MDS revealed that Resident #142 required total dependence of one staff member for ambulation on and off resident's nursing unit and required total dependence of two staff members for transferring between surfaces. Review of documentation provided by the facility dated (MONTH) 1, (YEAR), revealed that Resident #142 ambulated to the bathroom without assistance and received a laceration to the right great toe. Review of Resident #142's Wound/Skin Evaluation Report dated (MONTH) 9, (YEAR), revealed Resident #142 developed a 2.5 centimeter (cm) x 2.0 cm blister to the right great toe. Further review of Resident #142's Wound/Skin Evaluation Report dated (MONTH) 20, (YEAR), revealed the right great toe ulcer to be 2.5 cm x 2.0 cm x < (less than) 0.1 (depth) and was receiving treatment of [REDACTED]. Review of Resident #142's nursing notes dated (MONTH) 5, (YEAR), revealed noted with change in condition as follows: [MEDICAL CONDITION] (swelling/redness) Skin wound or ulcer. Resident observation/evaluation is: physician notified. Review of Resident #142's nursing notes dated (MONTH) 5, (YEAR), revealed Resident left by ambulance with wheelchair to (hospital). Further review of this note revealed sent out r/t (related to) [MEDICAL CONDITION] in right leg. Resident left with leg pain due to diagnosis. Review of Resident #142's hospital discharge summary dated (MONTH) 18, (YEAR), revealed [DIAGNOSES REDACTED]. Further review of the discharge summary revealed presented with worsening right lower extremity [MEDICAL CONDITION] with ulcer showing osteo[DIAGNOSES REDACTED]. Further review of the discharge summary revealed underwent amputation on 9/14. Further review of the discharge summary revealed right lower extremity (leg) [MEDICAL CONDITION] with infected right great toe ulcer with osteo[DIAGNOSES REDACTED]. Right great toe amputation on 9/14. Review of the discharge summary dated (MONTH) 18, (YEAR), revealed discharge instructions including Post-op shoe on right foot for all ambulation. M, W, F (Monday, Wednesday, Friday) dressing changes right foot. Weight bearing as tolerated (WBAT) for essential ADLs (activities of daily living) wearing post op shoe. Should otherwise stay off feet and keep right foot elevated higher than hips. Review of nursing progress notes dated (MONTH) 18, (YEAR), revealed Resident was readmitted .Right toe was amputated dressing is dry and intact, has a surgical shoe to be worn when OOB (out of bed). Review of Resident #142's Treatment Administration Record (TAR) dated (MONTH) (YEAR), failed to reveal that the facility obtained a physician's order regarding the discharge instructions given by the hospital for the use of a post op shoe to the right foot for all ambulation. Review of Resident #142's TAR dated (MONTH) (YEAR), revealed a physician's order obtained on (MONTH) 28, (YEAR), to cleanse right great toe incision site with normal saline solution, pat dry and cover with dry dressing daily until healed every day shift. Further review of the (MONTH) (YEAR) TAR revealed the treatment was not completed to resident's right great toe surgical site on (MONTH) 2, (YEAR), (MONTH) 9, (YEAR) and (MONTH) 10, (YEAR). Review of Resident #142's Wound physician consult dated (MONTH) 9, (YEAR), revealed The patient had been discharged with instructions to always use offloading shoe when weight bearing. (Resident) states (resident) does not like to use (resident's) shoe, therefore (resident) has been wearing rubber bottom slippers and ambulating in those. The patient has a slight dehiscence (opening of surgical wound) that is most likely from lack of offloading. (Resident) is to return to using offloading shoe whenever weight bearing. Review of Resident #142's nursing progress notes dated (MONTH) 15, (YEAR), revealed Resident #142 was sent to a geri-psych facility for psychiatric admission from (MONTH) 15, (YEAR) through (MONTH) 19, (YEAR). Review of Resident #142's Wound physician's consult dated (MONTH) 23, revealed The patient was supposed to be wearing (resident's) offloading shoe since last visit but ambulated in today with no dressing on (resident's) foot wearing slippers. (Resident) states that (resident) has not worn the offloading shoe since I last saw (resident). Right great toe amputation site dehiscence/ulceration. (Resident) is to return to wearing (resident's) offloading shoe whenever (resident) is weight bearing. We will follow culture and sensitivity data and prescribe antibiotics once that information is available. Review of Resident #142's nursing progress notes dated (MONTH) 26, (YEAR), revealed new order to insert mid line or peripheral line (intravenous) to start [MEDICATION NAME] (antibiotic) 2 grams IV (intravenous) every 12 hours for 10 days. Review of Resident #142's active plan of care revealed Resident #142 was to wear post op shoe with any/all ambulation. This care plan was not initiated until (MONTH) 12, (YEAR) one month after the surgical amputation of Resident #142's right great toe. The above-information was conveyed to the Nursing Home Administrator and the Director of Nursing on (MONTH) 19, (YEAR), at approximately 12:00 p.m. The facility failed to ensure that Resident #142 wore the post operating shoe while weight bearing and failed to follow the physician's orders in the completion of treatments to the post op surgical site which resulted the Resident #142 right great toe surgical site to open, becoming infected and requiring intravenous antibiotic treatment. Review of Resident #154's clinical record revealed an admitted (MONTH) 7, (YEAR). Review (MONTH) (YEAR) physician's orders revealed and order for weekly weights upon admission x 4 weeks. Review of the resident's weight record revealed that the resident was weighed on (MONTH) 7, 14, and 28, (YEAR) and no weight was recorded as obtained on (MONTH) 21, (YEAR). An interview with the Director of Nursing on (MONTH) 18, (YEAR), at approximately 1:15 p.m. revealed that there was no documentation demonstrating that the weight was obtained on (MONTH) 21, (YEAR). Review of Resident #206's clinical record revealed a [DIAGNOSES REDACTED].Review of Resident #206's physician's orders revealed an order dated (MONTH) 7, (YEAR), for accuchecks (blood glucose measuring system) twice daily and to call the physician if the resident's blood sugar was less than 70 or greater than 400 and an order dated (MONTH) 6, (YEAR), for Glimepiride (medication used to control high blood sugar) 2 milligrams (mg) once daily in the morning. Review of Resident #206's (MONTH) (YEAR), Medication Administration Record [REDACTED]. Further review of Resident 206's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #206's interdisciplinary notes revealed a nurse's note on (MONTH) 7, (YEAR), stating that the resident was found unresponsive with a blood sugar of 44. The note stated Resident was unresponsive but he was mumbling his words with his eyes partially open. He was non diaphoretic (sweating) but his skin was pale. He was given [MEDICATION NAME] (hormone that raises blood sugar) 1 mg IM (intramuscularly) and blood sugar went up to 61 and he remained unresponsive. Blood sugar was rechecked and went up to 75 and he continued to be unresponsive. Further review of the nurse's note revealed that the resident's physician was contacted, and orders were obtained for [MEDICATION NAME] 50% 50 ml (milliliters) IV (intravenously) one time and to discontinue the resident's Glimeperide 2 mg. The nurse's note further stated Resident was given [MEDICATION NAME] IV and after a minute he was aroused and responsive. He denied any pain or discomfort. He recalled that his blood sugar yesterday was in the (60's) but he did not pass out. He stated that this is the first that his blood sugar went down that low and he passed out. Review of Resident #206's clinical record did not reveal any evidence that the resident's physician was notified of the blood sugar of 60 on (MONTH) 6, (YEAR), at 8:00 a.m. Interview with the Director of Nursing on (MONTH) 19, (YEAR), at 10:20 a.m. confirmed that there was no evidence that the resident's physician was contacted about the resident's blood sugar of 60 on (MONTH) 6, (YEAR), at 8:00 a.m. The facility failed to ensure that physician's orders were followed for obtaining weights and notification to the physician's of abnormal blood sugar levels. 483.25 Quality of Care Previously cited 9/4/18, 12/16/16 28 Pa. Code 211.10(d) Resident Care Policies Previously cited on 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.12(c) Nursing Services Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited on 11/1/18, 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 9/4/18, 1/23/18, 12/16/16

Based on clinical record review, resident observations, and interviews it was determined that the facility failed to timely identify pressure ulcers and provide appropriate interventions to prevent pressure ulcer development for two of ten residents reviewed with pressure ulcers resulting in actual harm to Resident 126 and Resident 154 with the development of unstageable pressure ulcers (Residents 126 and Resident 154). Findings include: Review of Resident 126's [DIAGNOSES REDACTED]. Review of Resident 126's Braden Scale (a tool used for predicting pressure sore risk) completed on (MONTH) 11, 27, and 24, (YEAR), revealed that the resident was in the moderate risk category for skin breakdown. Review of Resident 126's care plan dated (MONTH) 12, (YEAR), revealed that the facility identified the resident as at risk for skin breakdown due to impaired mobility and bowel and bladder incontinence. The care plan goal was for the resident to have no pressure ulcer formation. The interventions included encourage the resident to get out of bed daily, keep skin clean and dry, moisturize dry skin, pressure reduction cushion in chair, and pressure reduction device to bed. Review of Resident 126's daily skin observations from the (MONTH) 11, (YEAR), admission to (MONTH) 5, (YEAR), revealed no areas of concern observed. Review of Resident 126's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 18, (YEAR), revealed that the resident had a BIMS (Brief Interview for Mental Status a tool used to assess a resident's cognitive status) score of 3, indicating severe cognitive impairment. The MDS identified the resident as requiring extensive assist of two persons for bed mobility and transfers and no ambulation capabilities. Further review of the MDS assessment indicated that the resident was at risk for pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure) development. Review of Resident 126's progress notes revealed a note from the wound nurse, Employee E8, on (MONTH) 5, (YEAR), stating This resident was assessed by this wound nurse today. (Resident) presents with an unstageable pressure area (localized areas of tissue necrosis (dead tissue) that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough (non-viable yellow or white tissue that adheres to the ulcer bed in strings or thick clumps) or eschar (dead tissue that sheds or falls off from healthy skin) are by definition unstageable) to the coccyx, measuring 3.0 x 3.5 x 0.1cm (centimeters) 75% yellow (slough) and 25% black soft eschar with serosanguinous (drainage that is both pale yellow and bloody) and no odor and positive for pain. Recommendations to cleanse coccyx with NSS (normal saline solution) pat dry apply skin prep (treatment used to prevent further breakdown from occurring) to periwound (area surrounding the wound) then apply nickel size (amount) of Santyl (ointment that breaks down dead tissue allowing healthy tissue to grow) cover with a sacral dressing change daily and PRN (as needed). Also please order an air mattress. Review of the resident's plan of care for the unstageable pressure ulcer to the coccyx, initiated on (MONTH) 5, (YEAR), revealed the following interventions: pressure redistribution device in bed-air mattress, pressure redistribution device on chair, turning and repositioning. Review of Resident 126's wound consult dated (MONTH) 9, (YEAR), revealed that the CRNP (Certified Registered Nurse Practitioner) wrote that part of the plan for treating the wound was to off-load pressure to that area. The CRNP indicated that the resident had a wedge already in place as an intervention to off-load pressure to the area. Review of (MONTH) (YEAR), physician's orders [REDACTED]. Review of Resident 126's wound/skin evaluation report revealed that for each weekly assessment of the resident's unstageable wound to the coccyx from (MONTH) 5, (YEAR), to the most current (MONTH) 13, (YEAR), the resident was identified as positive for having pain to the area. Interview with nursing assistant Employee E3 on (MONTH) 19, (YEAR), at approximately 11:20 a.m. revealed that Resident 126 regularly gets out of bed before lunchtime. Interview with licensed nurse, Employee E4, on (MONTH) 19, (YEAR), at approximately 11:22 a.m. revealed that Resident 126 gets out of bed sometimes. Interview with licensed nurse, Employee E7, on (MONTH) 19, (YEAR), at approximately 11:25 a.m. revealed that Resident 126 gets out of bed three to four times a week. Interview with Resident 126's representative on (MONTH) 12, (YEAR), at approximately 11:50 a.m. revealed that the resident developed a pressure ulcer to the coccyx (tailbone) sometime in October. The resident's representative stated that she was told the pressure ulcer developed due to the resident's noncompliance with getting out of bed. The resident's representative expressed concern that staff were not getting the resident out of bed or utilizing the resident's wedge (used to position the resident in bed to offload pressure to the resident's coccyx) properly. Observation of Resident 126 at this time revealed the resident was laying flat on his back with the wedge positioned under his left arm. Staff brought in the resident's lunch tray at this time and set the resident up for the meal in bed; the resident was not asked if he wanted to get out of bed. Further observations of Resident 126 on the same day revealed the resident was in bed at 3:25 p.m. and again at 5:15 p.m. Observations of Resident 126 on (MONTH) 13 and 14, (YEAR), at approximately 11:45 a.m. both revealed the resident in bed. Observations of Resident 126 on (MONTH) 17, (YEAR), throughout the day revealed the resident in bed. Interview with Resident 126's representative at approximately 2:45 p.m. the same day revealed They only get him out of bed on shower days, so he should be out of bed tomorrow. Observation of Resident 126's pressure ulcer treatment on (MONTH) 18, (YEAR), at 10:00 a.m. with the wound nurse, Employee E8, and licensed nurse, Employee E9, revealed an open area to the resident's coccyx that appeared to be approximately the size of a half dollar. At the time of observation, the wound nurse indicated that the wound was 50% granulation (reddish connective tissue that forms on the surface of a wound when the wound is healing) with 50% slough. The resident was noted to yell out whenever the wound was touched during the treatment. Observation of Resident 126 on (MONTH) 18, (YEAR), at 2:40 p.m. revealed the resident in bed with no wedge being utilized. Interview with Resident 126's representative at this time revealed that the resident had been in bed when she arrived at the facility, a little before lunchtime. Observation of Resident 126 on (MONTH) 19, (YEAR) at approximately 11:15 a.m. revealed the resident in bed with no wedge being utilized. Review of Resident 126's clinical record revealed no documented evidence that the resident was refusing to get out of bed prior to development of the unstageable pressure ulcer to the coccyx on (MONTH) 5, (YEAR). The above was discussed and confirmed with the Nursing Home Administrator and the Director of Nursing on (MONTH) 19, (YEAR), at 12:40 p.m. The facility failed to timely identify the development of a pressure ulcer to Resident 126's coccyx which resulted in actual harm to Resident 126 with the development of an unstageable pressure ulcer to the coccyx, causing pain and infection requiring antibiotic treatment. Review of Resident 154's nursing admission assessment dated (MONTH) 7, (YEAR), identified the resident as alert and oriented times 3 (person, place and time) and to be unsteady on her feet. The resident exhibited weakness and was unable to bear own weight. Further review of the nursing admission assement noted that the skin on the resident's sacrum was identified as pink but blanchable (when the skin is pressed on, the color disappears and then quickly returns). Review of the Resident 154's care plan initiated (MONTH) 7, (YEAR), noted that the resident was at risk for skin breakdown due to impaired mobility. The interventions included for the resident to be encourage to be out of bed daily, pressure reduction cushion in chair and pressure reduction device to bed. Further review of the resident's care plan revealed that the resident was identified with a Stage I (intact skin with nonblanchable redness of a localized area usually over a bony prominence). Interventions included position devices in bed: (no specific devices stated), pressure reduction cushion in chair, pressure reduction device to bed: (no specific devices stated), treatment per Dr's order. Review of Resident 154's initial Minimum Data Set assessment (MDS an assessment of resident care needs) dated (MONTH) 17, (YEAR), revealed the resident was identified with a BIMS (Brief Interview of Mental Status a tool used to assess a resident's cognitive status) score of 9 out of 15 which indicated that the resident had moderate cognitive impairment. Further review of the MDS assessment noted that the resident required extensive assist of two-person physical assist for bed mobility, transfers, ambulation, locomotion on the unit. The resident was not steady and only able to stabilize with staff assistnace when moving from survey to surface with transfers and the activity for locomotion off the unit occurred only once or twice with two-person physical assist. The resident active [DIAGNOSES REDACTED]. The MDS assessment further indicated that the resident was at risk of developing pressure ulcers. Review of Resident 154's nursing documentation revealed an entry dated (MONTH) 3, (YEAR), resident's sacrum assessed and presented with an unstageable pressure area (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), measuring 1.3 cm (centimeter) x .7 cm, 100% slough with serous drainage and no odor and no pain. A treatment of [REDACTED]. Resident also needs an air mattress. Review of wound assessment documentation dated (MONTH) 29, (YEAR), revealed that the unstageable pressure ulcer to the sacrum was resolved, no open area was present. The facility failed to ensure proper monitoring of Resident 154's skin and timely identification of the development of a pressure ulcer to the resident's sacrum which resulted in Resident 154 developing an unstageable pressure ulcer to the sacrum. 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcer Previously cited 1/23/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 9/4/18, 01/23/18, 12/16/16 28 Pa. Code 201.18(b)(1) Management Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.5(f) Clinical records Previously cited 11/1/18, 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 9/4/18, 12/16/16 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/1/18, 9/4/18, 1/23/18, 12/16/16

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of five residents reviewed (Resident 129) was free of accidents, which resulted in actual harm to Resident 129 resulting in a fall and a [DIAGNOSES REDACTED]. The facility failed to ensure adequate supervision for one of 35 residents reviewed (Resident 46). Findings include: Review of facility policy title Safety and Supervision of Residents, last reviewed (MONTH) (YEAR), revealed Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, risk assessments and evaluations, and Minimum Data Set assessment (MDS - periodic assessment of resident needs). Further review of facility policy stated Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff .(and) ensuring that interventions are implemented. Review of Resident 129's [DIAGNOSES REDACTED]. Review of Resident 129's quarterly MDS dated (MONTH) 20, (YEAR), revealed the resident required extensive assistance of two persons for bed mobility, dressing, toileting, and personal hygiene. Review of Resident 129's care plan initiated on (MONTH) 11, (YEAR), identified the resident's deficit with activities of daily living related to a decline in functional mobility and a decline in personal care awareness. An intervention added to the resident's care plan on (MONTH) 23, (YEAR), revealed that the resident required extensive assistance in grooming, personal hygiene, dressing, and toilet use. Review of Resident 129's progress notes dated (MONTH) 26, (YEAR), revealed Called to assess resident for a fall witnessed in her room found resident sitting on the floor at bedside, (window side) with her back against the bed. Resident stated she was receiving PM care as she rolled to one side, her legs/body slipped off the bed and she was lowered to the floor by the CNA (certified nursing assistant). Resident landed on her knees and received a superficial abrasion on the (right) knee, no other injuries noted. Denied hitting her head, pupils equal and reactive to light, equal hand grasps. Resident is (paralyzed) from her waist down. Resident assisted off the floor with a mechanical lift, she did (complain) of back/neck pain, received routine pain medication. Review of witness statement from nursing assistant Employee E14 revealed I was washing up (Resident 129), as I washed her backside she was on (her) left side and her leg started slipping off the bed. Review of Resident 129's facility's investigation into the fall sustained by Resident 129 revealed that the resident's fall could have been avoided if there were two persons assisting with her care. Further review of Resident 129's progress notes dated (MONTH) 28, (YEAR), revealed Around (10:20 a.m.) called to assess resident in room with fell ow nursing staff .Observed Right Knee swelling, with large purplish discoloration, skin tightness and slightly warm to touch, resident unable to feel pain due to [MEDICAL CONDITION], intact blister with dressing clean and dry . Recommendation for X-ray of the Right knee . to (rule out) fracture .Around (1:00 p.m.) received report with conclusion: Right Knee non displaced [MEDICAL CONDITION] tibia ((the shinbone just below the knee)) . Mild osteopenia (a condition in which bone mineral density is lower than normal), this appears acute((recent onset). Review of Resident 129's radiology results report from (MONTH) 28, (YEAR) ,confirmed that the resident sustained [REDACTED]. Mild osteopenia. This appears acute. Interview with nursing assistant, Employee E3, on (MONTH) 19, (YEAR), at 11:20 a.m. revealed that Resident 129 required two staff persons for care. Interview with licensed nurse, Employee E4, on (MONTH) 19, (YEAR), at 11:22 a.m. revealed that Resident 129 required two staff persons for care. Interview with licensed nurse, Employee E5, on (MONTH) 19, (YEAR), at 11:28 a.m. revealed that Resident 129 required two staff persons for care. Interview with nursing assistant, Employee E6, on (MONTH) 19, (YEAR), at 11:30 a.m. revealed that Resident 129 required two staff persons for care. Interview with the Nursing Home Administrator on (MONTH) 19, (YEAR), at 12:36 p.m. confirmed that Resident 129's Kardex (information obtained from the resident care plan that nursing assistants use to provide care) had not been updated prior to the resident's fall to reflect that the resident was an extensive assist for care with two persons. The facility failed to ensure that Resident 129 was provided hygiene with the assistance of two staff persons which resulted in Resident 129 falling out of bed and sustaining a [MEDICAL CONDITION]. Review of Resident #46's clinical record revealed [DIAGNOSES REDACTED]. Observation on (MONTH) 19, (YEAR), at approximately 12:25 p.m. revealed Resident #46 was observed next to the medication cart on Appel wing rummaging through the garbage container of the medication cart. Resident #46 was observed searching through the garbage container for approximately 3 minutes. Once licensed personnel, Employee E11, observed the resident digging through the trash, the resident was redirected towards own unit, Rosemont. The facility failed to ensure two person transfer during care which resulted in harm to Resident # 129 and to supervise resident #46 to avoid rummaging in the medication cart garbage container on Appel unit. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 12/16/16 28 Pa. Code 211.5(f) Clinical records Previously cited 11/1/18, 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 11/1/18, 9/4/18, 1/23/18, 12/16/16 28 Pa. Code 211.12(c) Nursing Services Previously cited 9/4/18, 1/23/18, 12/16/16 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited on 11/1/18, 9/4/18, 1/23/18, 12/16/16

Based on review of facility policy and procedure, review of facility staff education, clinical record review and review of documentation provided by the facility to the State Agency, the facility failed to ensure that one of three residents reviewed was free from neglect during the provision of Activities of Daily Living (ADL) care to Resident R1 which resulted in Resident R1 sustaining a [MEDICAL CONDITION] humerus (Resident R1). Findings include: Review of facility policy and procedure titled, Abuse Identification, revealed that abuse is defined as the infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish or deprivation by a caretaker of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Further review of this policy revealed Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility policy and procedure titled Abuse Prevention revealed that each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including but not limited to facility staff, other resident, consultant or volunteers, staff or other agencies surveying the resident, family members or legal guardians. Review of Resident R1's [DIAGNOSES REDACTED]. routine), and [MEDICAL CONDITION] (decreased bone density and softening of the bone). Review of Resident R1's quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs) dated (MONTH) 4, (YEAR), revealed that Resident R1 had a Brief Interview for Mental Status (BIMS - a tool used to assess a residents cognitive status) score of 5 which indicated severe cognitive impairment. Review of Resident R1's comprehensive plan of care dated (MONTH) 11, 2012, revealed Resident R1 had an ADL (activities of daily living) self-care performance deficit related to dementia, [MEDICAL CONDITION] and contractures with interventions including encourage resident to participate in care. Review of Resident R1's comprehensive plan of care dated (MONTH) 8, (YEAR), revealed Resident R1 had the potential to demonstrate verbally abusive behaviors. Interventions for this plan of care included when resident becomes agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. Review of nursing notes dated (MONTH) 23, (YEAR), at 7:00 a.m. revealed when doing care of bathing and dressing . moving left arm and heard a pop is known to resist care now complaining of pain On examine discomfort in left elbow and left shoulder. Did reposition on pillow. New order for X-ray left elbow and left shoulder [MEDICATION NAME] (pain medication) given. Review of nursing notes dated (MONTH) 23, (YEAR), at 10:04 a.m. revealed complaining of pain in left elbow and shoulder repositioned arm not effective. New order for X-rays left elbow and shoulder. Review of X-ray report dated (MONTH) 23, (YEAR), at 1:26 p.m. confirmed There is a [MEDICAL CONDITION] neck with minimal impaction there is osteopenia. There is angulation. Review of nursing progress notes dated (MONTH) 23, (YEAR), at 2:48 p.m. revealed X-ray results positive for humeral neck (upper portion of bone located in upper arm) Fx (fracture - broken bone) with osteopenia (bones weaker than normal) New order send to ER (emergency room ) for stabilization of Fx. Review of nursing note dated (MONTH) 23, (YEAR), at 3:04 p.m. 911 (Emergency Medical Services) called. Further review of nursing documentation dated (MONTH) 23, (YEAR), at 10:33 p.m. indicated that the resident returned to the facility from the hospital around 7:10 p.m. and the resident's left arm was noted to be on a sling. Review of documentation provided by the facility to the State Agency revealed a written statement obtained from nursing assistant, Employee E4 which revealed As we were washing (Resident R1), (Resident R1) began to fight and resist. (Employee E5) put her arm under (Resident R1's) contracted arm and pushed it back towards (Resident R1's) head. I then heard a 'pop' and that's when (Resident R1) started screaming in pain. Telephone interview conducted with nursing assistant, Employee E4 on (MONTH) 31, (YEAR), at approximately 10:56 a.m. confirmed the above statement and revealed this occurred at approximately 5:30 a.m. and further revealed after we heard the pop we continued to dress (Resident R1) and then we told the nurse. Review of documentation provided by the facility to the State Agency revealed a written statement obtained from nursing assistant, Employee E5 which revealed we were giving a.m. care on (Resident R1). We were washing (Resident R1) and I went to lift (Resident R1's) paralyzed arm up to wash and dry under it. While lifting it up (Resident R1) was trying to resist me trying to lift her arm and when I lifted (Resident R1's) arm up to do care I heard a crack in (Resident R1's) arm. Review of documentation provided by the facility to the State Agency revealed a statement was obtained from Licensed nursing staff, Employee E3 which revealed This (Licensed Employee E3) assessed residence left arm. Residence left arm is very contracted and is not able to use (Resident R1's) arm. Review of facility staff education documentation revealed that nursing assistants Employees E4 and Employee E5 were educated on the Accident Prevention, and Abuse Identification, policy upon hire. Interview with the Director of Nursing and the Nursing Home Administrator on (MONTH) 29, (YEAR), at approximately 2:30 p.m. confirmed that Resident R1 suffered a [MEDICAL CONDITION] humerus while receiving care from two facility employees. The facility failed to ensure Resident R1 was free from neglect during the provision of ADL care with a contracture of the left arm which resulted in Resident R1 transfer to the hospital and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/23/18, 07/24/17, 12/16/16 28 Pa. Code 201.18(a) Management Previously cited 12/16/16 28 Pa. Code 201.18(b)(1) Management Previously cited 01/23/18, 07/24/17, 12/16/16 28 Pa. Code 201.18(b)(3) Management Previously cited 01/23/18, 02/22/17, 12/16/16 28 Pa. Code 201.18(e)(1) Management Previously cited 12/16/16 28 Pa. Code 201.29(j) Resident rights Previously cited 01/23/18, 12/16/16 28 Pa. Code 211.5(f) Clinical records Previously cited 01/23/18, 12/16/16 28 Pa. Code 211.10(d) Resident care polices Previously cited 01/23/18, 02/22/17, 12/16/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 01/23/18 28 Pa. Code 211.12(c) Nursing services Previously cited 01/23/18, 12/16/16 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 01/23/18, 02/22/17, 12/16/16 28 Pa. Code 211.12(d)(2) Nursing services

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that nursing interventions communicated to the physician were acted upon in a timely manner which resulted in a decline in the resident's medical condition requiring hospitalization and resulting in actual harm for one of 5 residents reviewed (Resident CL2). Findings include: Review of Resident CL2's closed clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident CL2's closed clinical record revealed that the resident had a laboratory blood test completed on February 2, 2016, which indicated a low platelet count (laboratory test that measure how many platelets are in the blood. Platelets are parts of the blood that help in the clotting process) of 127thou/ul (normal ,[DATE] thou/ul(thousand counts per minute)), high sodium count of 146 mmol/L (normal ,[DATE]mml (millions moles per)/L (liter)), a low potassium count of 3.5 mmol/L (normal 3XXX,[DATE].1 mmol/L), a low calcium level of 8.6 mg/dL (normal 8XXX,[DATE].3 mg/dL(milligrams per deciliter)) and a low protein level of 6.0 g/dL (normal 6XXX,[DATE].1 g/dL (grams per deciliter)). Review of the nursing notes from February 2, 2016 through February 15, 2016, did not reveal any documentation that the physician was notified of the abnormal laboratory results. Further review of the resident's clinical record revealed no documented evidence that the results of the laboratory study completed on February 2, 2016 were reviewed by a physician. Review of the closed clinical record revealed that the physician was notified via Fax on February 5, 2016 of the following: Resident pocketing food in his cheeks. He is on regular consistency finger foods, thin liquids. Staff are having great difficulty removing the food from his mouth, he is a dementia patient. May we have a speech evaluation. Last speech evaluation was [DATE]. There was no documented evidence in the resident's clinical record that the physician responded to the recommentdations for a speech evaluation until February 22, 2016. Review of Resident CL2's closed clinical record revealed a dietary note dated February 8, 2016 at 1:49 p.m., stating, Resident has experience a 7.2% weight loss over the past 30 days. Spoke to nursing staff who reports resident is going though a period with variable by mouth intake. Will recommend to increase Med Pass (high caloric nutritional supplement) to four times a day and continue on weekly weights. Further review of Resident CL2's closed clinical record revealed that on February 8, 2016, a communication form was faxed to the physician stating, Resident has experienced a significant weight loss over past 30 days. Recommend - to increase Med Pass to 4 ounces to four times a day and to discontinue the diet order for finger foods (resident receives sandwiches with meals and snacks). On February 10, 2016, the nursing staff faxed a communication form to the physician stating, Resident energy level had definitely decreased of the past few days-a lot more sleeping, lethargy, his appetite has been poor. He doesn't have any recent labwork. Resident has advanced dementia, do you feel labwork would be appropriate or is this decline part of his diagnosis. Any recommendations? There was no documented evidence that the physician acknowledged/responded to this recommendation until February 22, 2016. Review of Resident CL2's closed clinical record revealed a nursing note dated February 10, 2016 at 11:35 p.m., stating, Residents intake has been poor today. He took medications but staff report he only ate 25% of dinner. Physician faxed regarding poor appetite and requested labwork if appropriate. There was no documented evidence that the physician responded to the request for laboratory studies to be completed until February 22, 2016. Review of Resident CL2's closed clinical record revealed that on February 15, 2016 at 12:30 a.m., it was noted the following, Charge nurse reported at 11:00 p.m. that resident was having labored respiration with an oxygen saturation (how much oxygen is in the blood) of 82% (normal levels would be betweeen 95 and 100%) on oxygen at 3 liters per minute by nasal cannula (tubing that is placed in the nostrils that delivers the oxygen into the nose); he was seen laying in bed unresponsive to verbal and touch stimuli; his respiration was deep with a rate of 22 per minute (normal is ,[DATE] per minute); he had supraclavicular retractions (area around neck when a person has difficulty breathing you can visualize movement in the area due to struggling to breathe) and use of accessory muscle (muscles that contribute to inhalation and exhalation - and the use indicates indicates trouble breathing) with each respiration; his blood pressure was taken manually at ,[DATE] on his left arm and ,[DATE] on his right arm (normal blood pressure is ,[DATE]); his heart rate was 72 and regular; his temperature was 97.5 (normal temperature is 98.6); his skin appeared pale and dry; noted some fine crackles on chest auscultation (the use of a stethescope to hear lung sounds); he had no [MEDICAL CONDITION] (swelling of the arms or legs); per charge nurse resident did not eat today and had a poor oral intake for the past few days and was confined to bed today and yesterday. The physician was notified with order to send resident to emergency room , wife was also notified and in agreement; resident was transported to hospital by emergency medical team at around 11:45 p.m. Review of the documentation from the local hospital revealed that the resident arrived to the emergency roiagnom on [DATE] at 12:16 a.m., and was seen by the emergency room physician. The hospital documentation revealed that the resident had [MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (high levels of sodium in the blood, indicates dehydration), acute [MEDICAL CONDITION] (lungs not working properly-inability to breathe correctly), acute [MEDICAL CONDITION] (swelling of the brain), urinary tract infection with hematuria (blood in the urine) and acute [MEDICAL CONDITION] (the kidneys inability to filter wastes and other by products in the blood and urine causing the kidneys to shut down). The emergency room clinical notes further indicated that the resident's family did not want any aggressive medical measures to be initiated on the resident since the resident was a DNR (Do Not Resuscitate-if a resident stops breathing or heart stops beating no heroic measures such as CPR would be initiated). According to the emergency room clinical medical records, the resident, is obtunded (no response), has an irregular respiratory pattern (not breathing correctly), does not answer questions, open eyes or responds to pain. The resident was admitted to the inpatient medical unit on February 15, 2016 at 4:19 a.m., and the resident expired on [DATE] at 8:00 a.m. An interview with the Director of Nursing on [DATE] at 3:00 p.m., confirmed that there was no documentation in the closed clinical record that the physician responded to the communication forms that were faxed to the physician on February 5, 2016, February 8, 2016 and February 10, 2016, in regard to the resident's decline in condition until February 22, 2016, 8 days after the resident was sent to the emergency room for medical evaluation. The facility failed to ensure that interventions communicated by nursing staff to Resident CL2's physician to address Resident CL2's decline in condition were followed and acted upon in a timely manner, which resulted in actual harm to Resident CL2, requiring hospitalization [MEDICAL CONDITIONS], urinary tract infection, acute respiratory status and [MEDICAL CONDITION]. 483.25 Quality of Care Previously cited: [DATE], [DATE] 28 Pa Code 211.5(f) Clinical records Previously cited: [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.10(d) Resident care policies Previously cited: [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(1) Nursing services Previously cited: [DATE], [DATE], [DATE]

Based on a review of the Professional Nurses' Practice Act, facility policy, clinical records , and interviews with staff, it was determined that the facility failed to meet professional standards of quality, regarding the monitoring of pain for one out of 5 residents reviewed, causing actual harm to the resident. (Resident: CL4) Findings include: The Pennsylvania Code, dated November 15, 2008, Title 49 Professional and Vocational standards, Chapter 21.11(a)(4) states that a registered nurse is responsible for the carrying out of nursing that promotes, maintains, and restores the well-being of individuals. Review of the facility policy and procedure for Pain Management Protocol dated March 2011 indicated that the purpose of the procedure was to provide guidelines for the consistent assessment, management and documentation of pain in order to provide maximum comfort and the highest practible quality of life. Review of Resident CL4's August 2011 physician orders indicated that the resident had [DIAGNOSES REDACTED]. A Wound Care Specialist Evaluation dated August 29, 2011 indicated that the resident had peripheral artery disease, and had an arterial ulcer on his left foot that was 3.3 by 3.4 centimeters, and an arterial ulcer on his right heel that was 2.3 by 2.7 centimeters. The report further indicated that debridement was refused, that the patient was concerned over the effect debridement would have on raising his blood pressure, and that better pain management was discussed. Review of Resident CL4's current care plan for pain indicated that the resident was at risk for pain related to a foot ulcer as evidenced by his reports of pain in the foot. The care plan also detailed that staff were to assess the resident's pain using a numeric scale, but gave no indication as to how staff were to routinely determine if the resident was in pain. Review of September 2011 physician orders indicated that the resident had physician orders to receive [MEDICATION NAME] 50 mg as needed every 4 hours for moderate to severe pain. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nursing notes dated September 8, 2011 indicated that the resident was having a pain level of 10 out of 10 (most severe) and that pain medication relieved his pain. Another nursing note dated September 15, 2011 indicated that the resident was having significant pain this morning in his back and both legs. A nursing note dated September 22, 2011 indicated that the resident was complaining of pain today being 10 out of 10. Further review of the resident's record and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s severe pain. During an interview with Employee E6, a registered nurse, on October 3, 2011 at 9:20 a.m. the employee indicated that the resident did suffer from a significant amount of pain, and that he did get routine pain medication as ordered. However, Employee E6 was but was not sure how often nursing were assessing and monitoring the residents pain level. The facility was unable to show how the nursing staff were monitoring, assessing, or managing this resident's aforementioned reports of severe pain, resulting in actual harm to the resident. F309 483.25 Quality of Care Previously cited 8/25/2011, 7/27/2011, 12/2/2010, 8/10/2010, 2/7/2010, 8/4/2009, 28 Pa. Code 211.5(f) Clincial records Previously cited 8/25/2011, 8/4/2009 28 Pa. Code 211.10(d) Resident care policies Previous cited 8/25/2011, 2/17/2010, 11/6/2009, 8/4/2009 28 Pa. Code 211.11(d) Resident care plan Previously cited 8/25/2011 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/25/2011, 7/31/2011, 7/27/2011, 7/23/2011, 5/13/2011, 12/8/2010, 12/2/2010, 8/10/2010, 7/22/2010, 2/17/2010, 11/5/2009, 8/4/2009

Based on a review of clinical records, staff interviews and hospital records, it was determined that the facility failed to assess and monitor a resident with a [DIAGNOSES REDACTED]. Findings include: Review of Resident CL2's June 2011 care plan revealed that the resident was at risk for complications related to [DIAGNOSES REDACTED]. A review of care plan interventions for the risk of complications related to [MEDICAL CONDITION] and a history of urinary track infections indicated that the resident's vital signs should be monitored and the resident should be monitored for signs and symptoms of a urinary tract infection and fluids should be encouraged. Review of the quarterly nutritional assessment, dated June 24, 2011, revealed that the residents fluid requirements were 2168 cubic centimeters daily and that the resident generally consumed 83% of meals. Review of the fluids record for July 18 through July 21, 2011 indicated that the resident consumed 720 cubic centimeters of fluid on July 18, 2011; 960 cubic centimeters of fluid on July 19, 2011; 1140 cubic centimeters of fluid on July 20, 2011 and 480 cubic centimeters of fluid through 5:44 p.m. on July 21, 2011. There was no evidence in nursing notes for this period that the resident was encouraged to consume fluids as per the care plan interventions. Review of the meal consumption record for July 18 through July 21, 2011, revealed that the resident refused lunch and consumed 25% of her evening meal on July 18, 2011, consumed 25% of her breakfast and refused lunch and dinner on July 19, 2011, refused breakfast, consumed 50% of lunch and refused dinner on July 20, 2011 and on July 21, 2011 refused all three meals. There was no evidence that the reduced fluid and meal consumption was reported to the physician. Review of the nursing notes on July 21, 2011 at 1:26 p.m. indicated that the resident was described as very lethargic during this shift and had refused breakfast and lunch. Nursing note further stated that at lunch the resident was warm to the touch with a temperature of 97.8 Fahrenheit, heart rate of 128 (normal rate is 60 to 100), respirations of 36 (normal is 16 to 20) and irregular pulse ox fluctuating between 83% and 90% on room air. The notification of vital signs was faxed to the physician but the notification did not include the fluid and meal consumption percentages over the past four days. Nursing note on July 21, 2011 at 6:38 p.m. revealed that the resident's responsible party was at the facility and asked the nurse about the resident's condition. Nursing note further indicated that the daughter requested that her mother be sent to the hospital. Nurses notes dated July 21,2011 at this time also related that a verbal order from the physician to transfer the resident to the hospital on July 21, 2011 and ther resident was sent out at 6:45 p.m. Review of Resident CL2's clinical record revealed no evidence of any nursing notes for the dates reviewed from July 7, 2011 until July 21, 2011 when the nursing notes indicated the resident's change in condition. An interview with the Director of Nursing on August 24, 2011 at 12:30 p.m. confirmed the absence of any of nursing notes from July 7, 2011 until July 21, 2011. An interview with licensed staff Employee E3 on August 24, 2011 at 12:40 p.m. revealed that Employee E3 also did not know why there weren't any nursing notes from July 7, 2011 through July 21, 2011 as normally if there was a change in intake or output there would be a certified nursing aide alert. Employee E3 could not explain why the fluid and meal consumption percentages for Resident CL2 would not have been addressed in the nursing notes. Further review of Resident CL2's clinical record revealed no evidence that on July 21, 2011, during the period from 1:26 p.m. when the resident's change of condition was first noted until the documented note of 6:38 p.m., that the resident's vital signs were assessed or the resident was monitored in any way. The facility transfer to hospital form, dated July 21, 2011, indicated that [MEDICAL CONDITION] (low oxygen levels) was the reason for the transfer to the hospital and that the vital signs at the time of transfer were as follows: temperature 100.4, pulse of 126, respiration of 24 and blood pressure of 100 over 44. A review of the emergency medical services report, dated July 21, 2011, indicated that the resident was found lying in bed, unresponsive, with six liters of oxygen on and that the nurse indicated that the resident had not eaten for the past two days and had been unresponsive since the morning. The report further stated that the nurse indicated that the patient had a temperature of 104 degrees Fahrenheit, a pulse ox of 88% on six liters of oxygen and was hypoxic. A review of hospital documentation, dated July 21, 2011, revealed that upon admission the clinical impression was acute [MEDICAL CONDITION], dehydration, altered mental status [MEDICAL CONDITION]. The resident was admitted to the hospital in the intensive care unit. Laboratory test results completed in the emergency room revealed that the resident's blood urea nitrogen level (indication of kidney function) was 197 which was reviewed as abnormal and her [MEDICATION NAME] (test to assess kidney function) level was 8.9 which was reviewed as abnormal. In a telephone interview on August 25, 2011 at 1:30 p.m., the director of nursing confirmed that there was no written documentation that the resident was monitored or assessed from the period of time when the resident's change in condition was noted until the resident's daughter requested that the resident be sent to the hospital. The facility failed to assess a resident with a [DIAGNOSES REDACTED]. and admission to the hospital. F309 483.25 Quality of Care Previously cited 7/27/2011, 12/2/2010, 8/10/2010, 2/7/2010, 8/4/2009 28 Pa. Code 211.5(f) Clincial records Previously cited 8/4/2009 28 Pa. Code 211.10(d) Resident care policies Previous cited 2/17/2010, 11/6/2009, 8/4/2009 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 7/31/2011, 7/27/2011, 7/23/2011, 5/13/2011, 12/8/2010, 12/2/2010, 8/10/2010, 7/22/2010, 2/17/2010, 11/5/2009, 8/4/2009

Based on a review of clinical records, and interviews with facility staff, it was determined that the facility failed to assure that for one of eight residents reviewed that medications were received as ordered by the physician. (Resident R5). Findings include: A review of Resident R5's October 2011 physician orders [REDACTED]. Further review of these orders indicated that the resident was ordered to receive 2 units of [MEDICATION NAME] (a medication used to regulate blood sugar levels) with meals at 8:00 a.m., 12:00 p.m., and 4:00 p.m. daily. The order further stated that staff may hold the medication if the resident did not eat these meals. A review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 4:00 p.m. dose on October 18, 19, 21, 25, 26, and 28, 2011 also indicated that the dose was not administered to the resident and that staff had circled their initials to indicate that the medication was not administered on those dates and at those times. Further review of meal percentage documentation indicated that the resident had eaten between 75% to 100% of his meals on the aforementioned dates. During an interview with the Director of Nursing and the Assistant Director of Nursing on November 3, 2011 at 11:10 a.m., they could not give a justifiable reason as to why the medication had not been administered to the resident as ordered, and why nursing staff had circled to indicated that they had not administered the medication on those aforementioned dates. F309 483.25 Quality of Care Previously cited 8/25/2011, 7/27/2011, 12/2/2010, 8/10/2010, 2/7/2010, 8/4/2009 28 Pa. Code 211.5(f) Clinical records Previously cited 10/3/2011, 8/25/2011, 8/4/2009 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/3/2011, 8/25/2011, 7/31/2011, 7/27/2011, 7/23/2011, 5/13/2011, 12/8/2010, 12/2/2010, 8/10/2010, 7/22/2010, 2/17/2010, 11/5/2009, 8/4/2009

Based on a review of clinical records and interviews with facility staff, it was determined that the facility failed to obtain an order for [REDACTED]. Findings Include: A review of Resident J1's December 2011 physician orders [REDACTED]. Observation of resident J1 on January 9, 2012 at approximately 11:00a.m. revealed that the resident had a molded ankle foot orthosis applied to the posterior (back) of the lower right leg (an external device applied to a lower body segment to improve function by controlling motion). A review of the December, 2011 physician orders [REDACTED]. This was confirmed with licensed therapy employee E5 during an interview on January 10, 2012 at 2:30 pm. A review of Resident J1's the skin review sheets dated October 4, 2011 thru January 5, 2012 indicated that a skin checks were being done every three days by a nursing assistant and then signed off by licensed nurse. A review of Resident J1's nurses notes dated January 3, 2012 indicated that an opened blister was observed to the back of the right calf measuring 4cm x 1.5cm. The skin review sheet dated January 5, 2012 identifed skin problem on the right posterior lower leg. The physical therapy note dated January 9, 2012 related the brace was ill-fitting and the brace was adjusted. Review of Resident J5's December 2011 physician's orders [REDACTED]. The resident was ordered to received Asprin 81 milligrams tablet once a day. On December 9, 2011 the physician ordered for the Aspirin to be given in the am. Review of the December, 2011 Medication Administration Record [REDACTED]. Further review of December 2011 physician's orders [REDACTED]. Review of the December 2011 Medication Administration Record [REDACTED]. Interview with Employee E7 on January 10, 2011 at 1:00p.m. confirmed that Resident J5's Aspirin was held and not administered as ordered by the physician and Trazadone (antidepressant medication) was not administered during the above stated days. F309 483.25 Quality of Care Previously cited 11/3/2011, 8/25/2011, 7/27/2011, 12/2/2010, 8/10/2010, 2/7/2010, 8/4/2009, 28 Pa. Code 211.5(f) Clinical records Previously cited 11/21/2011, 11/3/2011, 10/3/2011, 8/25/2011, 8/4/2009 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/21/2011, 11/3/2011, 10/3/2011, 8/25/2011, 7/31/2011, 7/27/2011, 7/23/2011, 5/13/2011, 12/8/2010, 12/2/2010, 8/10/2010, 7/22/2010, 2/17/2010, 11/5/2009, 8/4/2009

Based on a review of clinical records, facility documentation, and interviews with facility staff it was determined that the facility failed to assure that safety devices were in place for one of seven residents reviewed who was ambulated in a wheelchair, resulting in actual harm to the resident. (Resident: R1) Findings include: A review of Resident R1's admission physician note of January 13, 2011 indicated that the resident was being admitted to the facility after sustaining a left leg fracture and a pelvic fracture. Further review of the resident's clinical record showed evidence of a comprehensive assessment completed on the resident on April 12, 2011 that indicated the resident required the assistance of two staff for transfer, and required the extensive assistance of one staff for ambulation. The assessment went on to indicate that the resident had limited mobility to one side of her lower extremities, and required a wheelchair, or walker for ambulation. Review of the resident's current plan of care for activities of daily living further documented that the resident required extensive assistance with activities of daily living related to her decreased mobility. A review of facility documentation on May 5, 2011 indicated that the resident was taken from the bingo activity in her wheelchair without leg rests to her room. The facility investigation further indicated that the resident was being transported to her room by a member of the therapy department to obtain her leg rests. During the transport back to her room the resident was noted to drop her foot under her wheelchair causing her to scuff her left toe underneath the wheelchair. Further review of the investigation indicated a statement from a nurse on the unit that day, that documented a communication with the therapy department later that afternoon. The witness further indicated that the resident was expressing that she had some pain while receiving therapy related services and that they believed that the resident was trying to get out of therapy treatment that day. A nurses note on May 6, 2011 indicated that the therapy notified the nurse on this day that the resident had some pain during therapy and was noted to have a bruise to her left ankle area and that this area was bruised and swollen. Physician orders [REDACTED]. Review of the x-ray report completed on May 6, 2011 indicated that the the resident had a transverse fracture of the distal tibula (inner larger leg bone extending from the knee to the distal ankle) and fibula (outer larger leg bone) just above the ankle joint. Interview with Employee E4, a member of the therapy staff, on May 6, 2011 at 11:50 a.m. found that the resident had always used foot rests during transport, that she should have had the foot rests in place, and that the foot rests were initially implemented on her first evaluation by the physical therapy department. The facilities failure to assure that foot rests were properly in place for ambulation of this resident in the wheelchair, resulted in the resident dragging her foot during transport, and sustaining actual harm to the resident in the form of a left ankle fracture. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 12/2/2010 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 12/2/2010, 12/8/2010 28 Pa. Code: 211.12(c)Nursing services. Previously cited 8/10/2010, 12/2/2010 28 Pa. Code: 211.12(d)(1)Nursing services. Previously cited 2/17/10, 8/10/2010, 12/2/2010, 12/8/2010 28 Pa. Code:211.12(d)(5) Nursing services Previously cited 12/2/2010, 12/8/2010