Every finding on record at Newport Meadows Health and Rehabilitation Center

Based on review of facility policy, medical records, and staff interview the facility failed to maintain medication administration records that were complete and accurate for one out of three residents reviewed (Resident 1).Findings include:Review of Resident 1's latest annual MDS (Minimum Data Set - a comprehensive evaluation of a resident's functional, medical, psychosocial, and cognitive status) dated December 12, 2025 revealed that Resident 1 was re-admitted to the facility on [DATE] with multiple diagnoses including: bladder cancer, diabetes mellitus, depression, adjustment disorder with mixed anxiety and depressed mood, insomnia due to mental disorder, acquired absence of right leg below the knee, chronic pain syndrome, and lumbago with sciatica, unspecified side. Resident 1's BIMS (Brief Interview of Mental Status - a standardized tool to evaluate a resident's cognitive status) was a 15 (indicating the resident is cognitively intact).Review of facility policy titled Administering Pain Medications, undated, revealed: Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose; 4. Route of administration; and 5. Results of the medication (adverse or desired).Review of Resident 1's February 2026 MAR (Medication Administration Record) revealed an order for Oxycodone HCL (a controlled medication used for moderate to severe pain) oral tablet 15MG, give 1 tablet by mouth every 8 hours as needed for chronic pain, moderate, severe with a start date of January 16, 2026 and an end date of February 16, 2026.Review of Resident 1's Individual Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:February 2, 2026, one dose administered at 00:00 (midnight), 9:00AM, and 4:00PM. Only one dose is documented in the resident's EMR at 5:55AM.February 3, 2026, one dose administered at 00:00 (midnight), 7:50AM, 3:20PM, and 11:20PM. The 7:50AM dose is not recorded in the resident's EMR.February 4, 2026, one dose administered at 8:00AM, 3:05PM, and 11:00PM. The 8:00AM dose is not recorded in the resident's EMR. February 6, 2026, one dose administered at 4:15PM and 11:30PM. The 11:30PM dose is not recorded in the resident's EMR. February 11, 2026, one dose administered at 5:30AM, 1:30PM, and 9:00PM. The 1:30PM dose was not recorded in the resident's EMR.February 15, 2026, one dose administered at 7:00AM, 4:00PM and 11:15PM. The 7:00AM dose was not recorded in the resident's EMR. Review of Resident 1's February 2026 MAR revealed the order for the Oxycodone every eight hours was changed to every six hours due to the resident having a surgical procedure. The new order for Oxycodone HCL oral tablet 15MG, give 1 tablet by mouth every 6 hours as needed for chronic pain, moderate severe was entered on February 16, 2026 and had a duration of 5 days (end date February 21, 2026).Review of Resident 1's Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:February 17, 2026, one dose administered at 3:00AM, 8:00AM, 2:00PM, and 9:00PM. The resident's EMR revealed one dose administered at 3:00AM, 9:11AM, 3:00PM, and 9:00PM.February 21, 2026, one dose administered at 4:00AM, 10:00AM, 4:00PM, and 10:00PM. The 4:00PM and 10:00PM doses were not recorded in the resident's EMR.Review of Resident 1's February 2026 MAR revealed the order for Oxycodone every six hours was discontinued and the order for Oxycodone HCL oral tablet 15MG, give 1 tablet by mouth every 8 hours as needed for chronic pain, moderate severe was entered on February 21, 2026 with no stop date. Review of Resident 1's Patient Controlled Substance Administration Record for 30 doses of Oxycodone revealed the following:February 23, 2026, one dose administered at 4:15AM, 12:30PM, and 8:30PM. The 12:30PM and 8:30PM doses were not recorded in the resident's EMR. February 25, 2026, one dose administered at 4:00AM, 12:30PM, and 8:00PM. The 8:00PM dose was not recorded in the resident's EMR.March 4, 2026, one dose administered at 4:20AM, 12:00PM, and 7:30PM. The 4:20AM dose was not recorded in the resident's EMR.Findings were reviewed with the DON on 3/5/2026 at approximately 2:20PM, who agreed that the documentation in the EMR was incomplete in that it did not reflect the documentation in the Patient Controlled Substance Administration Record. 28 Pa. Code 211.5(f) Clinical records

Based on review of facility's policy, observation, clinical records review and staff interviews, it was determined that the facility failed to ensure incontinent care was provided for one of two residents reviewed (Resident 1).Findings include:A review of the facility's policy titled Urinary Continence and Incontinence - Assessment and Management , dated 2001, revealed that the staff and management will appropriately screen for, and manage, individuals with urinary incontinence. The staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.A review of Resident 1's Quarterly MDS Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 12, 2025, revealed resident was frequently incontinent of bladder and was dependent with toileting.An observation conducted on October 30, 2025, at 11:00 a.m., in the presence of unlicensed Employee E3 revealed resident laying in bed wearing a blue gown, with disheveled hair. Additional observations revealed resident's incontinence breif was soaked with dark yellow/light brown urine. An interview conducted with Nursing Employee E3 on October 30, 2025, at 11:05 a.m. revealed that she/he was the resident's morning aide. Nursing Employee E3 reported that she got in today at 7:00 a.m. but had to pass breakfast tray then prepare residents scheduled for hair salon in the morning. Employee E3 confirmed that she/he has not provided incontinent care to Resident 1 since 7:00 a.m. Employee E3 reported that the night shift must have provided incontinent care but not sure when. A review of the Resident 1's task revealed that Resident 1 was last observed incontinent on October 30, 2025, at 1:08 a.m. The same documentation revealed that at 1:08 a.m., toileting hygiene was marked as not applicable .An interview with the Director of Nursing on October 30, 2025, at 2:00 p.m., confirmed that Resident 1 was not provided with incontinent care timely.The facility failed to ensure Resident 1 was provided with incontinent care as needed.28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(c)(d)(3) Nursing Services

Number of residents sampled: Number of residents cited: Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure appropriate storage and labeling of medications in three of four medication carts observed (Chestnut Medication Cart 2, Evergreen Medication Cart, and Birch Medication Cart 1).Findings include:Review of facility policy and procedure titled Medication Labeling and Storage revealed multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Review of manufacturer information for Dorzolamide Eye drops (medication used for glaucoma treatment) revealed Dorzolamide eye drops should be discarded 28 days after opening.Review of manufacturer information for Latanoprost Eye drops (medication used for glaucoma treatment) revealed Latanoprost eye drops should be discarded six weeks after opening.Observation of the Chestnut Medication Cart 2 on September 9, 2025, at 11:15 a.m. revealed one open vial of Lispro insulin with an expiration date of September 8, 2025.Observation of the Evergreen Medication Cart on September 9, 2025, at 11:25 a.m. revealed an open and undated container of Dorzolamide eye drops.Observation of the Birch Medication Cart 1 on September 9, 2025, at 11:32 a.m. revealed a vial of Lispro insulin with an open date of August 2, 2025, and no expiration date. This medication expired on August 29, 2025.Further observation of the Birch Medication Cart revealed an open container of Latanoprost eye drops with no open and no expiration date.The above information was conveyed to the Nursing Home Administrator on September 10, 2025, at 1:00 p.m. 28 Pa. Code 211.12(c)(d)(3) Nursing ServicesPreviously cited 9/25/2024, 11/10/2024

Based on observation, it was determined that the facility failed to ensure that privacy curtains were clean on one of five units (Dogwood unit).Findings include: The facility failed to ensure a clean and homelike environment by not ensuring privacy curtains were clean when visibly soiled.Observations made on September 7, 2025, at 12:15 p.m., of 12 rooms on the Dogwood unit, revealed that nine of the residents' rooms had privacy curtains that were stained with brown and/or red substances, the rooms of Resident 7, Resident 22, Resident 47, Resident 50, Resident 53, Resident 54, Resident 56, Resident 59, Resident 68, Resident 78, Resident 88, Resident 94, Resident 108, Resident 112, Resident 121, and Resident 123.During an interview on September 9, 2025, at approximately 1:30 p.m., when the above was presented the Nursing Home Administrator (NHA) stated she would investigate the matter. During phone interview on September 15, 2025, at 10:20 am, the Director of Nursing (DON) stated housekeeping usually cleans the privacy curtains upon discharge of a resident or when notified the curtains are visibly soiled. 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

Number of residents sampled: Number of residents cited: Based upon interview and clinical record review, it was determined that the facility failed to ensure appropriate notification was provided to a resident prior to a room change for one of twenty-five residents reviewed (Resident 16).Findings include:Review of Resident 16's diagnosis list revealed diagnoses including major depressive disorder (major loss of interest in pleasurable activities, characterized by changes in sleep patterns, appetite and/or daily routine), diabetes mellitus (failure of the body to produce insulin to enable sugar to pass through the bloodstream to cells for nourishment), and bladder cancer.Review of Resident 16's progress notes revealed that Resident 16 was sent to the hospital on August 11, 2025, related to abdominal pain.Further review of Resident 16's progress notes dated August 14, 2025, revealed resident arrived from hospital via stretcher with 2 attendants and taken to room [ROOM NUMBER] for admission, upon seeing [resident's] room had been changed, [resident] began hollering that [resident] was not going into that room. Resident continued to scream, reorienting to the situation as this is the room given [resident] in the admission process, [resident] continued to scream, reminded [resident] choice was to accept the room or return to the hospital [resident] stated, take me back; attendants exited building with [resident] on the stretcher to return to hospital.Interview with Resident 16 on September 8, 2025, at 1:00 p.m. revealed Resident 16 was not informed of his room change prior to the room change. This interview further revealed that Resident 16's room was changed while Resident 16 was a patient in the hospital.Interview with the Nursing Home Administrator on September 9, 2025, at 11:00 a.m. confirmed that Resident 16's room was changed while Resident 16 was in the hospital. The interview further confirmed that Resident 16 was not notified of the room change prior to the facility assigning the resident to a different room. 28 Pa. Code 201.18(b)(1)(2) ManagementPreviously cited 9/25/202428 Pa. Code 201.29(a)(b)(c) Resident RightsPreviously cited 9/25/2024

Number of residents sampled: Number of residents cited: Based on facility policy and procedure review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow physician orders and appropriately monitor fluid intake for one of one resident reviewed (Resident 3)Findings include:Review of the facility policy titled Encourage and Restricting Fluids (2001) states: Licensed staff will document on the eMAR (electronic medication administration record) yes or no if the fluid restriction is accepted or not accepted by the resident.Clinical medical record review for Resident 3 identified an active physician's order, dated March 17, 2025, for a 1500 ml (milliliter) fluid restriction. The order specified the following distribution: 7 a.m.-3 p.m. nursing: 330 ml; 3 p.m.-11 p.m. nursing: 330 ml; 11 p.m.-7 a.m. nursing: 120 ml. Dietary allocations were as follows: breakfast 360 ml, lunch 240 ml, and dinner 120 ml, for a total of 1500 ml within a 24-hour period.Review of the clinical medical record further identified the following diagnoses: acute on chronic diastolic congestive heart failure (a medical condition where the heart cannot pump blood effectively, causing fluid buildup in the lungs and other parts of the body), end-stage renal disease (ESRD, final stage of chronic kidney disease where the kidneys can no longer function well enough to meet the body's needs), and type 2 diabetes mellitus with hyperglycemia (The body does not use insulin properly and/or does not make enough insulin, leading to high blood sugar).Review of Resident R3's August MAR documented staff entries indicating yes or no to reflect whether Resident R3 was compliant with the prescribed fluid restriction.An interview with Licensed Practical Nurse (LPN) E3, conducted on September 10, 2025, at approximately 11:46 a.m., revealed that staff are instructed to document only yes or no regarding compliance with the fluid restriction, without recording the actual amount of fluid consumed. LPN E3 stated, By looking at the MAR you are not able to tell if Resident R3 is consuming 500 ml a day or 1500 ml a day, only that they are not going over 1500 ml over a 24-hour period.An interview with the Registered Dietitian (RD), conducted on September 10, 2025, at approximately 12:24 p.m., revealed that the RD is unable to accurately assess Resident R3's actual fluid intake due to the limitations of the facility's documentation practices.An interview conducted on September 10, 2025, at 1:32 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the above findings.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Number of residents sampled: Number of residents cited: Based on review of facility records and interview with staff, it was determined that the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or resident's representative when Medicare services ended for two of two residents (Residents 7 and 72). Findings include: Review of facility documentation revealed that Resident 7's last covered day of Medicare Part A services was July 11, 2025. Review of the SNF beneficiary Protection Notification Review revealed that the SNF ABN form was not provided. Documentation indicated we sent it to the family by mail. Never got it back. The facility was unable to provide any further documentation to indicate that the resident or resident's representative was made aware of potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of facility documentation revealed that Resident 72's last covered day of Medicare Part A services was July 24, 2025. Review of the SNF beneficiary Protection Notification Review revealed that the SNF ABN form was not provided. Documentation indicated we sent it to the family by mail. Never got it back. The facility was unable to provide any further documentation to indicate that the resident or resident's representative was made aware of potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Interview with the Nursing Home Administrator on September 10, 2025, at 12:48 p.m. confirmed that there was no evidence that Residents 2 and 72 were provided with the SNF ABN. 28 Pa. Code: 201.14(a) Responsibility of licensee.Previously cited 7/22/25, 9/25/24 28 Pa. Code 201.18(b)(2)(3) ManagementPreviously cited 9/25/24

The facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a change in condition/status for one of three residents reviewed (Resident R1). Findings include:Review of facility policy titled Change in a Resident's Condition or Status, revised 2021, revealed the facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition.Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included severe protein calorie malnutrition (inadequate intake of essential nutrients, particularly protein and calories), epilepsy (brain condition that causes reoccurring seizures), and dysarthria (slurred speech). Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated May 13, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition.Interview on July 18, 2025 at 12:05 p.m. with Employee E2, Licensed Practical Nurse, revealed he/she identified Resident R1 had increased slurred speech on the evening of July 17, 2025. Employee E2 confirmed he/she did not notify the physician or document his/her observation due to relating the slurred speech to Resident R1's previous respiratory illness he/she was recovering from since May 2025. Review of Resident R1's clinical record from the months of May 2025 through June 2025 revealed no progress note on slurred speech or worsening slurred speech related to respiratory illness. Interview on July 18, 2025 at 11:55 a.m. with Employee E1, Nurse Practitioner, confirmed when resident has change in condition/status for example slurred speech, staff is expected to document and notify physician. Review of Resident R1's nursing progress note, dated June 16, 2025 at 6:18 p.m., stated resident relative here and concerned as she has seen a dramatic negative change in him since Thursday. Noted by this nursing supervisor a dramatic change in vocal ability. His voice sounds as if his tongue is too big. Was able to follow conversation and was able to change an answer to a question from narrative to yes/no answer when asked about going to hospital for further evaluation. Relative getting guidance from wife. She has confirmed desire for him to be seen. Call out to on-call for confirmation. Review of Resident R1's nursing progress note, dated June 16, 2025 at 6:25 p.m., revealed Resident R1 was transferred to hospital for evaluation.Review of Resident R1's hospital record, dated June 17, 2025, revealed Resident R1 presented with worsening dysarthria, left sided chest pain and left shoulder pain. Patient was found to have elevated Dilantin level of 29.5. Exam notable for confusion, bilateral lower extremity weakness, and severe dysarthria. Further review of Resident R1's hospital record, dated June 18, 2025, stated the patient was found to be less responsive than normal yesterday with worsening slurred speech. Personally called [NAME] Meadows and spoke with Nursing Supervisor who stated she was informed that the patient had a steady decline in his speech over the weekend and when a visitor came to see the patient yesterday (Monday) the visitor thought the speech changes were more pronounced. Resident R1's hospital records revealed Resident R1 was diagnosed with Dilantin toxicity (prescription drug used to treat seizures, but it can cause severe toxicity if the dose is too high or if it interacts with other drugs.The facility failed to notify the physician in a timely manner related to a change in Resident R1's condition/status. Resident R1's family requested resident to be assessed, which resulted in resident being transferred to hospital and diagnosed with Dilantin toxicity. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to ensure that residents were free from significant medication error for one of three residents, resulting in Resident R1 needing emergency medical treatment (Resident R1). This situation was identified as past non compliance. Findings include: Review of facility policy titled Administering Medications revealed number nine indicating the following: The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. Further review of the facility policy revealed number ten which indicated: The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of Resident R1's clinical record revealed diagnoses including but not limited to the following: Dementia (loss of thinking, remembering, and thinking skills) Chronic Kidney Disease Stage 3 (gradual loss of kidney function); Cerebrovascular Disease (condition that affects blood flow to the brain); Psychotic Disorder with Delusions; and Depression (persistent feeling of loss and lack of interest in activities of daily living). Review of Resident R1's clinical record revealed a progress note dated October 13, 2024 (10:49 a.m.) Resident was mistakenly given (his/her) roommates medication which included carvedilol,lisinopril,clonidine and Keppra. [Resident's] BP/HR are low 74/40 and 42 [on call physician] returned the undersigned's call to the answering service and gave the directive for the resident to be sent to the hospital. [family member] contacted/apprised. Further review of Resident R1's clinical record revealed a progress note dated October 13, 2024 (12:18 p.m.) indicating the undersigned mistakenly administered this residents' roommate's medications @ 0800, Resident was in the hallway sitting on a chair. After realizing this error @0900, the residents bp/HR (blood pressure/heart rate) was rechecked and was 72/40 HR42. Supervisor notified immediately. attempts to reach on-call @0910 Medications that were given are: Sinemet 25-100mg (medication used to treat Parkinson's disease), hydralazine HCI 100mg (medication used to treat high blood pressure), Carvedilol 25mg (medication used to treat high blood pressure), clonidine HCI 0. 1mg (used to treat high blood pressure), Keppra 750 mg (medication used to treat seizures), and Lisinopril 40mg (used to treat high blood pressure). resident is alert and oriented. On-call [physician] returned phone call to supervisor @ 10:28, and EMS (emergency medical service) was called. resident BP was continued to be monitored until MD instructions were received and EMS arrival, BP/HR fluctuated from 72/40 HR 46 to 74/38 HR 42 @ 10am, resident responded appropriately for situation. last set of BP/HR @1045 before EMT arrival was 74/38 HR46. POA (power of attorney) was notified. Review of Resident R1's hospital progress notes dated October 14, 2024 through October 17, 2024, revealed under section titled Assessment and Plan Acute Conditions indicated number of accidental medication administration, number two Bradycardia (slow heart rate) improving, and number three Hypotension resolved. Further review of Resident R1's hospital documentation revealed a progress note dated Ocober 16, 2024 by hospital physician noting history of HTN (Hypertension), who presented on 10/13/2024 after accidental medication administration at (his/her) skilled nursing facility - pt (patient) received ACEi (Angiotensin-converting enzyme (ACE) inhibitors are medicines that help relax the veins and arteries to lower blood pressure), hydralazine, clonidine, keprpa, sinemet, lisinopril that was meant for another patient. (He/she) arrived bradydcardic and hypertensive (high blood pressure of 180/120). (He/she) received glucagon for beta blocker reversal. admitted to ICU (Intensive Care Unit) for monitoring. Did require inotropic and vasopressor support. Weaned off of these interventions. Review of facility documentation titled Verification of Investigation revealed under section titled detailed description of event indicated, On 10/13/24 at approximately 0744 (7:44 a.m.), (Licensed Practical Nurse) asked [Resident R1] if (his/her) name was [NAME] and the (Resident R1) replied yes. LPN then administered (Resident R2) medication to (Resident R1). At approximately 0900 [Resident R1] stated that (he/she) did not feel well, and the LPN took the blood pressure of the (resident), and it was noted to be at approximately 72/40. The LPN went to the (resident's) room and noted that [Resident R2] was in (his/her) bed, and (Licensed nurse Employee E2) accidently gave the incorrect medications to the wrong (resident). Further review of facility documentation including section titled Assessment of resident/describe injury revealed the following: Assessment completed by RN (Registered Nurse) in house, VS (vital signs) taken and noted to have a change in condition. The (resident) laid flat and feet elevated, the fluids pushed. (Resident's) blood pressure remained low, (resident) remained conscious the entire time until the EMT (Emergency Medical Team) arrives and transported to the ER (emergency room ). Additional review of facility documention titled Verification of Investigation revealed under section titled Summary and Outcome of Investigative findings the following: Employee (Licensed Employee E2) did not follow facility policy and will receive a final written warning. Employee will have 3 consecutive observations to ensure understanding of identifying residents prior to administering medications. Further review of facility documents including Employee E2 (LPN [NAME])'s statement which revealed [Resident R1] was sitting in the hallway and the first thing I did was go around and take my parameters for blood pressure medications and when I asked [Resident R1]if his name was [NAME] (he/she) stated yes. So I took (his/her) BP (blood pressure) and it was 136/78 or so. Then I administered Resident R2's medication to Resident R1. Then about 45 minutes later [Resident R1] was still sitting in the hallway and then (he/she) said I don't feel very well so I rechecked (his/her) blood pressure because I knew that I gave (him/her) all those blood pressure medications, and (his/her) blood pressure was really low 72/40 or something and then I walked back to (his/her) room and I was like oh no (he/she) is in A bed, not B bed so I realized (employee E2) had the wrong patient. Then (Employee E2) notified the supervisor right away, I got (him/her) back in bed laying flat and (Employee E2) kept rechecking (his/her) blood pressure every 10-15 minutes, it was fluctuating up and down at the time. RN supervisor called the on call and came over to assessed the (resident) . The facility initiated a full sweep of all the residents to determine if any others received incorrect medications. The review of all residents did not reveal any other residents effected by the deficient practice. The facility began to provide education to all licensed staff regarding administration of medications including reeducation on proper medication administration policy and protocols. Review of education documentation revealed that education was completed on October 21, 2024. Interviews conducted with three licensed staff (Employee E3, E4, E5) on November 10, 2024 revealed education was provided regarding medication administration and ensuring proper identification of resident prior to administering medications. Interview conducted on November 10, 2024 at approximately 2:00 p.m. with the Director of Nursing confirmed that Resident R1 was given another resident's medications which resulted in the need for emergency medical intervention and hospitalization . The facility failed to ensure that Resident R1 was free of significant medication error when facility staff administered roommate's medications (Resident R2) to Resident R1 causing a physical decline and needing emergency intensive evaluation and treatment. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 201.18(b)(3)(e)(1) Management 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(3) Nursing services

Based on review of facility policy and procedure and clinical record and staff interview, it was determined the facility failed to safely reheat a beverage for one of 32 residents reviewed causing actual harm to Resident 32 who developed a 2nd degree burn. Findings Include: Review of facility policy and procedure titled Microwave Use, undated, revealed staff should remove beverage from microwave, uncover, stir and insert thermometer probe into center of beverage item ensuring contact with beverage only. Check digital display for a maximum temperature of <165. Let sit for three minutes before serving. Review of Resident 32's Progress Notes revealed a nursing entry dated July 10, 2024 at 8:16 a.m. indicating While administering medication [resident] states that [resident] burned [himself/herself] while drinking [his/her] coffee. [Resident] states, I asked him to heat up my coffee and I spilled it on myself. [Resident] reports [he/she] burned both [his/her] butt cheeks. Further review of Resident 32's progress notes revealed a skin and wound note dated July 10, 2024 at 10:08 a.m. indicating staff reports resident sustained burns to bilateral (both) buttocks due to coffee on July 9. An assessment of the wound included in the progress note read as follows: wound 4, left buttock, 2nd degree burn, 16 cm (centimeters), x 16 cm x 0.1 cm. 60% erythema (redness), 20% intact fluid filled blister, 20% epithelial (pink or pearly white tissue and wrinkles when touched). Wound 5 right buttock, 2nd degree burn, 8 cm x 6.7 cm, 0.1 cm, 100% epithelial. Review of Facility Action Plan, signed by the Nursing Home Administrator on September 4, 2024 revealed Resident 32 is a [AGE] year-old [male/female] with a BIMS (brief interview for mental status) of 15 (indicating no cognitive deficit). On July 9, 2024 [Resident] kept [his/her] coffee from dinner and asked for it to be heated up prior to bed (approximately 10:45 p.m.). (Nursing Employee E4) honored [his/her] request to heat the coffee and placed it in the microwave for approximately 30 seconds, three time (testing between each time). Interview with the Director of Nursing on September 24, 2024 at 11:30 a.m. revealed (Nursing Employee E4) was asked to heat up coffee left over from dinner by Resident 32. He heated it up and when he returned Resident 32 said it wasn't hot enough, so he heated up and again Resident 32 said it was not hot enough. When he heated it up a third time, he left it on the bedside table for Resident 32 because it was the end of the shift. On September 24, 2024 at 11:30 a.m. the facility was asked to provide any evidence the beverage was temperature tested each time it was heated up by the nursing Employee E4. The Director of Nursing stated, we do not have logs for when (Nursing Employee E4) heated up the coffee for Resident 32 and a statement was taken from (Nursing Employee E4) but was unable to be found. The facility failed to ensure beverages that were heated in a microwave were safe temperature prior to serving to residents resulting in actual harm to Resident 32. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate adherence to Infection Prevention measures in regard to COVID-19 for one of five units observed (1st Floor Chestnut Unit). Findings include: Review of facility policy and procedure titled Coronavirus Disease (COVID-19) - Resident Exposure, Quarantine and Isolation revealed staff will use full PPE (N95 or approved equivalent respirator, gown, gloves and eye protection) before entering the room and to provide care for the resident(s) in isolation; PPE will be discarded prior to exiting the room, or between care of residents residing in same room, with the exception of reusable universal eyewear to be cleaned at least daily and after patient encounter; N95 respirator will be removed and universal source control (i.e. facemask) will be worn upon exit if indicated. Observation of the 1st Floor Chestnut Unit on September 22, 2024, at 9:30 a.m. revealed Licensed Employee E5 standing in the hallway outside a resident room. Licensed Employee E5 was wearing a cover gown, N95 and gloves and stated that he/she was testing residents on the unit due to a resident testing positive for COVID-19 the prior evening, September 21, 2024. Further observation of the 1st Floor Chestnut Unit failed to reveal evidence of any staff persons wearing masks or providing any universal precautions. Further observation of Licensed Employee E5 revealed the employee moving from room to room conducting COVID-19 tests without changing cover gown, N95 respirator, or gloves. Licensed Employee E5 was further observed to place a second pair of gloves over the first pair of gloves and not removing/changing the first pair of gloves between residents during testing. No handwashing or hand sanitization was observed to occur during the observation. Observation of the entrance of the facility failed to reveal evidence that notification of COVID-19 presence in the building to family members or visitors. Observation on September 23, 2024, at 8:30 a.m. of the entrance and reception area to the building failed to reveal notification of COVID-19 in the building and no monitoring of visitors was conducted. Observation on September 24, 2024, and September 25, 2024, of the entrance and reception area failed to reveal notification of COVID-19 or any screening procedures, recommendations, or observations in place. Interview with the Director of Nursing on September 25, 2024, at 10:30 a.m. confirmed Licensed Employee E5 should have changed all PPE prior to entering resident rooms; all staff should have been wearing face masks upon detection of a positive COVID-19 resident and additional screening completed at the entrance/reception area. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 10/20/2023, 6/13/2024

Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor and assess residents for side effects of antipsychotic medications for three of five residents reviewed for unnecessary medications (Residents 2, 84, and 93). Findings include: Review of Resident 2's physician's orders revealed an order dated March 31, 2023, for Abilify (antipsychotic medication) 5 milligrams (mg) once daily. Review of Resident 2's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication. Review of Resident 84's physician's orders revealed an order dated September 14, 2024, for Abilify 10 mg once daily. Review of Resident 84's clinical record failed to reveal evidence of side effect monitoring for the antipsychotic medication. Interview with licensed nurse Employee E3 on September 25, 2024, at approximately 10:50 a.m. revealed side effect monitoring for residents on antipsychotics should be found on the residents' Medication Administration Record (MAR). Review of Resident 2 and Resident 84's September 2024 MAR's failed to reveal evidence of side effect monitoring for the antipsychotic medications. Review of Resident 93's physician's orders revealed an order dated July 1, 2024, for Risperidone (antipsychotic medication) 0.5 mg twice daily. Further review of Resident 93's orders revealed an order dated November 3, 2023, to monitor for side effects for antipsychotics every shift. Each side effect was numbered 1-14. Document N if monitoring was conducted and no side effects were observed; document Y if monitoring was conducted and side effects were observed. Review of Resident 93's September 2024 Treatment Administration Record revealed staff were not documenting N or Y and the side effect monitoring was signed off via a checkmark and staff initials. The above findings were confirmed with the Director of Nursing on September 25, 2024, at approximately 11:30 a.m. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of Consultant Pharmacy Reviews, it was determined the physician failed to ensure a rationale was provided in declining a Consultant Pharmacist recommendation for one of five residents reviewed (Resident 102). Findings include: Review of Resident 102's Consultant Pharmacy Medication Review dated March 27, 2024, regarding a Gradual Dose Reduction (GDR) revealed the physician disagreed with the request from the Consultant Pharmacist. Further review of Resident 102's medication review failed to reveal a clinical rationale for declining the recommendation. Interview with the Director of Nursing on September 25, 2024, at 10:15 a.m. confirmed no clinical rationale was provided by Resident 102's physician for declining the consultant pharmacist's recommendation. 28 Pa. Code 211.9(a) Pharmacy Services

Based on clinical record review, it was determined the facility failed to follow physician orders in regard to fluid restriction for one of 25 residents reviewed (Resident 11). Findings include: Review of Resident 11's physician orders revealed an order dated August 13, 2024, stating 1500 ml (milliliter) fluid restriction, 900 ml from nursing, 600 ml from dietary. Review of Resident 11's clinical record failed to reveal evidence of fluid consumption amounts administered by nursing. Review of Resident 11's dietary fluid consumption from August 13, 2024, through September 24, 2024, revealed on multiple dates Resident 11 consumed greater than the 600 ml fluid restriction as ordered by Resident 11's physician as follows: August 13, 2024 - 1080 ml; August 16, 2024 - 720 ml; August 17, 2024 - 960 ml; August 18, 2024 - 1080 ml; August 19, 2024 - 880 ml; August 20, 2024 - 1340 ml; August 21, 2024 - 720 ml; August 22, 2024 - 920 ml; August 23, 2024 - 970 ml; August 25, 2024 - 3240 ml; August 26, 2024 - 840 ml; August 28, 2024 - 620 ml; August 29, 2024 - 730 ml; September 1, 2024 - 1080 ml; September 2, 2024 - 780 ml; September 3, 2024 - 1020 ml; September 4, 2024 - 1140 ml; September 7, 2024 - 1020 ml; September 9, 2024 - 660 ml; September 11, 2024 - 800 ml; September 12, 2024 - 1040 ml; September 13, 2024 - 710 ml; September 15, 2024 - 980 ml; September 16, 2024 - 960 ml; September 17, 2024 - 1740 ml; September 18, 2024 - 860 ml; September 19, 2024 - 1040 ml; September 20, 2024 - 720 ml; September 21, 2024 - 960 ml; September 22, 2024 - 1080 ml; September 24, 2024 - 960 ml. Interview with the Director of Nursing on September 25, 2024, at 10:00 a.m. confirmed there was no nursing documentation to indicate Resident 11's fluid consumption from nursing and further confirmed Resident 11 did not adhere to the 600-milliliter dietary fluid restriction as ordered by Resident 11's physician. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 10/20/2023, 6/13/2024

Based on clinical record review, it was determined the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of 25 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed a podiatry consult dated April 15, 2024, which stated that the resident was seen at request of floor nurse - [resident] had a fall a week or 2 ago & is complaining of pain in [left] foot. Further review of same podiatry consult dated April 15, 2024 under the subsection titled Recommendations/New Orders the podiatrist wrote for the resident to have an x-ray of the left foot. Review of Resident 2's progress notes revealed a nurse's note dated April 15, 2024, which stated: Resident seen by the Podiatrist today for [complaints of] left outer foot pain near [his/her] pinky toe. [No new orders] received. Review of Resident 2's x-ray results revealed the x-ray was not obtained until April 23, 2024, which showed a fracture of the distal fifth metatarsal bone. The delay in obtaining Resident 2's x-ray was confirmed with the Director of Nursing on September 25, 2024, at approximately 11:30 a.m. Pa. Code: 211.12(b) Nursing services Pa. Code: 211.12(d)(1)(3) (5) Nursing services Pa. Code: 211.10(d) Resident care policies

Based on observation, review of the clinical record, and interview with staff, it was determined that the facility failed to develop a plan of care with interventions for two of 31 residents reviewed (Residents 26 and 93). Findings include: Observation on September 22, 2024, at 11:00 a.m. revealed Resident 26 was receiving oxygen at 2 liters per minute through a nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help). Review of Resident 26's physician's orders included an order for oxygen at 2 Liter/minute via nasal cannula PRN (as needed). Review of the Resident 26's current active care plan failed to reveal a care plan or interventions for oxygen therapy. Interview with the Director of Nursing on September 25, 2024, at 9:50 a.m. confirmed that Resident 26 did not have a care plan for oxygen therapy. Observation of Resident 93 on September 22, 2024, at 10:05 a.m. revealed the resident had a left wrist contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Review of Resident 93's clinical record including progress notes revealed a nurse's note dated August 13, 2024, which indicated, [Nurse] was made aware by bedside nurse that resident's left wrist is contracted and swollen. This bedside nurse does not know patient and asked an aide if this was resident's usual presentation. One aide stated no that is new, another aide stated that it has been like that for about 3 weeks. [Nurse] assessed and left wrist is a little swollen. [Resident 93] did not let [nurse] touch the wrist. Further review of Resident 93's progress notes revealed a nurse's note on August 16, 2024, which stated: Hospice nurse stated to roll up a washcloth and put in his hand to slow the progression of the contracture. Review of Resident 93's current active care plan failed to reveal a care plan addressing the resident's contracture and limited range of motion. Review of Resident 93's Kardex (tool used to instruct nurse aides on providing care to residents) revealed an intervention to apply a rolled up washcloth in left hand daily to slow progression of the contracture. Observations of Resident 93 on September 22, 2024, at 10:05 a.m. and on September 25, 2024, at 11:00 a.m. revealed the resident did not have a rolled up washcloth in the left hand. Interview with the Director of Nursing on September 25, 2024, at 11:30 a.m. confirmed there was no active care plan addressing Resident 93's contracture and that staff did not implement the intervention to use a rolled up washcloth in the resident's left hand. 483.21(b) Comprehensive care plans Previously cited 10/20/23 28 Pa. Code 211.5(f) Clinical records Previously cited 6/13/24, 10/20/23 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 10/20/23 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/20/23

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 three of three residents reviewed (Residents R1, R2, and R3). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions dated April 2024, revealed that EBP is indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO (Multiple Drug Resistant Organism) infection or colonization status. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instruction for PPE (Personal Protective Equipment) use. PPE will be available to staff for donning before entering the resident's room. Observation conducted on June 13, 2024, at 11:00 a.m., revealed Resident R1 in bed with a dressing on the left foot. Review of Resident R1's clinical record revealed Resident R1 has a left heel ulcer. Review of Resident R2's clinical record revealed Resident R2 has a sacral pressure ulcer. Review of Resident R2's clinical records revealed Resident R3 has a left lateral foot wound. Observation of Resident R1, R2, and R3'2 room entrances revealed no signage for EBP and no PPEs. Interview conducted with licensed nurse, Employee E5 on June 13, 2024, confirmed Resident R1, R2, and R3 all have wounds. Employee E5 reported the staff had to request housekeeping to send PPEs to the unit if needed. The above information was discussed with the Nursing Home Administrator on June 13, 2024. The facility failed to ensure the EBP process was implemented for Resident R1, R2, and R3. 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 service

Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure the physician medication orders were accurately entered and followed for one of four residents reviewed (Resident CL1). Findings include: Review of CL1's clinical records revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of Epilepsy (abnormal movements due to unusual electrical activity in the brain), and Irritable Bowel Syndrome (IBS- disorder that affects the stomach and intestines). Review of Resident CL1's Hospital Discharge Summary, Medication List, revealed a list of the medications for the resident to take. The list includes an order for Prednisone (anti-inflammatory medication)10 mg. Take four tablets by mouth daily for five days, then three tablets daily for seven days, then two tablets daily for seven days, then one tablet daily for seven days. Start taking on May 19, 2024. Review of Resident CL1's physician's order dated May 18, 2024, revealed Prednisone 10 mg four tablets by mouth every five days until May 23, 2024; three tabs by mouth daily until May 31, 2024, two tablets by mouth every seven days until June 6, 2024, and one tablet by mouth once daily until June 15, 2024. Review of Resident CL1's May 2024, Medication Administration Record (MAR) revealed that the Prednisone 10 mg four tablets was transcribed to be given every five days instead of daily for five days which was the hospital's medication order sent to the facility. The MAR revealed that the Prednisone 10 mg four tablets was only administered on May 19, 2024, until the resident left the facility in the afternoon of May 21, 2024. Interview with the licensed nurse, Employee E3 conducted on June 13, 2024, revealed upon residents' admission, hospital medication orders were reviewed by the nursing supervisor with the physician. If the physician does not agree with the hospital medication order, a note is written in the medication list from the hospital or on the resident's medical record. Employee E3 then reported that upon the physician's approval of the medication list from the hospital, the nursing supervisor enters the order into the physician's order and will automatically be transcribed in the resident's medication administration record. Employee E3 confirmed that licensed nurse Employee E4 entered the Prednisone order in the physician's order but was unable to provide an answer as to why it was entered as every five days instead of daily for five days. Review of Resident CL1's clinical record failed to reveal documentation the physician wanted Prednisone 10 mg four tablets every five days instead of daily for five days which was the order from the hospital. The facility failed to ensure that the hospital medication order was accurately entered into the physician's order. Review of Resident CL1's physician order dated May 18, 2024, revealed an order for Mesalamine 800 mg given 1600 mg by mouth three times daily for IBS. The medication was scheduled to be administered at 12 midnight, 8:00 a.m., and 4:00 p.m. Review of May 2024, MAR revealed that Mesalamine medication was not administered from the midnight of May 19, 2024, until the midnight of May 21, 2024. Review of Resident CL1's clinical record revealed, Mesalamine medication was not administered due to the unavailability of the medication. Clinical records further revealed that the physician was notified of the missed medication from May 19, 2024, until midnight May 20, 2024. Clinical records review revealed physician was not notified that medication was still unavailable and therefore was missed on May 20, 2024, at 8:00 a.m., May 20, 2024, at 4:00 p.m., and May 21, 2024, at midnight. The above information was conveyed to the Nursing Home Administrator on June 13, 2024. The facility failed to ensure physician's order was accurately entered and followed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on review of the clinical record, and staff interview, it was determined that the facility failed to ensure that physician's orders for immediate care were obtained at the time of admission for one of three residents reviewed (Resident R2). Findings include: Review of R2's hospital discharge documentation dated February 29, 2024, revealed follow up appointments to include Nephrology, resident should continue dialysis on Tuesday, Thursday, and Saturday. Review of R2's clinical records revealed an admission MDS dated [DATE], documenting resident receives dialysis treatments. Further review of R2's clinical records revealed a care plan date March 1, 2024, documenting R2 has renal insufficiency and on dialysis three times a week related to end stage disease. Review of R2's clinical records revealed physician's admission orders that failed to include orders for dialysis. Interview with the NHA and Assistant NHA on March 11, 2024, at 3:10 p.m. confirmed that the physician's admission orders did not include orders for dialysis three days per week. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.5(f) Clinical records

Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for four of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining. Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator on October 20, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining. 28 Pa. Code 201.20(a)(c) Staff Development

Based on review of clinical records and facility provided documentation it was determined that the facility failed to timely identify a [CONDITION(S)] after a fall, resulting in a delay of services causing continued pain to a resident and resulting in actual harm to one of six residents (Resident 39) and to timely assess a resident and notify attending physician of a fall for one of six residents reviewed (Resident 100). Findings include: Review of Resident 39's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 39's Quarterly Minimum Data Set (periodic assessment of resident needs) dated September 6, 2021 revealed Resident 39 required supervision of one staff person for ambulating in resident's room and in the hallway of the nursing unit. Review of Resident 39's progress notes dated October 9, 2021 revealed Resident observed laying on her back on the floor near her bed with blanket around her feet. Staff report that resident had been sleeping in her bed prior to fall. Resident alert, has full passive ROM [range of motion] but slight limp noted on right leg once she was stood up by staff. [Physician] made aware and new order for xray right knee received. Further review of Resident 39's progress notes dated October 9, 2021 revealed s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . [mobile x-ray company] here and x-ray rt. Knee done at approx 1830. Tylenol given for pain with little effect. Further review of Resident 39's progress notes dated October 9, 2021 revealed x-ray report to Rt knee is negative for fx. [fracture] No acute findings. Resident still showing signs of pain to Rt side. Will address with [physician] in the morning in regards to ordering a possible xray to Rt hip. Review of Resident 39's progress notes dated October 10, 2021 at 6:31 a.m. revealed s/p unwitnessed fall, neuro checks continued this shift. VSS. No issues resident was awake throughout shift but stayed in bed. Further review of Resident 39's progress notes dated October 10, 2021 at 2:39 p.m. revealed resident continues to express pain with movement to right leg. Tylenol given with minimal effect. Resident not ambulating this shift. [Physician] made aware and new order for xray right hip received. Further review of Resident 39's progress notes dated October 10, 2021 at 8:40 p.m. revealed s/p fall, neuro checks WNLs, slept most of shift, will not ambulate, cont with s/s pain right leg. Total assist with ADLs. Review of Resident 39's progress notes dated October 11, 2021 at 4:46 a.m. revealed s/p unwitnessed fall on 10/09/2021, neuro checks WNL, grimacing and moaning with T&R [turning and repositioning] and ADL [activities of daily living] care, full, passive ROM to LLE, partial, passive ROM to RLE, non weight bearing, ice pack to right hip and Tylenol 650 mg at 0200 with + effect, in bed at this time in low position w/call bell in reach, drank approx. 240 ml [milliliters] fluids, awaiting mobile xray will cont. to monitor. Further review of Resident 39's progress notes dated October 11, 2021 at 6:42 p.m. revealed x-ray result right hip show acute right femoral neck [top of femur at hip joint] fracture. [physician] made aware and requested resident sent to ER. Daughter informed and would like resident to go to [acute care facility] 911 contacted and resident transferred to hospital. Review of Resident 39's x-ray report dated October 11, 2021 at 12:31 p.m. revealed acute femoral neck fracture is noted, nondisplaced with mild angulation. Interview with Director of Nursing and Nursing Home Administrator on October 26, 2021 confirmed that Resident 39 had a fall on October 9, 2021. Interview further confirmed that Resident 39 continued to complain of pain to right leg, remained in bed and did not receive an x-ray of right hip until October 11, 2021 two days after the fall and one day after Resident 39's physician ordered the x-ray. The facility failed to obtain an x-ray of Resident 39's right hip until two days after Resident 39's fall and one day after Resident 39's physician ordered the x-ray despite continued complaints of pain and lack of mobility causing actual harm to Resident 39. Review of Resident 100's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 100's Minimum Data Set (MDS- assessment tool used to determine the management of care), dated March 2, 2021, revealed that the resident had severe cognitive impairment. The same MDS revealed that the resident was able to ambulate with the extensive assistance of one person. Review of the nursing progress notes dated April 24, 2021, at 3:47 a.m., revealed that Resident 100 was administered [MEDICATION(S)]-Acetaminophen 5-325 mg for a complaint of right hip pain. The same note revealed that the resident was guarding his hip, moaning when rolled, and was not ambulating well. Review of the nursing progress notes dated April 24, 2021, at 3:49 a.m., revealed the 3-11 shift staff reported that the resident was having trouble ambulating on 3-11 shift and had to have the care done in bed. The same note revealed that Resident 100 resisted care during the 3-11 shift, holding the right hip area, facial grimacing. As needed pain medication was administered. Review of the nursing progress notes dated April 24, 2021, at 7:20 a.m., revealed that Resident 100 was evaluated due to a complaint of pain while being turned in bed. The resident complained of right hip pain, the right leg was observed shorter than the left. The resident was medicated for pain and was kept in bed with a pillow in between legs. The same note revealed, reported to the supervisor who is going to evaluate. Review of the nursing supervisor's progress notes dated April 24, 2021, at 1:50 p.m., revealed that on the night shift, Resident 100 had complained of right hip pain when rolled from side to side for incontinent care. The staff had the resident remain in bed due to complaints of pain with weight-bearing. The same note revealed that upon the nursing supervisor's examination, the resident had some shortening and some external rotation of the affected limb (right leg). The physician was notified and X-ray was ordered. Review of the nursing progress notes dated April 24, 2021, at 6:40 p.m., revealed that Resident 100's right hip X-ray result was an Acute right intra-trochanter fracture (break on the thigh bone). The physician was notified and ordered to transfer Resident 100 to the hospital. The resident was admitted to the hospital for a right [CONDITION(S)]. Review of the facility documentation, including a statement of Nurse Assistant (NA), Employee E5 who worked on April 23, 2021, at 7-3 shift, revealed that Resident 100 was toileted but would not put his feet down. Review of the facility documentation, including a statement of Nurse Assistant (NA), Employee E6, who worked on April 23, 2021, at 3-11 shift revealed that a report was given to him that the Resident 100 would not stand in the afternoon when being toileted. The statement revealed that during supper, the resident was heard saying ow, ow, ow, when asked if he was in pain, the resident just mumbled. No further signs of pain were observed. The statement further revealed that after supper, the resident was brought to the bathroom. Employee E6's statement revealed, I went to stand him up at the bar to sit him on the toilet like he usually does, he was not able to bear weight, so I sat him back down. Employee E6's statement revealed that the charge nurse was notified of the resident's pain. Review of the progress notes dated April 23, 2021, at 7:32 p.m., revealed that Resident 100 was administered [MEDICATION(S)]-Acetaminophen 5-325 mg. Review of Resident 100's clinical records failed to reveal that an assessment was conducted regarding resident 100's change in a condition identified on April 23, 2021, at the 3-11 shift. Clinical records reviewed also failed to reveal that the physician was notified of Resident 100's change in condition which included the inability to bear weight during toileting, and right hip pain during bed mobility until the afternoon of April 24, 2021. The above informatin was conveyed to the Nursing Home Administrator on October 26, 2021, at 11:00 a.m. The facility failed to timely assess and notify the physician of the change in condition related to right [CONDITION(S)]. 483.25 Quality of Care Previously cited 1/31/20, 9/1/20 28 Pa. Code 201.18(b)(1) Management Previously cited 1/31/20, 9/1/20 28 Pa. Code 211.5(f) Clinical records Previously cited 1/31/20, 9/1/20 28 Pa. Code 211.12(c) Nursing services Previously cited 1/31/20, 9/1/20 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 1/31/20, 9/1/20

Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to provided adequate supervision to ensure resident safety, causing actual harm to one of three residents reviewed (Resident R1) which resulted when Resident R1 accessed a door to the stairwell, sustained a fall, required transfer to the hospital and resulted in fractures of the left scapula and the right thumb. This was identified as a past non-compliance actual harm situation for one resident. Findings include: Review of Resident R1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) completed on April 19, 2017, revealed that Resident R1 had a Brief Interview for Mental Status (BIMS - a tool used to assess a residents cognitive status) score of 3 out of 15, indicating that Resident R1 was severely cognitively impaired. Further review of Resident R1's quarterly MDS revealed that the resident required extensive assistance of two persons with transfers and ambulation. Review of Section 0400, Functional Limitation in Range of Motion, assessed the resident with no upper or lower extremities limitations. Section G (G0600), Mobility Devices, identified the resident use of a wheelchair. Review of the resident's care plan developed on January 12, 2017, identified the resident at high risk for falls in relation to the resident being unaware of safety needs, confusion, poor communication/comprehension, and balance problems. The interventions included for the resident to wear appropriate footwear when mobilizing in the wheelchair, and the need for a safe environment with even floors free from spills and/or clutter. Review of the wander/elopement risk evaluation completed on January 15, 2017, identified that the resident was not at risk for elopement. Review of the information dated May 8, 2017, submitted by the facility revealed that on May 7, 2017, Resident R1 was found in the stairwell laying on his right side on the first-floor landing with his wheelchair on top of him. Further review of the facility documentation noted that 911 (emergency services) were called and the resident was transferred to the hospital by Emergency Medical Services (EMS). Review of Resident R1's progress notes revealed an incident note dated May 7, 2017, which noted that at 7:15 p.m. aide came to get him ready to take to bed, he wasn't in front of nurse station, found resident in rear stair way face down on right side wheelchair on top of resident. Review of the incident report dated May 7, 2017, revealed that the resident was last seen 7:05 p.m. at the nurses' station and the resident was last toileted at 6:45 p.m. Further review of Resident R1's progress notes revealed a nurse entry on May 7, 2017, at 9:18 p.m. which noted that the resident was found on his right side with his wheelchair on top of him. The resident was unable to describe what happened. The progress note stated, Bleeding noted coming from head. Charge nurse was sent to call 911. This nurse stayed with resident until EMS arrived. Resident awake and alert with confusion. Resident stated he had pain in right arm. The resident was transferred to the local hospital. Review of Resident R1's progress note revealed a nurse entry dated May 8, 2017, at 1:34 p.m. which confirmed that Resident R1 was admitted to the local hospital. Review of Resident R1's hospital records dated May 7, 2017, revealed that the resident was admitted to the hospital and treated for [REDACTED]. Review of Resident R1's progress notes revealed a nursing entry on May 10, 2017, at 12:58 p.m. stating that Resident R1 returned to the facility, status [REDACTED]. Review of the facility investigation report dated May 7, 2017, at 7:45 p.m. confirmed that Resident R1 was found in the stairwell on a landing in-between the Chestnut Unit (a unit on the first floor of the facility) and the ground floor, laying on his right side with his wheelchair on top of him. The initial cause of the fall was determined to be that the resident opened the door to the back stairwell and the door was unlocked due to a magnet malfunction in the locking mechanism. The resident was alone and unattended. The failure of the malfunction of the locking mechanism of the door was identified as past non compliance actual harm for Resident R1. Review of the investigation report dated May 7, 2017, noted the facility's immediate corrective action plan to include: magnet to the stairwell door fixed, maintenance to perform five times a weekly checks to door magnets to ensure functioning. Alarms to those doors were also engaged to sound. The facility repaired the locking mechanism as soon as it was found defective and added an audio mechanism. Review of the facility stairwell door function test for the magnetic function of the stairwell doors dated May 8, 2017, revealed that the corrective action had been fully implemented. Review of inservices with facility staff revealed that as of May 9, 2017, a total of 20 facility staff members were inserviced on ensuring that all stairwell door were secured and if the facility staff were to find the stairwell doors not functioning properly they were to notify maintenance staff, nursing unit manager/supervisor immediately for repair and were not to leave unsecured doors unattended. Review of the monthly inspection of all doors by the maintenance department showed an initial by the maintenance staff with a date of April 20, 2017, as the last time the door was checked before the May 7, 2017, Resident R1 fall incident. An interview with Nursing Home Administrator on May 25, 2017, at 2:00 p.m. confirmed that Resident R1 had gained access to the stairwell because of a malfunctioning magnetic lock, and had fallen half a flight of stairs causing a fracture to the right thumb and the left scapula. The facility failed to ensure that the locking mechanism on a door leading to a stairwell was properly functioning and failed to provide adequate supervision to Resident R1 which resulted in actual harm to Resident R1 when the resident accessed the door to the stairwell, sustained a fall, required transferred to the hospital with a [DIAGNOSES REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident hazards/supervision/Devices Previously cited 10/20/16 28 Pa. Code 210.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 04/29/16 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.12(c) Nursing services Previously cited 10/20/16, 04/26/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/29/16, 07/05/16, 07/29/16, 10/20/16, 04/26/17

Based on clinical record review, observations and staff interviews, it was determined that the facility failed to provide the necessary care to maintain the highest practical physical well-being and caused actual harm for one of 14 residents reviewed (Resident E10). Findings include: Review of Resident E10's clinical record revealed an admitted [DATE], with a [DIAGNOSES REDACTED]. Review of Resident E10's clinical record revealed that the resident was admitted to the hospital on [DATE], with fever, cough, hypoxemia (low oxygen level in the blood) , [MEDICAL CONDITION](high heart rate), [MEDICAL CONDITION] exacerbation, and pneumonia (infection of the lungs). The resident also had surgery for [REDACTED]. The resident was readmitted to the facility on [DATE], and was receiving enteral (through the PEG tube) feedings of [MEDICATION NAME] 1.2 calorie liquid 40 ml per hour continuously. According to the clinical nursing standards of practice, any person receiving liquid nutrition supplement through a PEG tube while bedbound during the infusion, the individual is to be placed in a position of comfort with the head of the bed in a 45 degree upright position to prevent aspiration (when liquid or food items go into the lungs due to a resident having swallowing issues) of the liquid supplement. (http://ajcc.aacnjournals.org Preventing Respiratory Complications of Tube Feedings: Evidence Based Practice, 2006, Metheny, N). Observations of Resident E10 on [DATE] at 9:30 a.m., 10:30 a.m., and 11:35 a.m. revealed the resident in his bed with the resident receiving his tube feeding and the head of the bed only slightly elevated, not at a 45 degree angle. There were no signs and symptoms of distress noted by the surveyor during the above mentioned observations. During the observation on [DATE] at 10:30 a.m. the surveyor observed a woman sitting in a chair next to the resident's bed. Observation of two licensed nurses in the Arbor Nursing Station at 1:10 p.m. on [DATE], revealed a conversation regarding whether they should suction Resident E10 due to the resident having difficulty breathing and gurgling sounds in the back of his throat. The two licensed nurses retrieved the resident's chart from the surveyor to determine if they could suction the resident and were heard having a discussion in regards to if the Resident was a Full Code (providing life- saving intervention CPR-cardiopulmonary resuscitation- when an individual stops breathing or when the heart stops beating) or a Do Not Resuscitate (not providing any life-saving interventions) since the resident was under Hospice care. Based on observation of the conversation between the two licensed nurses, an additional observation of Resident E10 was obtained at 1:15 p.m. and Resident E10 was making gurgling sounds when breathing and appeared to have difficulty breathing even with oxygen on at 4 liters per minute as ordered by the physician. The surveyor immediately notified the Director of Nursing (DON) of the change in the resident's medical status and confirmed with the DON who the woman was that was observed to be present and next to Resident E10 at 10:30 a.m. The DON stated that she was a Hospice aide. Review of Resident E10's clinical record revealed a nursing progress note dated [DATE] at 3:08 p.m., stating, Resident gurgling and coughing up tube feeding. Zero residual from peg tube. Oxygen level dropped to 71%, heart rate 127. Received verbal order from physician to send resident out to hospital at 2:30 p.m. Review of Resident E10's hospital admission record, physician's history and physical completed for the resident after arriving to the emergency room of the hospital on [DATE], revealed, The patient was brought to the emergency room and in an unresponsive state. The patient was found to have severe shortness of breath with severe hypoxemia (low oxygen levels in the blood). Upon arrival in the emergency room he was started on [MEDICAL CONDITION] (Bilevel positive airway pressure-non-invasive ventilation-breathing help) and found to have significant [MEDICAL CONDITION] (low blood pressure) as well as evidence [MEDICAL CONDITION] (infection in the blood). Assessment is acute hypoxemic [MEDICAL CONDITION] (low oxygen levels in the blood due to difficulty breathing) with chronic hypercarbia (increased carbon monoxide in the blood) and healthcare associated aspiration pneumonia (infection of the lungs due to swallowing food, liquid or foreign substance). Interview with the Director of Nursing (DON) at 1:20 p.m. on [DATE], the DON stated that the head of the bed of any person receiving peg tube feedings should be at 45 degrees to prevent aspiration. The facility failed to ensure that the resident was in the proper position for infusing a tube feeding which resulted in actual harm to Resident E10 requiring hospitalization for aspiration pneumonia. 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited: [DATE], [DATE], [DATE], [DATE] 28 Pa Code 201.29(j) Residents Rights Previously cited: [DATE], [DATE], [DATE] 28 Pa Code 211.10(d) Resident Care Policies Previously cited: [DATE], [DATE], [DATE]

Based on review of clinical records, review of facility policy and interview with facility staff, it was determined that the facility failed to obtain, clarify and follow physician's orders [REDACTED]. Findings include: Resident CL2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident CL2's clinical record failed to reveal signed physician admission orders [REDACTED]. Review of Resident CL2's [DATE], Medication Administration Record [REDACTED]. Review of Resident CL2's nursing notes on [DATE] (the date of admission) revealed that the resident was alert and oriented. Further review of Resident CL2's nursing notes noted that the resident sustained [REDACTED]. Review of the resident's [DATE], nursing note stated that the resident was alert with confusion, very weak with transfers and falling asleep sitting up in a chair. Review of Resident CL2's nursing notes of [DATE], revealed that the resident was alert with confusion, speaking incoherently, ambulation was unsteady and that the charge nurse expressed concern with regard to the resident's condition. Review of nursing notes on [DATE], noted that the resident was very anxious and unsure why she felt so nervous and worried. The nursing note dated [DATE], revealed that the resident was lethargic and alert but drowsy at times. On [DATE], the nursing note indicated that a physician's orders [REDACTED]. Further review of [DATE], clinical progress notes, also revealed that the resident was alert with confusion and had become aphasic (loss of ability to understand or express speech), spit food out at dinner and refused to eat, and the resident was having difficulty chewing and swallowing her food. Review of the nursing notes of [DATE], revealed that the resident was very confused and lethargic. A phone call was placed to the physician who ordered that the resident be transfered to the hospital. The resident was transferred to the hospital at approximately 8:55 a.m., on [DATE] and admitted with a [DIAGNOSES REDACTED]. Further review of Resident CL2's nursing notes revealed that the facility obtained the results of the [MEDICATION NAME] level on [DATE] that were ordered by the physician. The [MEDICATION NAME] level for this resident was 60 micrograms to mililiters According to the National Institutes of Health the normal range for therapeutic levels of [MEDICATION NAME] is 10 to 20 micrograms to milliliters. Also, according to the National Institutes of Health, the signs and symptoms of [MEDICATION NAME] overdose/toxicity include confusion, lethargy, slow or slurred speech, staggering gait and unsteadiness. An interview with the Director of Nursing on [DATE] at 11:50 a.m., confirmed that the facility failed to have signed admission orders [REDACTED]. The facility failed to verify the physician's orders [REDACTED]. Review of Resident CL3's clinical record and the physician's history and physical that was completed on [DATE], revealed that the resident was admitted to the facility on [DATE], after an admission at a local hospital for decreased sodium levels, dehydration (lack of sufficient body fluid) , and a fall in which the resident sustained [REDACTED]. Review of Resident CL3's clinical record revealed [DIAGNOSES REDACTED]. heart beating becomes fast and irregular), [MEDICAL CONDITION] (fluid accumulation), and muscle weakness. Review of Resident CL3's clinical record revealed a nursing note entry on [DATE] at 1:00 p.m., the day after the resident's admission that stated, Resident is assist by 1 staff with ADL's and transfers as needed. History of falls and generalized weakness. Physical therapy continues as indicated. Alert and oriented with confusion at times. Pleasant and cooperative with care. Out of bed to wheelchair for lunch. Fed self after set up. No acute respiratory distress noted. Lungs sounds clear, no cough noted. Oxygen level at room air is 96%. Review of the next nursing progress note dated [DATE] at 2:49 p.m., stated, Was notified by the receptionist that the resident's sister wanted to talk to the nursing supervisor about her sister. The sister thought that (the resident) was more confused. Review of Resident CL3's clinical record revealed a nursing note completed on [DATE] at 5:24 p.m., by licensed nursing staff, Employee E4 stated Resident sitting in front of the nurses desk when she started to complain of pain in lower calf, upon assessment was found to have a skin tear that measured 2.2 X 5.2 centimeters. Area was cleaned and dressed. According to the incident report that was completed by Employee E4 on [DATE] at 5:24 p.m., the Resident had a documented bruise to her left outer calf, she has plus 2 [MEDICAL CONDITION] (rating swelling-[MEDICAL CONDITION] from 1 being mild to 4 being severe) also, it appears that when her sock was removed it caused her very fragile skin over the bruise to tear causing injury. Resident had no idea what happened, she was complaining of pain to the area and that was how it was found. Handwritten on the facility's investigation into the skin tear incident dated [DATE], stated, Most likely due to plus 4 [MEDICAL CONDITION] at times. Review of the clinical record, revealed there was no notation that Resident CL3 had any [MEDICAL CONDITION] upon admission, and there was no notation that the physician was notified of plus 2 or plus 4 [MEDICAL CONDITION] of the leg on [DATE]. Review of Resident CL3's clinical record revealed a nursing note by licensed nursing staff, Employee E6 on [DATE] at 3:50 p.m., stating, Called into resident's room at approximately 11:30 a.m., by a CNA (Certified Nursing Assistant) due to resident having trouble breathing. Assessed the resident's lungs and found that she had a slight wheeze in the left lower lobe (of the lung). Vital signs were blood pressure ,[DATE], pulse of 113, respiration rate of 22, and temperature of 97.2 and an oxygen level of 93% on oxygen. Resident stated she was having a hard time breathing. I spoke to resident and tried to calm her, but she just was not able to settle. I went and got her a PRN (as needed medication) [MEDICATION NAME] (antianxiety medication) 0.25 mg at approximately 11:40 a.m., was called back to her room again at approximately 12:30 p.m., because she still was having trouble breathing. Oxygen level was 94% on oxygen. Speech therapy came to me and said that the resident was unresponsive. I went back to her room and approximately 12:50 p.m., performed a quick assessment and came out and informed the unit manager. The vital signs that were documented in the note did indicate the vital signs were abnormal findings including an elevated blood pressure, pulse and respiratory rate (as per the National Institute of Health National Heart, Lung and Blood Institute at www.nhlbi.nih.gov) and the licensed staff who wrote the note also did not indicate how much oxygen was being delivered to the resident to achieve a 94% oxygen level. Review of Resident CL3's clinical record revealed a nursing note by licensed nursing staff, Employee E5 dated [DATE] at 1:10 p.m., which stated, Called to resident's room at approximately 12:53 p.m., by charge nurse and speech therapist who reported that the resident was unresponsive. Upon assessment, resident was unable to be aroused, respiratory rate was 5 (normal rate would be anywhere between 15 and 18) and irregular. Pulse ox (measurement of oxygen concentration in the blood) unable to be obtained. Apical heart rate muffled and faint. Resident is a full code. Ambulance was called and crash cart obtained at approximately 12:55 p.m. CPR (cardiopulmonary resuscitation-when a resident's heart stops beating, a person will start chest compressions and mouth to mouth rescue) at 12:55 p.m., at which time the resident was pulseless and on oxygen via a mask. Suctioning initiated at 12:57 p.m. Ambulance arrived at 12:59 p.m. Resident left facility via stretcher at 1:01 p.m. for hospital. Review of Resident CL3's clinical record revealed a nursing note dated [DATE] at 2:36 p.m., by Employee E5, that stated, Hospital contacted at approximately 2:30 p.m. Reported that the resident had expired. Review of Resident CL3's clinical record did not reveal that Employee E6 contacted the physician regarding the resident having difficulty breathing, or receiving an order to administer oxygen when the resident first became short of breath or how much oxygen the resident needed. The clinical record did not reveal that any further vital signs were completed, or that the abnormal vital signs taken at 11:30 a.m., including the elevated blood pressure, elevated pulse and elevated respirations, were discussed with a physician. The clinical record also did not reveal what the outcome of the assessment that Employee E6 completed at 12:50 p.m. was and what the resident's level of consciousness or vital signs were in regard to the unresponsiveness the Speech Therapist reported. It was also not documented why CPR was not initiated at 12:50 p.m. by Employee E6 and why he left the room of the resident who was in distress. An interview with the Nursing Home Administrator and the Director of Nursing on [DATE] at 11:30 a.m., confirmed the incident with Resident CL3 did occur and that the physician should have been made aware of the plus 4 [MEDICAL CONDITION] and the respiratory decline the resident was experiencing on [DATE]. The facility failed to promptly notify the physician of the change in Resident CL3 oxygen levels and elevated vital signs and failed to continue monitoring the resident's vital signs during a change in the resident medial condition. Review of the facility's policy titled, Blood Sugar Monitoring, reviewed [DATE], revealed to ensure that diabetic (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) residents have continued monitoring of blood glucose and to provide appropriate interventions to residents who experience any hypoglycemic (low blood sugar) episodes. The policy indicated to administer glucose gel according to package instructions if a resident was able to respond and able to swallow, to administer [MEDICATION NAME] according to package instructions if a resident was not able to respond, and to monitor glucose level every 15 minutes until blood glucose level was within established parameters (65 - 99 micrograms per deciliters). Review of Resident CL4's physician's orders [REDACTED]. Review of Resident CL4's nursing notes dated [DATE] at 6:03 p.m., revealed that the resident was unresponsive and sweating profusely at approximately 5:10 p.m. and the resident's blood sugar that was taken at approximately 5:15 p.m. was 37 mg/dL. Clinical progress notes revealed that [MEDICATION NAME] was administered and that the blood glucose (sugar) rechecked at 5:45 p.m. was 64 mg/dL. The nursing notes also indicated that the resident was made a DNR/hospice consult (end of life care). There was no documentation to indicate that the resident's blood glucose was rechecked every 15 minutes until stable, as indicated in the facility's policy, after it was initially documented as 37 mg/dL at 5:15 p.m. on [DATE]. Further review revealed nursing notes dated [DATE] at 10:38 p.m., that the resident was unresponsive most of the shift and that the blood glucose at approximately 8:25 p.m. was 49 mg/dL. Nursing notes revealed that [MEDICATION NAME] injection was administered at approximately 8:30 p.m., and that the blood sugar at 9:00 p.m. was 59 mg/dL. There was no documentation that the resident's blood glucose was monitored every 15 minutes as indicated in the facility's policy and that further interventions were put in place to ensure that the resident's blood glucose levels were within established parameters (65 - 99) as indicated in the facility's policy. Review of the Resident CL4's Medication Administration Record [REDACTED]. Review of Resident CL4's Medication Administration Record [REDACTED]. Review of the resident's nursing notes and Medication Administration Record [REDACTED]. Interview with the Director of Nursing on [DATE] at 1:15 a.m.,confirmed that the resident's blood sugar level was not checked and should have been checked as indicated in the facility's policy. Review of Resident K9's physician's orders [REDACTED]. Interview on [DATE] at 11:40 a.m., with licensed nursing staff, Employee E11, confirmed that the medication should have been administered and not held. Review of Resident L4's eye consult dated [DATE], revealed a [DIAGNOSES REDACTED]. Review of the resident's treatment record, nursing notes and the physician's orders [REDACTED]. Interview on [DATE] at 11:40 a.m., with Licensed Employee E11 confirmed that the recommendation was not implemented. 42 CFR 483.25 Provide Care/Services For Highest Well Being. Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.29(j) Resident rights. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records. Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on observations, clinical record review, staff interview and facility policy and procedure review, it was determined that the facility failed to provide adequate supervision to ensure the safety of residents. The facility failed to ensure that procedures were in place to maintain adequate supervision when the staff needed to leave the unit and failed to ensure that the unit was adequately staffed to meet the safety needs of the residents on one unit (Evergreen) which placed the safety of residents in Immediate Jeopardy. The facility also failed to ensure that the residents were supervised to prevent falls for three of 23 residents reviewed (Residents G2, F2 and D8), and failed to ensure that the proper interventions were in place to prevent an elopement for one resident who was at risk of elopement (Resident B12). Findings include: Review of Resident B12's clinical record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Its primary feature is cognitive decline, which can lead to hallucinations, as well as varied attention and alertness when compared to a person's baseline function) and [DIAGNOSES REDACTED] (disease, damage, or malfunction of the brain). Review of Resident B12's nurses' notes revealed an entry dated February 16, 2015, at 6:54 a.m., stating, The resident became physically and verbally aggressive towards staff members, resident hit, kicked, and then proceeded to chase us out of the room with closed fist, threatening to punch staff. The nurses' notes for February 20, 2015, at 11:54 p.m., stated, Around 2100 (9:00 p.m.), resident went to his room and started moving the furniture around. Resident took adjacent bed, removed mattress from bed and dragged it into the hallway. Then he unlocked bed and tried to drag it into the hallway also. When staff went to get furniture from him, he pulled hands back as if to swing at staff. The nurses' notes dated February 22, 2015, at 11:22 p.m., stated, Resident was agitated and combative this shift. Resident tried to kick down the doors. When staff tried to apply PRN (as needed) Ativan Gel to resident, resident became agitated (an anti-anxiety medication in a topical form to be applied to the resident ' s skin). Gel was applied to the back of the resident and resident started to chase staff down the hall to hit staff. The nurses' notes dated February 24, 2015, at 7:21 a.m., revealed, Resident is a major safety threat for other residents, staff, and self. Resident attempting to move the closets and tipping furniture. Resident agitated and combative physically and verbally, and it became necessary to keep them (residents) apart throughout the shift. The nurses' notes dated February 25, 2015, at 2:01 a.m., revealed, Resident with increased aggression, combativeness and intent to move large furniture objects around, break down the doors and hit anyone or anything that interfered. Resident does not have the cognitive ability to comprehend the safety risk for himself or others related to his physical condition and dementia. On February 25, 2015, Resident B12 was sent to a geriatric psychiatric hospital and returned to the facility on [DATE]. The nurses' note entry on March 15, 2015, at 12:52 a.m., stated, Resident continues rattling doors, verbally belligerent with staff. The nurses' note dated March 15, 2015, at 1:12 a.m., stated, Resident increasingly belligerent and became physically abusive to staff, punching at CNA and RN. The nurses' note dated March 15, 2015, at 2:01 a.m., stated, Resident entered female resident's room, began to uncover female resident. When the RN intervened the resident became angry and attempted to punch the RN. The nurses' notes dated March 16, 2015, at 10:00 a.m., revealed, Resident became very agitated and threatening to staff and others, hard to redirect, pouring water in bedside drawer, yelling at another resident to get up so he could move his chair, hitting his open hand with his other hand in a fist in front of a female resident in a threatening manner . continued to move furniture and make threats. An entry dated March 18, 2015, at 9:32 p.m., revealed, Resident became agitated around 8:00 p.m. He closed the curtains in the activity room and began throwing items. He threw an activities board and a walker at first. Staff intervened and tried to distract resident from current behavior. Resident became more agitated when staff would approach so all staff kept their distance to encourage a de-escalation. Resident then started threatening to shoot staff while holding a wet floor sign. He started banging hard on resident doors. Signs were removed from the floor once the resident set them down. Resident then flipped the couches, took an end table and hit the window, took the feet off of one of the couches and began banging them on the glass windows. One of the couch pieces was broken by the resident. The doctor and the family were notified of the resident's condition and both agreed to send the resident to the emergency room . 911 was called and the police and ambulance worked together to transport resident. The nurses' note dated April 22, 2015, at 12:48 a.m., revealed the resident was back in the facility at 3:35 p.m., and an entry the same day at 1:11 a.m., revealed, the resident was observed pulling another resident out of her room by her wrist. Later that day an entry at 11:58 p.m. stated, Resident tried to push another resident in his wheelchair and when the resident was yelling at him to stop he grabbed the resident's left upper arm and started to shake and squeeze his arm. The nurses' notes dated April 24, 2015, at 7:22 a.m., revealed, Resident was physically aggressive with staff this morning trying to hit them with a belt. The nurses' notes dated May 6, 2015, at 6:37 p.m., revealed, Resident wandered into another resident's room and began to move his furniture around which upset the other resident. When the other resident complained he hit the resident in the left shoulder. The nurses' notes dated May 15, 2015, at 2:13 p.m., revealed, Resident attempted to get another residents walker, and knocked the residents hand off the walker causing skin tears on the resident's hand. An entry dated May 16, 2015, at 12:09 a.m., revealed that Resident B12 was in the activity room moving things around when another resident, Resident B6, told him to put them back. Resident B12 hit Resident B6 on the wrist then Resident B6 grabbed one of the binders and hit Resident B12 on the stomach and the side. The nurses' notes dated May 25, 2015, at 11:02 p.m., revealed, Resident was in the activity room and became agitated and hit another resident in his left upper arm. An entry dated May 28, 2015, at 6:43 p.m., revealed, Resident was very agitated this shift and hit myself (the nurse) in the arm and charged at me. Resident also kicked another resident twice in his lower leg, he also grabbed another resident's left forearm while a staff member was trying to walk (the other resident) into the activities room. Resident was sent via ambulance to (hospital) for further evaluation and treatment. The nurses' notes dated May 29, 2015, at 4:07 p.m., revealed the resident returned from the hospital around 1:30 p.m. he was placed in his room and began to eat lunch, about 15 minutes later came out of the room and started yelling at and going after another resident. The nurse then picked up the phone to call for assistance but the resident came and pulled the phone from the nurse and tried to rip it from the wall and started chasing the nurse around with the phone threatening her. 911 was called and the resident was taken again to the emergency room of a different hospital. The nurses' notes dated May 29, 2015, at 9:10 p.m., revealed the resident returned to the facility at 6:20 p.m. The nurses' notes dated June 2, 2015, at 6:00 p.m., revealed, Resident was in the activity room with other residents and was trying to get a board from another resident. After letting him have the board the resident was aggressive towards other residents. He was trying to wheel another resident in the wheelchair, and then kicked one resident and tried to hit another resident. Interview with Licensed Nurse, Employee E6, on June 4, 2014, at 12:30 p.m., revealed that Resident B12 has behavior issues which increase in the evening time and include moving furniture around the unit due to his history of being a mover, and physical and verbal abusive behaviors with staff and residents. During an interview with the wife of Resident B5 on June 4, 2015, at 3:30 p.m., it was revealed that the resident was admitted to the Evergreen Unit on October 31, 2014, with a [DIAGNOSES REDACTED]. Resident B5's wife stated that Resident B12, who also resides on the Evergreen Unit, becomes aggressive in the evening time and there is not enough staff on the unit to ensure the safety of the residents. Resident B5's wife indicated that there was one instance where Resident B12 became agitated with her husband and attempted to knock over his wheelchair. Resident B5's wife got between the two residents to protect her husband and sustained a bruise to her arm as a result. Observations of the Evergreen Unit on June 4, 2015, at 5:50 p.m. until June 4, 2015, at 6:00 p.m., revealed there were no staff members on the unit supervising the activities of 10 of the 11 residents who live on the unit. At 6:00 p.m. it was observed that nursing staff, Employee E3 walked out of the dining room which had the door closed and had no direct view of the rest of the unit. Interview conducted with Employee E3 at this time revealed that she was in the dining room because there was a resident in the dining room who was still eating dinner and it was the policy of the facility that when a resident was eating, there needed to be a staff member in there with them. Further interview revealed the door was closed because another resident kept coming by and closing it and Employee E3 decided to leave the door closed because she couldn't keep getting up and opening it again. Employee E3 also stated that there was another staff member (nursing assistant) assigned with her on the unit but she was unaware where she was and the nurse that was assigned to the unit was also assigned to move between the Arbor Unit and Evergreen Unit. Employee E3 stated that the other nursing assistant was probably at the other nursing unit (The Arbor) but did not know for sure. Further interview with Employee E3 revealed that this is the typical staffing and this has been happening a lot on this unit. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on June 4, 2014, at 7:30 p.m., revealed that the staff member who could not be accounted for by Employee E3, was using the bathroom on the unit. The NHA and DON also confirmed that there are periods of time when there is only one staff on the unit and it is not the policy of the facility for the staff to inform the rest of the assigned staff when they are using the bathroom despite being behind a closed door and unable to provide supervision to the residents of the unit. It was also confirmed during this interview that there is to be a staff member in the dining room when there is a resident eating. The facility was asked to provide a copy of the policy at this time and there was none provided by the facility. Review of the nursing staffing sheets for May 5, 2015 to June 3, 2015, revealed on the 3-11 shift every day of this period, there was only one Licensed Practical Nurse (LPN) assigned to both the 16 bed Arbor Nursing Unit and the 18 bed Evergreen Nursing Unit and on seven days during this time period, there was only one nurse aide assigned to the Evergreen Unit. The Arbor Nursing Unit requires the staff to go through two doors with a key code lock to access the Evergreen Unit. There is no no direct line of communication between the staff on the Evergreen Unit and the Arbor Unit, other than the telephones located at the nursess' station. Interview with the DON and the NHA on June 4, 2014, at 7:30 p.m., revealed that they were uncomfortable with the staffing levels of the nurses and aides on the Evergreen Unit and they were working on a plan to increase the numbers. The facility was asked to provide written documentation of what had been developed of the plan so far and none was provided by the facility. Immediate Jeopardy (IJ) was identified and communicated to the NHA and DON on June 4, 2015, at 8:25 p.m., for failing to ensure that proper supervision was being provided on the locked Evergreen Dementia Nursing Unit for the safety of the residents and failing to supervise a resident with an extensive history of aggressive behaviors. Resident B12 had required two inpatient psychiatric hospitalization s and had demonstrated physical behaviors that resulted in injuries to other residents, placing everyone on the Evergreen Unit in Immediate Jeopardy. Immediate jeopardy was removed, following the receipt of an acceptable plan, on June 5, 2015, at 3:45 p.m. The facility's plan of correction stated that the Evergreen Unit would be staffed minimally by one licensed nursing professional and two nursing assistants for each shift for all three shifts to ensure adequate nursing staffing and supervision to the residents on this unit. The facility indicated that Resident B12 would be appropriately supervised every 15 minutes or one to one staff supervision as needed and deemed appropriate by the licensed nursing staff in order to ensure the safety of the resident and other residents within the Evergreen unit. Interview with the Medical Director on June 5, 2015, at 9:30 a.m., revealed that he was unaware of any issues regarding a resident who was having dangerous behaviors and not enough staffing on the Evergreen Unit to ensure that there was proper supervision of the residents. An interview conducted with nursing staff, Employee E9 on June 10, 2015, at 9:30 a.m., revealed that the nurse who was assigned to the Evergreen Unit would have to float between the Arbor Unit and the Evergreen Unit and there were times when there was not enough staff on the Evergreen Unit. During an interview conducted with Licensed Nurse, Employee E11, on June 9, 2015, at 9:50 a.m., the employee stated that there was not enough staff assigned to the unit to ensure the safety of the residents. An interview conducted with Employee E11 revealed that the staff on the Evergreen unit was not enough and agreed that the residents were not able to be properly supervised. During initial tour of the Arbor Unit on June 4, 2014, at 12:40 p.m., a coffee pot in the utility room was observed to be turned on and the coffee pot was filled half way with coffee. The coffee pot was sitting on the burner and was very hot to touch. The door of the utility room was unlocked and was on the same hallway as residents' rooms. An observation on June 9, 2015, at 10:00 a.m., revealed that the coffee pot was again turned on and hot to touch. An interview conducted with nursing Employee E13 on June 9, 2015, at 10:00 a.m., revealed that residents do have access to this room; however, there is only one ambulatory resident on the unit and Employee E13 has never seen any residents in that room. Review of Resident G2's Minimum Data Set assessment (MDS- assessment of resident care needs and status) dated November 25, 2014, revealed that the resident needed limited assistance of one staff member to transfer and required one person assistance to walk in the room and required the extensive assistance (staff provided weight bearing support, resident involved in activity) of one person for toileting. Review of Resident G2's [DIAGNOSES REDACTED]. The Brief Interview Mental Status (BIMS) score of the assessment was 0 indicating that the resident had severe cognitive impairment. Review of Resident G2's January 21, 2015, significant change MDS indicated the resident needed extensive assistance with transfer with a two person physical assist, and was not ambulatory, was occasionally incontinent of bowel and frequently incontinent of bladder. Review of the fall care plan revealed there were interventions implemented January 3, 2015 after the resdent had a fall with injury. Interventions included have the call light in reach (Resident was severely cognitively impaired), monitor and provide toileting incontinence every 2-3 hours and as needed. The interventions were not followed or appropriate for the cognitively impaired resident. Review of Resident G2's nurses' note dated January 3, 2015, at 7:15 p.m., revealed, This nurse was called into the dining room bathroom where resident was found sitting on the floor. Resident asked what she was doing and she stated, (I fell off my seat.) It appeared that resident had already taken herself to the bathroom and got BM on the floor and may have slipped in the BM. Resident had facial grimacing when asked if her buttocks hurt and she finally replied yes. Review of the facility documentation of Resident G2's fall incident dated January 3, 2015, related that the resident was last seen in front of the nurses' station at 4:00 p.m., and was found in the bathroom in the dining room at 4:45 p.m. Review of the nurses' note dated January 4, 2015, at 3:07 a.m., stated, While CNA was turning resident, resident was yelling 'my back, my back,' PRN Tylenol was given at 02:40 a.m. for pain. Resident G2's nurses' notes dated January 4, 2015, at 9:31 a.m., related Call placed to MD regarding pain on movement in lower back and hips after falling yesterday, January 3, 2015. New order for X-ray to be done of bilateral hips and lower back. Review of the X-ray report dated January 4, 2015, indicated an acute fracture of the right pubic ramus (the bar-like projections that extend laterally from the pubic bone in the pelvis). This information was presented to the NHA and DON on June 10, 2015, at 3:15 p.m. The facility failed to provide supervision of cognitively impaired Resident G2 who was found on the floor of the dining room bathroom who was assessed to need assistance with transfers and toileting and who was at risk for fall and injury. Review of the facility policy titled, Wandering Resident, last updated March 2014, revealed residents whose assessment identified wandering behavior shall also be considered a risk for elopement. If a resident is identified as a risk for elopement, the following steps will be taken: a physician's order will be obtained for placement of a Wanderguard (bracelet applied to the resident which activates a locking mechanism on exit doors) and nursing will assess for placement of the Wanderguard on the residents every shift and record in the Treatment Administration Record (TAR). Review of Resident B12's wander risk assessment, dated April 22, 2015, revealed the resident was assessed as a moderate risk for wandering. There was no indication that a Wanderguard was initiated when the resident was assessed April 22, 2015 to be a wandering risk. Review of the nurses' note dated April 23, 2015, at 1:59 p.m., stated, Activities aide noted the resident on the breezeway knocking on the door of the Arbor (nursing unit). When bringing the resident back to the Evergreen Unit (nursing unit where resident resided), the nurse noted that the doors were not locking and latching. The nurses' note further stated that a Wanderguard was applied to the resident. The facility failed to place a Wanderguard on Resident B12 in April when the resdient was identified as a wandering risk, as indicated by the facility policy. This information was presented to the NHA and DON on June 10, 2015, at 3:15 p.m. Resident F2 was admitted to the facility on [DATE], after sustaining a fall with a resulting fracture and open head injury at an assisted living facility. Review of the admission MDS related the resident does not walk and uses a wheelchair. Review of facility documentation dated May 4, 2015, at 12:55 p.m., related, It was brought to this nurses attn by CNA that resident was on the floor in her bathroom. No unjury noted. Resident's wheelchair was in the bathroom near doorway out of resident's reach. Facility documentation related that the resident was identified with a gait imbalance. The immediate action taken by the facility was to educate the resident on the use of the call button when she needs assistance. Further review of Resident F2's nursing progress notes revealed that the resident continued to have falls on May 13, May 19, May 24, May 29, June 1 and June 2, 2015 and also noted increased confusion on an on-going basis. Review of Resident F2's plan of care revealed that the resident is at risk for falls secondary to previous history of falls. Further review of the plan of care failed to reveal new interventions to assist in preventing subsequent falls on May 4, May 13, May 24 and June 1, 2015. Interview with Licensed Nurse, Employee E5, revealed that Resident F2 is confused and continues to remove her oxygen and continues to try to climb out of her bed. Observation of Resident F2 on June 4, 2015, at approximately 1:00 p.m. revealed the resident in her room alone. Repeated observations by this surveyor on June 5, June 8, June 9 and June 10, 2015 all revealed Resident F2 alone in her room with no supervision. The facility failed to put new interventions in place for the resident with a history of falls. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 03/13/2014. 28 Pa. Code 201.18(a) Management. Previously cited 10/09/2013, 03/13/2014. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/09/2013, 03/13/2014, 09/08/2014. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 03/13/2014. 28 Pa. Code 211.5(f) Clinical records. Previously cited 10/09/2013, 03/13/2014, 09/08/2014. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 10/09/2013, 03/13/2014, 05/29/2014. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 10/09/2013, 03/13/2014, 09/08/2014. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services. Previously cited 10/09/2013, 03/13/2014, 09/08/2014.

Based on review of facility documentation and interviews with staff, it was determined that the facility did not maintain a current and detailed written emergency preparedness plan to address potential emergency evacuation situations and placed the safety of the residents, family and staff in Immediate Jeopardy. Findings include: Review of the facility's undated fire and disaster manual revealed that the fire and disaster plan was developed to better acquaint the staff with the procedures to be followed in case of a fire or any other emergency, to minimize and to overcome the effects of emergency/disaster circumstances to patients, staff and community. The plan further revealed, it is paramount that the staff know the plan, as it will be through the staff's knowledge and efforts that the procedures will work as planned and prevent serious injury or loss of life. Review of the facility's Fire and Evacuation Plan stated in regards to a major internal disaster, evacuation of residents would be to one of the following areas: "Victory Chapel" (It should be noted that there is no Victory Chapel church in existence since 2000. The new church at that location is called Freedom Life.); home (at request of family), hospital (depending on availability of beds). Transportation would be provided by fire department, police department,or civil defense as previously arranged (bus, van). The plan related that there would be a disaster drill (not a fire drill) once a year. Interview with the Fire Chief, E3, on March 12, 2014, at approximately 3:30 p.m., revealed that no emergency drill would be conducted at the facility since the disaster plan was not current. The Fire Chief, E3, reported that in the event of a disaster and an emergency evacuation, the county had a plan to temporarily evacuate the potential of 139 residents from Harrison Senior Living of Christiana, but wanted the facility to develop their own evacuation plan with places, mode of transportation, etc. The emergency evacuation disaster plan failed to provide current procedures for accessing electronic clinical record information for residents concerning physician orders, medication and treatment orders, etc. and to provide this information to the transfer sites. The disaster plan indicated families will be notified immediately of the residents' return. The disaster plan further failed to ensure procedures to include the residents' responsible party contact information upon emergency transfer of the residents. A interview with the Nursing Home Administrator (NHA) on March 12, 2014, at 1:30 p.m., regarding contacting "Civil Defense" in the event of a disaster, related she did not know who to contact. Interview with the Fire Chief, E3, on March 11, 2014, at 3:30 p.m., revealed that multiple attempts to meet with the facility representatives were made in an effort to help the facility develop and maintain their disaster preparedness plans as current, and the facility cancelled those meetings. The interview further revealed that the fire department would evacuate residents if necessary, but only to a temporary location that could accommodate the residents for a few hours. Furthermore, interview during the entrance conference with the NHA and the Director of Nursing (DON) on March 5, 2014, at approximately 12:15 p.m., revealed that the facility used electronic medical records. The interview revealed that the facility's electronic medical records included resident demographics (including family contact information), interdisciplinary progress notes, resident assessments, resident care plans, physician's records and medication and treatment administration records. The electronic records also included the point of care documentation. The interview revealed that these records were available by computer access. Review of the disaster manual faxed to the field office March 14, 2014 (copy requested during the survey but not received) did not include how the facility would obtain computers, how staff were to access electronic clinical records including medication and treatment orders and administration records. There were no directives on how staff would use the computerized electronic clinical information/records in the event of an emergency evacuation to ensure adequate care to the residents. In addition, the disaster manual did not include how disposable supplies and equipment for urgent, incontinence care and linens would be obtained in the event of an evacuation. During an interview with the NHA and the DON on March 12, 2014, at 1:30 p.m., the NHA confirmed that the disaster plan was not current and did not know when the policy was last updated. The NHA indicated that the facility would default to the community/township fire department in the event of an evacuation and had not met with Fire Chief, E3, to develop an effective evacuation plan unique to the needs of the facility. The NHA indicated during interview March 12, 2014, at 1:30 p.m., that during her orientation to the facility in November 2013, for new hire orientation, she "pulled" the disaster manual when she realized that the policy was not current and set it aside to update and review later. The failure of the facility to develop and implement a current disaster plan resulted in another Immediate Jeopardy issue. Immediate Jeopardy was called on March 12, 2014, at 2:50 p.m., for the lack of a working disaster evacuation plan. Refer to F323 and F518. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/09/2012, 07/01/2013, 10/09/2013. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/27/2011, 11/09/2012, 07/01/2013, 08/29/2013, 10/09/2013. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/27/2011, 11/09/2012, 10/09/2013. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/09/2012, 07/01/2013, 10/09/2013. 28 Pa. Code 201.18(e)(4) Management. 28 Pa. Code 209.7(a) Disaster preparedness.

Based on observations, facility policy reviews, clinical record reviews and staff and visitor interviews, it was determined that the facility failed to ensure the environment remained free of accident hazards and provide adequate supervision with regard to: the exposure to hazardous exhaust materials; the improper actions by the staff regarding the security of entrance/exit doors; the failure of the staff to ensure that residents at risk for wandering and elopement were secure from elopement. The facility further failed to establish and utilize a systematic approach to resident safety in regard to the investigation and analysis of a resident elopement (Resident E2), thereby placing the health and safety of the residents in Immediate Jeopardy. Additionally, other safety concerns were identified on two of five nursing units regarding the failure to ensure water temperatures were safe on one unit (Arbor Nursing Unit) and that hazardous substances were secured in a second unit (Chestnut Nursing Unit). Findings include: On March 11, 2014, at approximately 10:40 a.m., the survey team was notified by the field office of an anonymous concern received at the Lionville Field Office. The caller stated a strong gas odor was coming from the gas water heaters located in the laundry area and the caller expressed concern for the residents' safety. The caller further stated that this condition had existed for several weeks and that the facility staff were aware of the issue. Observation of the laundry area located on the ground level, on March 11, 2014, at approximately 11:30 a.m., revealed that no odor was detected at the four water heaters in the laundry. A small fan was observed running. The fan was located on top of a backup (extra) water heater that was not connected to the water lines. The door to the laundry area was also opened. This door leads into the hallway which is across from the rehab therapy area. A laundry staff worker, Employee E6, interviewed on March 11, 2014, at approximately 11:30 a.m., stated that there was a terrible odor in this area for about a month. Employee E6 displayed a hand held 'gas meter' and stated that a friend gave it to her to measure gas, i.e. carbon monoxide because of her concern about the smell. Employee E6 further stated, "I work part-time in the laundry area to help with the folding". Employee E6 reported that some full-time staff may have become ill from the smell. Interview with the Maintenance Director, Employee E12, on March 11, 2014, at approximately 12:00 p.m., revealed that he was aware of a problem with the water heaters for approximately one month. Employee E12 initially was unsure of the source of the problem but felt that it was a faulty exhaust fan and was possibly caused by a non-working fan located on the roof of the building. Employee E12 could not confirm this because he needed to rent a lift to examine the motor on the roof. Ice and snow had further delayed the investigation into the status of the fan motor. Employee E12 related that he had informed the Nursing Home Administrator (NHA) that he needed to order a fan motor which was an expensive item. During an interview with Employee E12, on March 11, 2014, at approximately 12:00 p.m. Employee E12 stated that he was waiting for approval from administration before going ahead and ordering the expensive item and had not received a verbal or written approval to order the exhaust motor to the fan. Interview with the NHA on March 11, 2014, at approximately 12:15 p.m., revealed that she was also aware of the problem with the non-working exhaust fan motor for the water heaters and had not mentioned this problem when she was touring the area with a surveyor on March 10, 2014. The NHA related that Employee E12 had completed the inspection of the exhaust fan motor and reinforced that there was a delay due to snow and ice on the roof. The NHA further stated, "I told Employee E12 to go ahead and order the necessary items for the repair approximately a week ago". The NHA was unsure of the date of that conversation. She revealed that she would monitor the ground floor area for odors twice daily, on the way in and the way out of the facilty. The ground floor area included the main kitchen, the laundry, the therapy department, the housekeeping department, the social worker offices and the employee lounge. The area was used by staff in these departments as well as residents receiving therapy. Interview with the NHA on March 11, 2014, at approximately 12:20 p.m., confirmed that the new motor was not ordered and she did not pursue the issue with maintenance. She further stated, "It must have been a miscommunication about the ordering." The NHA stated that it did not occur to her to consult with the gas company or an outside contractor to address the gas/exhaust odor reported by staff. Observation on March 11, 2014, at approximately 12:00 p.m., revealed the police and fire department arrived at the facility due to a 911 dispatch relating to the strong gas odor. Observation on March 11, 2014, in the ground floor corridor at approximately 12:00 p.m., and interview with the Fire Chief at that time related that the Fire Chief stated that upon entering the ambulance entrance of the ground floor, his carbon monoxide device was alarming and the device was registering 200 ppm (parts per million). A second interview with the Fire Chief (E3) on March 11, 2014, at approximately 12:20 p.m., clarified that the carbon monoxide reader will start alarming when it registers at 35 ppm (parts per million) and that when he arrived it was registering at 200 ppm. Survey staff asked what the smell was. The Fire Chief (E3) stated that they were not smelling carbon monoxide but a byproduct since the exhaust fan motor is not pulling the exhaust out. Interview with the Fire Captain (E4) on March 11, 2014, at 12:30 p.m., in the presence of the Fire Chief (E3) stated that the exhaust is back up and the carbon monoxide reader is now showing a low explosive level which was recorded at 19. The Fire Chief then stated the gas fired water heaters needed to be shut down. The ground floor area includes the kitchen, the laundry area, the therapy rooms and gym, the social work offices, the employee lounge and the ground floor ambulance entrance and parking area. Interview with the Fire Chief (E3) on March 11, 2014, at 12:30 p.m., also related that the Fire Chief (E3) repeatedly told the facility staff to shut off the gas to the hot water heaters. The Fire Chief also related that no staff had informed him that the problem with the exhaust had been a problem for about one month. During an interview on March 11, 2014, at 12:45 p.m., Fire Chief, E3, stated, "the lower level of the building needed to be evacuated immediately." The four water heaters were shut down. Two hot water heaters controlled water for the laundry and the kitchen and two water heaters controlled the hot water to the first floor Chestnut Nursing Unit and the second floor Dogwood Nursing Unit which are located directly above the laundry and the kitchen areas. Immediate Jeopardy was identified to the NHA on March 11, 2014, at 1:15 p.m., for failing to promptly investigate and repair a non-functioning exhaust fan motor to assure adequate ventilation, which resulted in the buildup of carbon monoxide in the ground floor level of the nursing home which placed the health and safety of residents, staff and visitors in Immediate Jeopardy. During an environmental tour on March 7, 2014, observations of the facility's main entrance and ambulance entrance, all doors that exit into stairwells, all doors leading directly to another nursing unit and all doors exiting to the exterior of the facility or into an enclosed courtyard, revealed that these doors were all equipped with an electronic keypad lock (lock is released by using a number code or with a fire alarm). An interview with the Director of Nursing (DON) and the NHA on March 12, 2014, at 6:30 p.m., confirmed that all the keypad doors use the same code to unlock the doors. The NHA and the DON further comfirmed that only two keypad doors lock at 8:00 p.m. These doors were the main entrance door and the ground floor ambulance entrance door. The keypads for these doors were to provide the facility with a safe environment, to oversee all persons who gain entrance and exit from the facility or areas in the facility, and to minimize the safety risk for those residents who are at risk for wandering or eloping. Observations of the secured locked Evergreen Nursing Unit (the secured dementia nursing unit) on March 7, 2014, and on dates, March 11 to March 13, 2014, revealed that this secured unit was constructed with four glass doors, each labeled as an exit door. These four doors further provided electronic keypad code access for exiting from the Evergreen Nursing Unit to an unsecured courtyard and two parking areas. Residents and visitors were observed, throughout the survey days of March 7, 2014, and March 11 to March 13, 2014, to be utilizing the electronic keypad device to enter the unit and exit the unit, independent of the staff assistance. There was no evidence of increased staff supervision of residents in the secure unit to ensure the whereabouts of the residents and that the residents were not inadvertently leaving with visitors or staff that were exiting the unit. Further observations on March 7, 2014, and March 11 to March 13, 2014, revealed that individuals exited through the secured Evergreen Nursing Unit to obtain access into the Arbor Nursing Unit from inside the facility. The staff, residents and visitors had to first walk through the secured Evergreen Nursing Unit. The second step, then required individuals to exit from the Evergreen Nursing Unit through a keypad exit door that goes into an opened, unlocked courtyard. The courtyard lead to the sidewalk and then to the outside keypad entrance into the Arbor Nursing Unit. To access the Arbor Nursing Unit, without walking through the secured Evergreen Nursing Unit, individuals entered the Arbor Nursing Unit through an outside entrance door. Interview with Nurse Aide, Employee E13, on March 11, 2014, at 9:30 p.m., (and two additional nursing staff who did not want to identify themselves), indicated that they were concerned for the safety of themselves and the residents because the electronic keypad code was being given to anyone, even residents, whenever necessary. Employee E13 further alleged that the current code had never been changed since inception; and those employees who were fired, could still gain unauthorized access into the building. In addition, Employee E13 provided, to the surveyor, an observation on March 11, 2014, at 9:30 p.m., of an electronic intercom doorbell system, located on the Chestnut Nursing Station. Employee E13 alleged that after 8:00 p.m., the electronic keypad code was locked to the ground floor ambulance entrance from outside, and could only be accessed if the staff used their employee swipe card, or if the staff answered the doorbell, after a verbal communication, and released the lock at the intercom station. Employee E13 demonstrated for the surveyor, the doorbell alarming, and how the staff would just press the intercom and request a verbal identification of anyone who wanted entrance and then released the lock. There was no evidence of a policy or procedure that indicated how staff would verify that the person entering was authorized to come in the facility or that a resident was possibly exiting the facility when a visitor was entering. Employee E13, on March 11, 2014, at 9:30 p.m., alleged that the staff were not expected to leave the Chestnut Nursing Unit, to go downstairs to the ground floor ambulance entrance, but to obtain visual observation of the visitor prior to unlocking this ground floor entrance, and were not required to escort visitors after 8:00 p.m. through the facility. Employee E13 indicated that there were no current safety requirements for staff to monitor the whereabouts of visitors once the visitors were in the facility (such as a sign in book listing who the person is visiting) and the facility was not equipped with any video monitoring system for surveillance of the ground floor ambulance entrance, or anywhere in the facility. This was confirmed during interview with the NHA and the DON on March 12, 2014, at 3:00 p.m., at which time, both confirmed the facility had one doorbell and it was located by the ambulance entrance and there were no video monitoring systems for the doors. Interview with Employee E13 on March 11, 2014, at 9:30 p.m., indicated that everyone (visitors, families and residents) knew the code and the doors would not alarm when the code was entered, therefore, the staff are not alerted when a door is being opened, unless the staff had a visual observation of the door at all times. Observation on March 11, 2014, with Employee E13 at 9:40 p.m., on the first floor, designated resident smoking secured courtyard area, confirmed that the door exiting outside to the smoking courtyard was equipped with an electronic keypad, but it was disengaged so the residents could access the courtyard to the designated safe smoke area with ease. The gate, at the end of the courtyard, which secured the area, was also equipped with a keypad code. Employee E13 confirmed that the electronic keypad on the exterior gate was a good idea but again, staff and family who knew the code would enter the facility through this gate, into the courtyard, and into the facility. During an interview on March 12, 2014, at 3:00 p.m., the NHA and the DON confirmed that the secured Evergreen Nursing Unit would afford corridor access into both the Birch and Arbor Nursing Units and access to an unsecured courtyard and two small parking areas. The NHA and the DON also confirmed the surveyor team findings related to the electronic keypad system, and they were aware that the Evergreen Nursing Unit was not only being used by staff, but was also used by visitors and a few independent residents, by entering the same electronic code which was used by staff. The NHA and the DON both confirmed that it was determined that the staff were likely sharing this code for a long time with visitors. The NHA further indicated that the doors do not alarm when the code is entered and when the door is opened, and the code was not likely changed for at least two years because the facility did not have the manufacturer's instructional steps or a staff designated to routinely change the code. The DON further confirmed, on March 12, 2014, at 3:00 p.m., that the secured Evergreen Nursing Unit was not currently equipped with a different access code from the rest of the facility, and indicated that residents residing on the secure Evergreen Nursing Unit were safeguarded from elopement because many were wearing an alarming Wander Guard bracelet. Review of the facility policy, "Wandering Resident/Elopement," dated June 2008, indicated that the facility would provide a safe environment for all residents. The facility would properly assess residents and plan for their care to prevent accidents related to wandering behavior and elopement. The policy proceeded for all residents to be assessed for the risk of wandering/elopement on admission, readmission, quarterly and following a significant change in condition, and the care plan would be modified as necessary. A resident's assessment that identified wandering behavior would also be considered and assessed for being at risk for elopement. If it was determined that the resident was at risk for elopement, then a Wander Guard alarming bracelet (a device used to alert staff that a resident was leaving the unit) would be applied. Licensed nursing staff would be responsible to check for the placement of the Wander Guard bracelet each shift. To ensure that the Wander Guard bracelets functioned, the Assistant Director of Nursing (ADON) was responsible for the weekly performance checks that the battery inside the bracelet was functioning properly. When the survey team discussed the facility wide wandering and elopement incidents, with the DON and the NHA on March 12, 2014, at 3:00 p.m., both confirmed that Resident E2 was reviewed for elopement. The incident report documented that the resident was wearing a bracelet when he eloped from the secured Evergreen Nursing Unit in December 2013. However, the bracelet was not effective in alerting staff to this elopement because Resident E2 eloped through a first floor window by cutting the window screen. The DON also confirmed, on March 12, 2014, at 3:00 p.m., that a while ago, she recognized the facility had a problem with elopements in regard to not having all the residents at risk of elopement photographed. These photographs were posted so staff would be able to identify those residents who were at risk for elopement and were wearing a Wander Guard bracelet. The DON confirmed that the only photographs posted a while ago (time not provided) were for Residents E2 and E17, but then the DON commented that she just forgot about the problem with the photographs for other residents at risk for elopement. Observation by a surveyor on March 10, 2014, at approximately 1:00 p.m., of the laundry department, revealed two photographs were posted for residents at risk for elopement (Residents E2 and E17). The DON confirmed on March 12, 2014, at 6:30 p.m., that only two photographs of residents at risk for elopement were posted on the Chestnut Nursing Unit in the microwave room and the photographs were of Residents E2 and E17. The DON further related there were six residents at risk for elopement that should have had photographs and a Wander Guard bracelet applied, but did not have these measures in place. The DON further reported that the facility did not have extra bracelets available. Interview with the NHA and the DON on March 12, 2014, at 3:00 p.m., indicated they were unaware of those staff who were to be documenting for the function check of the Wander Guard battery on a regular basis, but thought it was weekly. The DON and the NHA thought the nursing unit managers were responsible for battery function test but there was no documentation to confirm the testing. The NHA and the DON did not confirm that the nursing units had access to a hand held device to check the function of the Wander Guard bracelets. Interview with the DON on March 12, 2014, at 3:00 p.m., also related that she was unaware if the Wander Guard system utilized batteries and, if so, when the Wander Guard batteries were last changed or how the facility ensured battery life. There was no evidence that the facility implemented alternative safeguards for resident safety when it was known that the staff failed to be compliant with the security of the facility, by allowing the electronic keypad code to be consistently and routinely shared with the residents and visitors. The facility failed to ensure for the security and safety of residents by never changing the code, by allowing easy access of individuals into the facility and easy egress of residents to the outdoors. The facility failed to ensure that residents identified at risk for elopement were photographed and applied a battery operated alarming bracelet, and failed to ensure the staff were documenting the routine function of the Wander Guard bracelets and that the facility had a system to ensure that battery life was maintained. Review of Resident E2's clinical record and admission record sheet, indicated that the resident was admitted to the facility, to the secured Evergreen Nursing Unit, on August 8, 2013. In addition, [DIAGNOSES REDACTED]. Resident E2's 7 day admission assessment, dated August 15, 2013, indicated that the resident was able to be interviewed for mental status and the BIMS score (brief interview for cognitive status) was 7, indicating severe impairment. Resident E2 was assessed upon admission for being an elopement risk/wanderer related to dementia and interventions were developed for Resident E2 on August 20, 2013, including the placement of the Wander Guard bracelet, as ordered by the resident's attending physician. Review of Resident E2's nurses note, dated December 11, 2013, at 3:41 p.m., documented that at 1:45 p.m., the aide notified the nursing unit manager, Licensed Employee E19, that the resident was not located on the unit. A complete search was conducted and a code green (code for alerting staff of a missing resident) was called. The resident returned to the facility with a staff member at approximately 2:15 p.m. Review of the facility's documentation of the incident dated December 11, 2013, at 3:09 p.m., indicated that the facility called the state police, the resident's family and the attending physician. Several staff members left the facility and got in their cars to look for the resident. The resident was found by a staff member along the road and the resident was brought back to the facility at 2:15 p.m. (a time lapse of 30 minutes from when the resident was discovered missing from facility). The resident's family and attending physician were notified of the resident's safe return to the facility. Review of Resident E2's facility elopement incident, dated December 11, 2013, at 3:09 p.m., documented that Resident E2's mental status was oriented to person, place, situation and time. This was in contrast to the 7 day admission assessment dated [DATE], which indicated severe cognitive impairment with a BIMS score of 7. Review of the facility documentation of the incident dated December 11, 2013, indicated that on December 11, 2013, at 1:45 p.m., the nurse aide notified Employee E19, the Evergreen Nursing Unit manager, of the missing resident. The unit was searched and it was determined that the resident was not in the facility. The window screen in the resident's room was open and there were footprints in the snow with a trail from the window and out to the pavement. The resident was last seen entering his room at approximately 12:45 p.m. It was documented that the resident stated, "I wanted to go for a walk. I wanted to go see my family. I knew what I was doing". A request by the survey team for review of any written staff/witness statements obtained by the facility for further analysis and evaluation into Resident E2's elopement incident, revealed the facility obtained only one written staff statement. The NHA and the DON both confirmed, on March 12, 2014, at approximately 10:00 a.m., that the facility did not obtain any additional written staff statements from those staff working in the secured Evergreen Nursing Unit, from any staff who were involved in the community search, or from the staff who allegedly found the resident in the community and who returned the resident to the facility. The DON confirmed that it was unclear as to where in the community the staff found Resident E2, but thought it was somewhere on Route 30, which is a heavily traveled route with truck traffic, and a pedestrian would be at risk for being struck by a motor vehicle. Review of a written staff statement, which was not dated as to when the statement was compiled by staff, documented the following, "On December 11, 2013, at approximately 12:45 p.m. I saw Resident E2 go into his room right after he ate lunch. He laid down and covered up. About 1:45 p.m. I went in his room to toilet another resident and I noticed the screen was up in the window. I went over to the window and noticed foot prints leading towards the parking lot. I notified the nurse right away." Immediate Jeopardy was identified on March 12, 2014, at 3:00 p.m., due to the facility's failure to provide adequate supervision for the residents at risk for wandering due to unsecured keypad doors throughout the facility resulting in free access by any person to gain entrance or exit from and into the secured dementia unit as well as other exit doors throughout the facility and failure to educate staff to secure these doors. Additionally the facility failed to ensure that residents at risk for elopement were wearing alarm devices and that these residents were readily identified to ensure their whereabouts and notification if they tried to exit the secure unit as per facility policy. The facility also failed to conduct a thorough investigation through interviews and analysis of the elopement of Resident E2 who eloped December 11, 2013, that could have resulted in serious harm to the resident. An action plan was requested on March 12, 2014, at 3:00 p.m., to immediately put systems in place to ensure adequate supervision of the facility and safety of the residents. Interview with Licensed Staff, Employee E14, on March 13, 2014, at 11:15 a.m., who was assigned to the secured Evergreen Nursing Unit, indicated that she had been working at the facility for approximately one year and does not recall that she was educated to not provide the keypad code to visitors or other residents who come through the unit. Employee E14 also confirmed that prior to this morning, March 13, 2014, the following residents on the unit were wearing Wander Guard bracelets: Residents E2, E3, E7, E10, E15, E16 and E17; and she was educated this morning that Residents E4 and E8 should be wearing a bracelet but they have to buy some more for these residents. Employee E14 confirmed that for the past year, she was not requested to check the function of Wander Guard bracelets and did not see this task being completed by any other nursing staff. Observation of Resident E2's Treatment Administration Records with Employee E15, for December 2013, and for February through March 2014, revealed no evidence that the resident's Wander Guard bracelet was checked for function, and there was no section in the records for this documentation to be recorded. Licensed Nurse, Employee E14, further confirmed that for Resident E2 and all other residents with Wander Guard bracelets, she would never check function unless she found a bracelet on the unit, then she would check function before reapplying the bracelet to the resident. Observation with Employee E14, revealed no evidence that the unit was storing a hand held device which would be used to check the function of the Wander Guard bracelets. Interview with Nurse Aide, Employee E13, on March 11, 2014, at 9:30 p.m., confirmed that the facility had a resident elope from the dementia unit in December 2013, and that Resident E2 was found by somebody at the Brass Eagle Restaurant on Route 30. An interview with Housekeeping Staff, Employee E16, on March 13, 2014, at 12:30 p.m., who rotates assignments on all nursing units, confirmed that Resident E2 had eloped from the secured unit through a window and the resident was at the Brass Eagle Restaurant. Mapquest calculations for the number of miles from the facility to the Brass Eagle Restaurant was 4.7 miles. An interview with Resident E2, on March 13, 2014, at 12:00 p.m., revealed that the resident was able to recall the incident when he left the facility and went out through his bedroom window. Resident E2 alleged that he did not cut open the window screen, as he didn't need to because the window just opened all the way up. Resident E2 confirmed that he was dressed appropriately for the weather, alleged that there was no snow on the road, just a pile of snow right outside his window which was left over from a previous snow fall. Resident E2 further revealed that his intent to leave was just to go visit his son who lived around the corner street in an apartment. The resident admitted that his son had already moved out because someone else was living there already. Resident E2 also indicated that his wife also moved out of the area (maybe New York) and has not visited the resident for many months. Resident E2 reported that after leaving his son's previous apartment, he just kept walking on the sidewalks and only returned to the facility because his feet were sore or he was hungry, "something like that." Resident E2 denied that staff located the resident in the neighborhood or at a restaurant, or that he was escorted back to the facility. The resident stated, "I just walked through the front door and came back here." Accident hazard concerns were identified during a tour of the Arbor Nursing Unit on March 5, 2014, at approximately 1:40 p.m. The shower room sink was noted to have a water temperature that measured at 115.1 degrees Fahrenheit (F). The sink in resident room 105, on the Arbor Nursing Unit, measured 117.5 degrees F. At approximately 1:49 p.m., on the Arbor Nursing Unit, the temperature of the water at the sinks in resident rooms 113 and 109 was 112.2 degrees F. Resident room 110 had a water temperature in the sink of 113.1 degrees F. Repeat temperatures were obtained on the Arbor Nursing Unit, on March 5, 2014, between 2:30 and 2:45 p.m., with the Maintenance Director, Employee E12. The three readings obtained were found to be 113.3 degrees F in the shower sink, 116 degrees F in resident room 105 and 117.6 degrees F in the resident restroom. Interview with Employee E12, on March 5, 2014, at 3:00 p.m., revealed that the three nursing units, Arbor, Evergreen and Birch, were on the same water line. They utilized a mixing value to control water temperature in the resident areas while the other two nursing units, Chestnut and Dogwood, had water heaters with thermostats. In addition, Employee E12 stated that the temperature always spiked a little high and took about 15 to 20 seconds to level out. Observation of the mixing valve, for the water heaters in the basement, at approximately 3:15 p.m., on March 5, 2014, revealed that the mixing valve was set at 115-116 degrees F. Employee E12 stated that the water provided to the facility from the borough water company was hard on the mixing valve and needed to be replaced yearly or every two years at the most. The current mixing valve was about one year old. Review of the temperature logs indicated that the maintenance staff were checking water temperatures on each nursing unit daily, and were found to be at 110 degrees or below, although the temperatures were checked at the same time every day. Employee E12 stated that the times should vary. Review of the facility policy provided by the NHA, dated March 5, 2014, (the same day as the observations) revealed that the facility will monitor temperatures daily on all units and that the time would vary. In attempting to adjust the mixing valve lower, Employee E12 was obtaining temperatures that were too low. During an observation on March 6, 2014, at approximately 9:30 a.m., Employee E12 checked the temperature on the Arbor Nursing Unit and noted a temperature of 95.5 degrees F in resident room 102. It was decided by the NHA and recommended by Employee E12, to change the mixing valve to assure stabilization of the temperatures. The facility failed to develop a water temperature policy and identify fluctuating water temperatures by routinely monitoring temperatures at random times to assure comfort and safety for the residents. During the initial tour of the Chestnut Nursing Unit on March 5, 2014, at approximately 1:00 p.m., a storage closet was observed to be unlocked at the end of the 328 to 333 hallway. This storage closet contained nail polish remover pads (one full box of 100), two boxes of 50-pack razors, denture cleaning tablets, and 10 bottles of spray-on lotion which read: "Keep out of the reach of children." The same storage closet was also observed to be unlocked on March 6, 2014, at 9:30 a.m. The unsecured medical supplies, being stored on the nursing unit, were discussed with the DON and the NHA on March 6, 2014, at 2:30 p.m. The facility submitted and implemented acceptable plans of action and the Immediate Jeopardy (IJ) was removed on March 13, 2014, at 2:00 p.m.. This was two days after the initial Immediate Jeopardy issue was identified for failure to repair the exhaust fan motor timely that was initially identified on March 11, 2014 at 1:15 p.m. F323 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 11/09/2012, 07/01/2013, 08/29/2013. 28 Pa. Code 20

Based on observations, review of facility policy, review of the clinical records and interviews with the staff, it was determined that the facility failed to accurately assess, timely identify, and provide all the necessary care and services to prevent the development of pressure ulcers, causing actual harm to six of 10 residents with pressure sores (Residents: CL4, N7, I10, B1, F5 and N2). Findings include: Review of facility's "Preventative Skin Policy" dated May 2011, indicated that the facility's goal was to provide the highest level of care to the residents including the assessment of skin on both a periodic and continuing basis. The policy indicated that the skin is assessed at the time of admission, quarterly and annually using the tools from Minimun Data Set Assessment 3.0 (an assessment tool to identify resident care needs and current status). The policy also indicated that the abnormalities that are identified are treated through the facility's skin and wound care programs. The policy further indicated that the abnormalities are immediately reported to the charge nurse and addressed. Review of Resident CL4's September 2013, physician's orders [REDACTED]. A review of the hospital transfer documentation dated July 5, 2013, noted that the residen'st skin was intact. A review of the resident's admission MDS dated [DATE], identified the resident as requiring extensive assistance of two staff persons for bed mobility and transferring and as having no ambulatory capabilities. Review of the Braden scale (a tool used to evaluate risk for skin breakdown) dated August 3, 2013, revealed a score of 17 which placed the resident at low risk of developing pressure ulcers (an area of damaged skin caused by staying in one position for a long time, that commonly form on the bony prominences of the skin). Review of Resident CL4's pressure ulcer report dated August 20, 2013, and wound care specialist evaluation dated August 20, 2013, revealed Resident CL4 had a left second toe Stage III pressure ulcer (full thickness skin loss involving the epidermis), measuring 0.5 centimeter x 1.0 centimeter x 0.2 centimeters, with light serous exudate (clear fluid, that leaks out of blood vessels) and 15 % necrotic tissue (black, dead tissue). A review of the pressure ulcer report dated August 27, 2013, one week later, related that the resident had a pressure ulcer of the right plantar (bottom of the foot) that was described as unstageable necrosis (dead tissue, full thickness tissue loss covered by 100% eschar (tan brown or black dead tissue in the wound) measuring 1 centimeter x 1 centimeter An interview with Employee E1, a licensed staff, on October 9, 2013, at 11:00 a.m., confirmed that the Stage III pressure ulcer of the left second toe and an unstageable pressure ulcer of the plantar of the right foot were initially identified as described on the August 20, 2013, and August 27, 2013, wound specialist reports. The facility failed to timely identify and monitor the resident's skin to prevent pressure ulcer development for a resident who was assessed as low risk for skin ulcers which resulted in actual harm to Resident CL4. Review of Resident N7's [DIAGNOSES REDACTED]. The resident's Braden scale completed on August 20, 2013, revealed a score of 17 that indicated the resident was assessed as being at low risk for developing a pressure ulcer. A review of the resident's quarterly MDS dated [DATE], revealed that the resident required the extensive assistance of one person for bed mobility, however, the resident routinely slept in a recliner chair. Resident N7's nursing progress note dated August 28, 2013, revealed that a certified nursing assistant reported to the nurse that when providing care to the resident she observed "a patch on the resident's buttocks." She removed the patch and observed an open area which she reported to the nurse. Review of the nursing progress notes failed to reveal any description of the wound including precise location, size, and depth, presence of exudate (fluid released usually from inflammation), tissue presentation and possible signs of infection. An interview with the unit manager, Registered Nurse, Employee E5, on October 9, 2013, at 10:00 a.m., revealed that she was not always comfortable or confident staging wounds (a grading of a wound to identify the degree of tissue damage observed as a tool for communication and assessment). Review of Resident N7's physician's orders [REDACTED]. After cleansing, cover with [MEDICATION NAME] (foam dressing) daily and as needed. Further review of the nursing progress notes failed to reveal any additional assessment or monitoring of the wound's status until the resident was seen by the wound physician on September 3, 2013, six days after the wound was identified. The wound physician identified the wound as a Stage III pressure ulcer, of the sacrum (large triangular bone at the base of the spine) with 80% of the wound revealing devitalized, necrotic tissue which required sharp debridement (surgical removal). The wound was measured as 0.8 centimeters long by 0.5 centimeters wide and 0.2 centimeters deep on the wound physician's evaluation notes dated September 3, 2013. The treatment was changed September 3, 2013, to address the identified stage and the debridement procedure. The facility failed to accurately assess (stage or describe) and document the status of Resident N7's wound to assure that the appropriate treatment and interventions were being provided. The facility also failed to document the discovery of the wound to prevent worsening of the wound prior to being evaluated by the wound physician on September 3, 2013, (6 days after the initial discovery on August 28, 2013) resulting in actual harm to the resident. Review of Resident I10's physician's orders [REDACTED]. Review of Resident I10's pressure ulcer risk assessment dated [DATE], revealed that the resident was at a low risk for developing pressure ulcers. Review of Resident I10's significant change Minumum Data Set (MDS) (comprehensive full assessment of resident status and care needs due to a significant change in the resident's condition) dated August 28, 2013, revealed that the resident was severely impaired for decision making and was dependent on two staff persons for transfer, hygiene and bathing. The assessment indicated that the resident was at risk for developing pressure ulcers and had no pressure ulcers at the time of the assessment. A review of the facility's documentation into an incident and nursing notes dated August 29, 2013, for Resident I10 revealed a left heel darkened area measuring 2.5 centimeters long x 2.5 centimeters wide. Skin prep (a liquid film dressing applied to skin) was applied to the area and Multi Podus Boots (a protective orthopaedic appliance that corrects foot misalignments and minimizes the chance of skin breakdown) were applied. There was no other description of what the wound looked like. Review of the physician's wound care specialist evaluation report dated September 3, 2013, revealed that the resident had a left heel unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (separation of dead tissue from living tissue, yellow tan, gray, green or brown in color) and eschar (black dead tissue in the wound bed)). It was described by the physician as 2 centimeters long x 2 centimeters wide, depth not measurable and 100% thick adherent black necrotic tissue. The wound physician recommended that the resident have an EZ boot (a boot used to eliminate pressure on the heel for treatment and prevention of heel pressure ulcers) to be worn while in bed and in the chair, to off load the wound (to reduce pressure and improve the condition of the heels/wound area). The facility failed to timely identify the resident's pressure ulcer and failed to ensure a complete and accurate description of the wound. Nursing notes dated October 1, 2013, for the resident revealed that the staff observed an open area on the resident's left heel which measured 1.5 centimeter long x 1 centimeter wide with no documentation of the depth, the surrounding tissue or of the wound. The nursing notes indicated that the area was cleansed, [MEDICATION NAME] gel (used to treat superficial to full thickness wounds) and [MEDICATION NAME] (wound dressing) would be applied daily and as needed for soiling. Review of Resident I10's care plan revised on October 7, 2013, revealed that the wound team would consult and treatments would be applied as ordered. An observation of the resident in the chair on October 7, 2013, at 12:50 p.m., revealed that the resident was wearing regular shoes. An observation during wound care on October 7, 2013, at 12:55 p.m., revealed that the area on the resident's heel was red and had depth to it. Interview with licensed nurse, Employee E1 immediately after the observation of Resident I10 revealed that the resident should not have the regular shoes on but that the resident's family liked that the resident wears normal shoes as much as possible. Review of the facility's current care plan for resistive to care revealed that the resident and the family would be educated for outcomes resulting from not complying with care. An interview with the Director of Nursing in the afternoon on October 8, 2013, revealed that there was no documented evidence available for review to indicate that the resident or the resident's family had been educated regarding proper foot wear. The facility failed to ensure that consistent care and services were in place to ensure timely assessment, treatment and healing of Resident I10's pressure ulcer resulting in actual harm to the resident. Review of Resident B1's physician's orders [REDACTED]. Review of Resident B1's significant change MDS dated [DATE], revealed that the resident was impaired for decision making and was dependent on staff for transfers, hygiene and bathing. The MDS indicated that the resident was at risk for developing pressure ulcers and had one unhealed pressure ulcer on the right heel at the time of the assessment. Review of Resident B1's care plan dated March 6, 2013, revealed that the staff were to monitor, document and report to the physician, any changes in skin status and that this documentation would include appearance, color, wound size measurements and the depth of the wound. Review of Resident B1's nursing notes dated June 30, 2013, revealed that the resident had a scabbed area approximately 2 centimeters long x 1 centimeter wide in the lower back of the right leg with no redness and no drainage. There was no description of the color of the wound. There were no prior notes of the skin condition of this area. Review of wound care specialist evaluation dated July 2, 2013, revealed that Resident B1 had an unstageable pressure ulcer on the right lower Achilles calf (the tissue that connects the heel bone and the lower back of the leg). It was described by the physician as 1.5 centimeters long x 1 centimeter wide, depth not measurable, light serous exudate (drainage) and 100% thick adherent devitalized (devoid of vitality) necrotic tissue. The wound consult notes also indicated that the resident's wound in the right lower Achilles calf was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) on July 2, 2013, through a surgical excision and that subcutaneous tissue (irregular connective tissue immediately beneath the skin) was removed along with the necrotic tissue. During an observation during wound care on October 7, 2013, at 12:25 p.m., Employee E 6 indicated that the area on the resident's right lower Achilles area was red and closed. Interview with licensed Employee E7 on October 9, 2013, at approximately 10:00 a.m., revealed that the area was not timely identified as the resident had some contracture's (normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue and this makes it hard to stretch the area and prevents normal movement) at that time. The facility failed to timely identify Resident B1's pressure ulcer, failed to ensure complete and accurate documentation and failed to ensure that adequate care and services were in place to prevent pressure ulcers in the resident's right Achilles resulting in actual harm to the resident. Review of Resident F5's admission assessment dated [DATE], stated the admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Resident F5 hospital transfer documentation dated May 23, 2013, revealed that he resident had a skin tear on the buttocks and the area had a [MEDICATION NAME] covering in place (a protective dressing). This is the only area of skin alteration documented in the hospital transfer record. Review of Resident F5's admission nursing assessment dated [DATE], at 5:57 p.m., revealed that the resident had a scratch in the iliac crest (thick curved upper border of the ilium (long pelvic bone) that measured 2 centimeters long by less than 0.5 centimeters wide. The admission nursing assessment (completed by both the Registered Nurse and the Licensed Practical Nurse on the resident's admission into the facility) did not mention that the resident had a skin tear as indicated in the hospital transfer. Further nursing documentation on May 23, 2013, at 8:01 p.m., by licensed Registered Nurse Employee E7 revealed that the resident had a 2 centimeter open area on the coccyx (tailbone), which was not documented on the initial admission assessment (completed 5:57 p.m.) There was no further description of this open area. Further nursing documentation on May 23, 2013, at 11:39 p.m., by Licensed Practical Nurse Employee E17 revealed that the resident had bright red bleeding from the buttocks skin tear. It was not clear what area of the buttock this skin tear was located. The descriptions of the site for skin alteration(s)/wound were not consistent. Review of the undated interim care plan for Resident F5 indicated to turn and reposition the resident every 2-3 hours and on an as needed basis and to report to the nurse immediately, any observations of skin breakdown. Further review of Resident F5's nursing notes dated May 25, 2013, revealed that the staff had observed an open area on the resident's sacrum with a bilateral (affecting two sides) purplish discoloration. Review of the nursing notes revealed no documented evidence that the purplish discoloration was communicated to the physician. Review of Resident F5's wound care specialist evaluation dated May 28, 2013, revealed that the resident had an unstageable pressure ulcer on the medial (extending toward the middle) sacrum that was described by the physician as 1.5 centimeters long x 1 centimeter wide, depth not measurable in centimeters, with a 50% thick adherent (attached) devitalized necrotic tissue and 50% granulation (connective tissue that form on the surfaces of a wound during the healing) tissue. The wound physician's documentation also indicated that the periwound (skin surrounding the wound) radius was surrounding DTI-(deep tissue injury purple or maroon localized area of discolored intact skin) due to damage of underlying soft tissue due to pressure and or shear (an applied force that tends to cause an opposite but parallel sliding motion. Such motion may cause tissues and blood vessels to move in such a way that blood flow may be interrupted placing an individual at risk for pressure ulcer). The wound specialist note dated May 28, 2013, recommended to off load (a technique used to reduce the pressure which can improve the condition of the heels/wound area) the wound. Review of Resident F5's nutrition assessment dated [DATE] by Registered Dietitian Employee E8, revealed that the resident's skin was intact. The resident's admission nursing assessment dated [DATE], at 5:57 p.m., revealed that the resident had a scratch in the iliac crest (thick curved upper border of the ilium (long pelvic bone) measured 2 centimeters long by less than 0.5 centimeters wide. Further documentation on the day of admission reveal that the resident had a skin tear in the bottom/coccyx. There was no documented evidence that the resident was seen by the dietician until June 25, 2013. Review of Resident F5's documentation for two hour repositioning, revealed no documented evidence that the staff repositioned the resident on May 23, 2013, from 9 p.m. to 12 a.m. (midnight); May 24, 2013, from 8:00 a.m. to 12 noon; on May 26, 2013, from 8:00 a.m. to 2:00 p.m.; on May 27, 2013 from 12 noon to 10:00 p.m.; on May 28, 2013, from 8:00 a.m. to 12:00 a.m.(midnight); and on May 29, 2013, from 1:00 a.m. to 2:00 p.m. Interview with licensed nursing Employees E1 and E7 on October 7, 2013, at 2:00 p.m., confirmed that the documentation of the resident's skin on admission into the facility on [DATE], was not consistent and did not reflect a true picture of the resident's wound on admission. Employee E1 indicated that a complete documentation of the assessment of the area should have been completed when the wound was first identified. Interview with licensed dietary Employee E8, on October 8, 2013, at 12:40 p.m., revealed that when the dietary documentation was made for Resident F5, she used the admission nursing assessment dated [DATE], which stated that the skin was intact. Dietary Employee E8, confirmed that the resident was first seen by the Registered Dietitian regarding the healing of the wound on June 25, 2013. Interview with the Director of Nursing on October 9, 2013, at approximately 11:45 a.m., confirmed that there was no documented evidence that the physician was notified of the skin change on May 25, 2013, when the sacrum area was observed to be bilaterally purplish in color. The facility failed to ensure complete and accurate assessment and documentation of Resident F5's wound to ensure adequate and timely care and treatment were in place to prevent development and/or worsening of Resident F5's pressure ulcer. Review of Resident N2's physician's orders [REDACTED]. Review of Resident N2's quarterly MDS dated [DATE], revealed that the resident scored a 13 out of 15 on the BIMS (Brief Interview of Mental Status) indicating that the resident was assessed as having modified independence for decision making, and dependent on staff for transfer, hygiene and bathing. The assessment indicated that the resident was not at risk for developing pressure ulcers and had no pressure ulcers at the time of the assessment. The facility's incident investigation dated July 9, 2013, for Resident N2, revealed that a pressure area was identified at the tip of Resident N2's left fourth toe. This is the first time a wound was identified in this area. Review of wound care specialist evaluation dated July 9, 2013, revealed that the resident had an unstageable pressure ulcer on the left fourth toe. It was described by the physician as a 0.5 centimeters long x 0.5 centimeters wide, depth not measurable with 100% thick adherent black necrotic tissue (eschar). The wound physician recommended to off load the wound. Review of the resident's care plan for maintenance of skin integrity dated June 25, 2013, revealed that the staff were to observe the resident's skin for redness at baths daily. Further review of Resident N2's pressure ulcer risk assessment dated [DATE], revealed that the resident was a low risk for developing pressure ulcers. The wound consult documentation of July 16, 2013, indicated that the resident's wound in the left fourth toe was debrided (surgical removal) through a surgical excision (remove by cutting) and that subcutaneous tissue was removed along with devitalized (devoid of vitality) tissue. Review of the wound care specialist evaluation report dated October 1, 2013, revealed that the resident had another unstageable pressure ulcer on the right fourth toe. This area was first identified by the wound physician on October 1, 2013, and was not identified by the nursing staff prior to October 1, 2013. It was described by the physician as a 0.5 centimeters long x 0.5 centimeters wide, depth not measurable with 100% thick adherent black necrotic tissue (Eschar). During an observation on October 7, 2013, at 3:10 p.m., of the wound sites, Employee E1 indicated that the area on the left fourth toe was scabbed, brownish in color and the area on the top of the right fourth toe was discolored and blackened. Interview with licensed dietary Employee E8 on October 8, 2013, at 12:40 p.m., revealed that Resident N2 had never been seen by the dietician for these wounds and there was no documented evidence that the dietitian was notified of the resident's wound, to have additional services in place to help with the wound healing. The facility failed to timely identify the resident's pressure ulcers and failed to ensure that necessary care and services were in place to promote healing and prevent another pressure ulcer from developing, resulting in actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/09/2012, 07/01/2013. 28 Pa. Code 201.18(a) Management. Previously cited 11/09/2012. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/27/2011, 11/09/2012, 07/01/2013. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/27/2011, 11/09/2012. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/09/2012, 07/01/2013. 28 Pa. Code 211.5(f) Clinical records. Previously cited 10/27/2011, 11/09/2012, 07/01/2013, 08/29/2013. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 10/27/2011, 11/09/2012, 07/01/2013. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/27/2011, 11/09/2012, 02/27/2013. 28 Pa. Code 211.12(c) Nursing services. Previously cited 10/27/2011, 11/09/2012. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/27/2011, 11/09/2012, 02/27/2013, 07/01/2013, 08/29/2013. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/27/2011, 11/09/2012, 02/27/2013.

Based on a review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to assure that staff were trained and monitored on the proper use of hoyer lifts to prevent serious injury from occurring, and that the facility failed to complete a through investigation of an incident to assure that all safety measures were in place and no other residents were at risk of being harmed for 2 out of 8 residents reviewed. (Residents: CL1, and R1) Findings include: Review of Resident CL1's August 2013 physician orders [REDACTED]. A review of an August 28, 2013 nursing note indicated that the the physician was updated on the residents status [REDACTED]. Review of an electronic event report submitted to Department of Health on August 28, 2013 indicated that the resident had fallen at 8:45 a.m. on August 28, 2013 from a Hoyer lift (mechanically operated lift that lifts a resident up in the air so they can be transferred from one surface to another surface) and stuck his head on the bed frame. Interview with Employee E1, a licensed nurse on August 29, 2013 at 10:10 a.m., indicated that this Employee had initially responded to the incident, and that after the resident went to the hospital, she conducted an investigation with staff. Employee E1, further reported that the two nursing assistants providing the Hoyer lift transfer did not preform the transfer safety. She went on to state that they failed to both check that the hooks on the lift were in proper position, and that they failed to assure that they correctly positioned themselves to guide the resident from one surface to the next. Licensed nursing Employee E1's investigation concluded that the nursing assistant spotting the transfer, had placed herself at an angle to the resident and that as she was guiding the resident, she was pulling and lifting the resident to maintain her own balance. As a result the hoyer lift hook became dislodged from the lift, and the resident slid off the pad into the bed frame, and landed on the floor. Further interview with Employee E1 indicated that all staff are trained on how to use the lift in Orientation (training that is provided to all new employees) with the use of a video. They then go to the unit and have a peer (another nursing assistant) verify that they performed the Hoyer lift transfer correctly. Employee E1 could not provide any further verification that staff are provided with routine training regarding these lifts after the orientation process is over. Further Interview with the Director of Nursing and licensed nursing Employee E1, at this time, revealed that there are no skills demonstrations preformed, or auditing of the current staff's ability to preform the Hoyer lift transfers throughout the year. Interview with Employee E4, a nursing assistant, on August 29, 2013 at 12:10 p.m. indicated that the employee had been working at the facility for 3-4 months, and that she could not recall ever getting any video training regarding the use of the lifts. Employee E4 further reported that the only training received on the lifts was by other coworkers during the time she was working on the unit. Interview with Employees E6 and E7, both nursing assistants, on August 29, 2013 at 1:05 p.m. indicated that they could not recall having any type of training specific to the use of the Hoyer lift in the past year. They further confirmed that it is the nursing assistants who train the new employees on the use of the lifts. The facilities failure to monitor that staff were all properly aware of how to use the Hoyer lift, resulted in the resident suffering serious harm from falling out of the lift, striking his head, and ultimately being sent to the hospital for sutures to a 4 centimeter laceration on the back of his head. Review of Resident R1's August 2013's physician orders [REDACTED]. slipped down and bumped into the frame of the door without warning, when the wheelchair rolled over the strip on the ground to the doorway. The note went on to disclose that the resident received a 2 centimeter by 2 centimeter bump to her forehead. Review of the facility investigation into the incident dated August 26, 2013 revealed that the facility did no further investigation to determine how the resident was injured. There was no evidence that the resident's wheelchair position was investigated or that the doorway was examined to assure that it was safe for other residents to be transported in wheelchairs. On August 29, 2013 at 1:00 p.m. the resident was observed to have a 2 centimeter by 2 centimeter purple raised area to the middle of her forehead just below her hair line. During and interview with the Director of Nursing on August 29, 2013 at 1:35 p.m., it was confirmed that there was no further investigation into this incident and that she had been unaware that the incident had ever taken place. 483.25(h) ACCIDENTS Previously cited 7/1/2013 28 Pa Code: 201.18(b)(1) Management Previously cited 11/9/12, 7/1/2013 28 Pa Code: 211.5(f) Clinical records Previously cited 11/9/12, 7/1/2013 28 PA Code: 211.12(d)(1)(5) Nursing services Previously cited 2/27/13, 11/9/12, 7/1/2013

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that a medical consultation was obtained in a timely manner and that a physician's orders [REDACTED]. (Resident A1) Findings include: Review of Resident A1's June 2013 physician's orders [REDACTED]. Review of nursing notes dated June 24, 2013 at 11:05 a.m. noted that the resident appeared to be in pain with agitation when the resident right arm was touched and the arm appeared limp compared to his normal status. A physician's order was obtained for an x-ray of the resident right shoulder, upper arm and forearm. Nurses noted ated June 24, 2013 at 7:14 p.m. revealed that at the change of shift it was reported that an x-ray report was pending of the resident right arm and shoulder. The x-ray result was obtained on this 3-11 p.m. shift and the resident was found to be positive for a fracture right humerus ( injury to the upper arm bone). Nurses notes dated June 24, 2013 related a new order was obtained for a stat (immediately) orthopedic consult. Further review of nursing notes revealed that an appointment with the orthopedic specialist was obtained on June 27, 2013, three days after the physician's orders [REDACTED]. Interview with the director of nursing on July 1, 2013 at 11:15a.m. confirmed that there was no evidence that the facility attempted to communicate to the resident's primary physician that an immediate orthopedic appointment was not available as it was ordered by the physician. Review of the consultation report confirmed that the resident was seen by the orthopedic physician on June 27, 2013 and there was no other evidence that the resident was seen by a physician from June 24, 2013 through June 27, 2013 after it was confirmed that the resident had sustained a fracture right humerus. Upon further review of nursing notes dated June 25, 2013 at 5:13 p.m. stated that per the othopedic office personal, that a humerus fracture (shoulder fracture) was usually repaired by surgery but due to the resident's condition, the resident's arm was to be immobilized with a splint or sling. Nurses notes at this time also stated that the sling was on order so that the resident's right arm was to be immobilized until seen by the orthopedic physician. Further review of the nursing notes dated June 25, 2013 at 8:55 p.m. noted awaiting availability of sling for immobilization. Nurses notes dated June 26, 2013 at 6:08 p.m. related that that the sling was not received as of that time and pharmacy was to deliver the sling to the facility within the next few days. The resident was noted to be guarding his right arm, did note facial grimacing, redness and [MEDICAL CONDITION] to the right elbow. The facility failed to ensure that the attending physician was notified of the delay in the stat orthopedic consultation and failed to endure that the immobilizer was timely obtained as advised by the orthopedic physician to provide for immobilization and proper care of the fractured humerus. This resulted in a delay in treatment and the need for additional narcotic pain medication ordered June 27, 2013 of [MEDICATION NAME] one tablet 5-325 mg as needed every 6 hours. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 11/9/12 28 Pa Code: 201.18(b)(1)(e)(1) Management Previously cited 11/9/12 28 Pa Code: 211.5(f) Clinical records Previously cited 11/9/12 28 Pa Code: 211.10(c) Resident care policies Previously cited 11/9/12 28 Pa Code: 211.12(d)(1)(5) Nursing services Previously cited 2/27/13, 11/9/12