Every finding on record at Oak Ridge Rehabilitation & Healthcare Center

Based on a review of clinical records, facility documentation, facility policy, and staff interviews, it was determined the facility failed to ensure one of 10 sampled residents (Resident 1) remained free from physical abuse when an employee used force while providing incontinence care.Findings include:A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that include dementia (a loss of memory, language, problem-solving, and other thinking abilities severe enough to interfere with daily life) and anxiety (a condition characterized by excessive fear, worry, or feelings of unease). A review of Resident 1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 29, 2026, revealed that Resident 1 had severe cognitive impairment with a BIMS score of 00 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 through 07 indicates cognition severely impaired). A review of Resident 1's comprehensive care plan revealed the resident required maximal assistance with toileting because of impaired ability to perform self-care related to dementia with behavioral disturbances. The care plan indicated Resident 1 frequently demonstrated verbal and physical behaviors, including hitting and grabbing staff. Staff interventions included approaching the resident slowly and from the side, respecting the resident's personal space, gaining the resident's attention before touching or speaking, allowing additional time to provide care, and discontinuing care and reapproaching later if the interventions were ineffective and it was safe to do so. The care plan directed staff to provide toileting assistance at 5:00 AM with two staff members. The care plan directed staff to provide incontinence care while the resident remained in bed and to transfer the resident to the toilet only for bowel movements. The care plan also documented the resident had a history of making false accusations and expressing racist remarks. Interventions included assigning Caucasian staff to provide care whenever possible and having non-Caucasian staff provide care with another nurse aide present. A review of documentation provided by the facility dated June 20, 2026, revealed Employees 1 and 2, both Nurse Aides (NAs), were providing incontinence care to Resident 1 at 5:00 AM when Employee 1 forcefully held the resident's arms across the resident's chest and covered the resident's mouth with a hand. A review of a written statement completed by Employee 1 dated June 20, 2026, revealed the resident scratched and spit during care. Employee 1 documented, I was not forceful in covering her mouth, and denied forcefully grabbing the resident. During a telephone interview conducted on July 16, 2026, at 10:00 AM, Employee 1 acknowledged covering Resident 1's mouth because the resident was spitting toward Employee 2. Employee 1 stated the purpose of covering the resident's mouth was to prevent Employee 2 from being spat upon. Employee 1 further stated he did not routinely care for Resident 1 and was unaware the resident's care plan directed staff to provide incontinence care in bed. Employee 1 stated he wanted to complete care quickly and covered the resident's mouth to stop the spitting. Employee 1 stated Resident 1 was not light he held the upright while pulling the resident's pants up and acknowledged continuing to provide care after covering the resident's mouth. Employee 1 reported he continued caring for other residents following the incident until a supervisor removed him from resident care. Employee 1 confirmed the facility suspended him pending investigation. A review of a written witness statement completed by Employee 2 on June 20, 2026, revealed Employee 2 requested Employee 1's assistance with providing incontinencecare. Employee 2 documented Resident 1 initially resisted care and that Employee 1 grabbed the resident's arms, pushed them downward forcefully, and placed a hand over the resident's mouth with significant force. Employee 2 further documented Employee 1 continued using force while assisting the resident to stand, causing the resident to be jerked while Employee 2 attempted to pull up the resident's pants. Employee 2 documented immediately notifying the nurse and supervisor after care was completed. During a telephone interview conducted on July 16, 2026, at 11:00 AM, Employee 2, Nurse Aide (NA), stated she asked Employee 1, NA, to assist with providing incontinence care to Resident 1 because she had never cared for the resident before. Employee 2 stated that after entering the bathroom, Resident 1 pushed Employee 2's hands away as Employee 2 attempted to lower the resident's pants. Employee 2 stated Employee 1 then grabbed Resident 1's arms, pushed the resident onto the toilet, and held the resident's arms tightly across the resident's chest. Employee 2 stated she observed Employee 1 forcefully place his hand over Resident 1's mouth. Employee 2 reported Resident 1 immediately began scratching Employee 1's hand in an attempt to remove it from her mouth. Employee 2 further stated Resident 1's eyes appeared to bulge while attempting to remove Employee 1's hand. Employee 2 reported Employee 1 repeatedly stated, Stop it, we need to clean you, while continuing to hold his hand over the resident's mouth. Employee 2 stated Employee 1 then held Resident 1 in a standing position while she attempted to pull up the resident's pants and repeatedly jerked the resident during the process. Employee 2 stated that after Resident 1 was returned to the wheelchair and taken to the nurses' station, Employee 1 attempted to approach the resident and Resident 1 immediately pulled away from him. Employee 2 stated she immediately reported the incident to the nurse and nursing supervisor, after which Employee 1 was removed from resident care. Employee 2 stated she was unaware Resident 1's care plan directed staff to provide incontinence care in bed but knew Resident 1 required the assistance of two staff members for toileting. Employee 2 stated she knew Resident 1 frequently displayed behavioral symptoms associated with dementia and was attempting to calm the resident during the episode. Employee 2 stated Resident 1 was making noises and pushing staff away while care was being provided but was not continuously spitting throughout the encounter. Employee 2 stated Resident 1 did not begin displaying combative behaviors until after Employee 1 became forceful while providing care. Employee 2 further stated she did not physically intervene because she feared Employee 1 might also harm her. Documentation provided by the facility revealed the Director of Nursing (DON) became aware of the allegation at 5:20 AM on June 20, 2026. Employee 1 was removed from resident care and suspended pending investigation at 6:30 AM. Facility documentation further revealed the facility completed assessments of residents who had received care from Employee 1 on June 20, 2026, and re-educated staff regarding abuse prevention, neglect prevention, and dementia care following the incident. A review of a nursing progress note dated June 20, 2026, revealed Resident 1 received a comprehensive physical assessment following the incident. The assessment identified no observable injury. A psychology consultation dated June 24, 2026, documented Resident 1 experienced significant agitation and physical aggression on June 20, 2026. The psychologist recommended non-pharmacological (interventions that do not involve medication) approaches, including reducing confusion and fear, providing comfort measures, maintaining the resident's routine, and utilizing the Tolerate, Anticipate, Don't Agitate ([NAME]) approach when responding to behavioral symptoms associated with dementia. During an interview conducted on July 16, 2026, at 1:00 PM, the aforementioned information was discussed with the Director of Nursing and the Nursing Home Administrator. The facility failed to ensure Resident 1 remained free from physical abuse when Employee 1 forcefully restrained the resident by holding the resident's arms across the chest and covering the resident's mouth while providing incontinence care. The facility also failed to ensure care was provided in accordance with the resident's individualized care plan, which directed staff to discontinue care and reapproach later if behavioral interventions were ineffective and to provide incontinence care in bed. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure injuries for two of 10 residents reviewed (Residents 1 and 2).Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines, indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility policy titled Wound Care, last reviewed by the facility on January 29, 2026, revealed it is the policy of the facility to provide wound care to new wounds and wounds present on admission to promote healing. The policy revealed it is the expectation of the facility to prepare to change wound care dressings by assembling the equipment and supplies needed to complete the wound care, follow the steps detailed in the policy to complete the procedure including: Use disposable cloth to establish a clean area on the resident's overbed table.Wash and Dry HandsPosition the resident in a position that would allow for a sterile dressing changePut on exam gloves, loosen the tape and remove the old dressing.Pull gloves over dressing and discard into the appropriate receptacle. Wash and dry hands thoroughly.Put on gloves, use a no touch technique, use sterile blades and applicators to remove ointments creams.Mark Tape with initials, time and date and apply the dressing as ordered by the physician.Discard any soiled laundry, linens, towels, and container. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including pressure ulcer of the buttock (tissue damage or pain caused by sustained pressure restricting blood flow), and disorientation (an altered sense of awareness). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 6, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). The MDS revealed at the time of assessment, Resident 1 had 3 Stage 3 pressure ulcers (severe, full-thickness skin injury where all layers of the skin are lost, exposing the fatty subcutaneous tissue beneath) that were present on admission, and one unstageable pressure injury (serious wound where full-thickness skin and tissue loss has occurred, but the true depth of the damage cannot be determined because it is obscured by dead tissue) A review of Resident 1's Treatment Administration Record (TAR) revealed a physician order placed May 13, 2026, for staff to cleanse the right buttock with 1/4 strength Dakin's solution (medical grade antiseptic solution used to clean, disinfect, and prevent bacterial infections in open wounds), apply calcium alginate (a wound dressing) topped with Medi-honey (a medical grade honey used for wound care) to the base of the wound. The order directed staff to pack the wound with Dakin's soaked gauze and cover with a dry dressing daily and as needed if soilage or dislodgement was present. An observation conducted on May 28, 2026, at 10:15AM in the presence of Employee 1 Licensed Practical Nurse (LPN) revealed Resident 1 to have no dry dressing in place. The right buttock was observed to be opened to air in Resident 1's brief which appeared to be soiled. The sheets under Resident 1 were observed to have serosanguineous (light pink, thin, and watery fluid containing serum and blood) drainage present, indicating the wound was leaking onto the sheets. The wound was observed to have no gauze packing present inside the area as ordered. Interview with Employee 1, LPN at the time of observation revealed Resident 1 should have had a dry dressing in place. Employee 1 LPN proceeded to provide wound care to Resident 1 as ordered by the physician. A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included muscle weakness and multiple wounds. A review of Resident 2's admission Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 2 was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates no cognitive impairment). The MDS revealed Resident 2 had one Stage 4 pressure area (a severe pressure injury with full-thickness tissue loss exposing bone, tendon, cartilage, fascia, or muscle) that was present on admission. The area measured 5.5 cm (centimeters) x 8cm x 1cm A review of Resident 2's clinical record revealed a physician order dated May 12, 2026. The physician order directed staff to cleanse the sacral wound with normal saline (a sterile saltwater solution commonly used for wound cleansing), gently pat the area dry, apply collagen (a wound care product containing proteins that support tissue growth and healing), then apply saline wet-to-dry gauze (gauze moistened with saline that assists with removal of dead tissue as it dries and is removed), followed by a foam dressing (a protective absorbent wound covering designed to maintain a moist healing environment) every day during the day shift. The order further directed staff to change the dressing as needed if it became soiled (contaminated with drainage, urine, stool, or other substances) or dislodged (moved from its proper position or no longer securely covering the wound). An observation conducted on May 28, 2026, at 10:39AM of Resident 2's coccyx (the small, triangular bone at the very base of the human spine) area revealed a dry dressing in place but the dressing was visibly soiled with no date time or initials written as indicated in the policy. It was unable to be determined when the dressing was applied. During an interview on May 28, 2026, at 11:30 AM, the above findings were reviewed with the Nursing Home Administrator. The facility failed to ensure Residents 1 and 2 received necessary treatment and services consistent with professional standards of practice to promote healing of pressure injuries, including ongoing wound monitoring and implementation of wound care as ordered by the physician and facility policy according to resident-specific clinical needs. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, and staff interviews, it was determined the facility failed to consistently implement person-centered care plan interventions related to fall prevention for three of six residents reviewed for falls (Residents 5, 7, and 9).Findings include: Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses to include nontraumatic intracerebral hemorrhage (bleeding into the brain not caused by trauma) and hemiplegia (paralysis) and hemiparesis (weakness) affecting the resident's left side.Review of Resident 5's current comprehensive care plan dated March 14, 2024, indicated the resident was at risk for falls due to impaired mobility, incontinence and spastic hemiplegia (paralysis characterized by stiff, tight muscles and involuntary spasms). Interventions included placement of bilateral (two) fall mats on the floor next to the bed while the resident was in bed. Observation on April 22, 2026, at 8:40 AM revealed Resident 5 in bed. The left fall mat was observed folded in half and propped between the PTAC unit (Packaged Terminal Air Conditioner, a self-contained, ductless heating and cooling system installed directly through an exterior wall) and the resident's wheelchair. The fall mat was not positioned on the floor as directed in the care plan to reduce the risk of injury in the event of a fall. Interview with Employee 1, Registered Nurse, on April 22, 2026, at 8:42 AM confirmed the fall mats were a fall prevention intervention and should have been positioned on both sides of the bed while the resident was in bed. Employee 1 confirmed the left fall mat was not in place as required. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses to include dementia (a progressive decline in cognitive functions including memory, thinking, reasoning and behavior what interferes with daily life) and chronic respiratory failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen in the blood). Review of Resident 7's current comprehensive care plan dated December 29, 2025, indicated the resident was at risk for falls due to weakness, unsteady gait (walking), and urinary incontinence (inability to control the flow of urine). Interventions included use of a bathroom door alarm (a safety device which uses a sensor to alert staff when a resident opens a door, primarily used for fall prevention and wandering detection for residents with dementia) and to maintain the call light within reach of the resident. Observation on April 21, 2026, at 12:26 PM revealed Resident 7 seated alone in a wheelchair next to the bed. The bathroom door was open, and the bathroom door alarm was not sounding. A second observation on April 22, 2026, at 8:49 AM again revealed Resident 7 seated alone in the wheelchair next to the bed with the bathroom door open and the alarm not sounding. Further observation revealed the call light was draped over a bedside chair located behind the resident and was not within reach. Interview with Employee 1, Registered Nurse, on April 22, 2026, at 8:58 AM confirmed the bathroom door alarm was a fall prevention intervention and acknowledged the bathroom door was open and the alarm was turned off. Employee 1 also confirmed the call light was not within the resident's reach as required by the care plan. Clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnosis to include fracture of the right femur (upper leg bone) and muscle weakness. Review of Resident 9's current comprehensive care plan dated March 30, 2026, indicated the resident was at risk for falls related to decreased strength, decreased endurance, and a history of falls. Interventions included maintaining the call light within reach of the resident. Observation on April 21, 2026, at 12:36 PM revealed Resident 9 seated in the wheelchair on the left side of the bed. The call light was attached to the right side of the bed near the pillow and was not within the resident's reach. Interview with Employee 2, Nurse Aide, on April 21, 2026, at 12:40 PM confirmed the call light was not within the resident's reach. During an interview on April 22, 2026, 11:45 PM, the findings were reviewed with the Nursing Home Administrator and Director of Nursing. They acknowledged that staff failed to consistently implement the fall prevention interventions identified in the care plans for Residents 5, 7, and 9. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to ensure a resident was afforded the right to participate in the planning of care and treatment, including the facility's failure to conduct a required quarterly care plan conference, for one of 10 residents reviewed (Resident 4).Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered last reviewed by the facility on January 14, 2026, indicated the interdisciplinary team (IDT, a group of facility staff from different professional backgrounds to develop, review and revise the residents plan of care) in conjunction with the resident and the resident's family or legal representative, is responsible for developing and implementing a comprehensive, person-centered care plan for each resident. The policy indicated that each resident has the right to participate in the development and implementation of the plan of care, including the right to participate in the planning process requesting care plan meetings or revisions, establishing goals and outcomes, and determining the type, amount, frequency, and duration of care provided. The policy required the IDT to review and update the care plan following a significant change in condition, when outcomes are not met, upon readmission, and at least quarterly in conjunction with the Minimum Data Set (MDS) assessment (a federally mandated standardized assessment process conducted periodically to plan resident care). Review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include post-polio syndrome (a neurological disorder causing new, slowly progressive muscle weakness, intense fatigue, and muscle and joint pain in polio survivors, typically occurring 10 to 40 years after the initial infection) and malignant neoplasm of the major salivary gland (a rare, fast growing cancer that develops in the salivary gland. The salivary gland is responsible for producing the majority of saliva to lubricate the mouth, aid digestion and protect teeth). A review of Resident 4's Quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 4 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). Review of a care plan meeting invitation letter revealed the facility scheduled a care plan conference with the resident and the resident's daughter for December 16, 2025, at 1:00 PM.Review of Social Services documentation dated December 16, 2025, at 1:15 PM revealed the resident's daughter contacted the facility on the day of the scheduled meeting and requested the meeting be rescheduled. Documentation indicated Social Services left a voicemail message for the daughter offering alternative dates and times for the meeting. There was no documented evidence that the facility rescheduled or conducted the quarterly care plan conference after December 16, 2025. There was also no documented evidence that the facility made additional follow-up attempts to contact the daughter or conducted the care plan meeting with Resident 4 independently, despite the resident being cognitively intact and able to participate in the care planning process. During an interview conducted on April 22, 2026, at 11:30 AM, the Social Services Director confirmed the care plan conference scheduled for December 16, 2025, was not conducted due to the daughter's request to reschedule the meeting. The Social Services Director stated a return telephone call was made and a voicemail message was left; however, no additional follow-up attempts were made after the daughter did not respond. The Social Services Director further confirmed there was no documentation the facility conducted the care plan meeting with Resident 4 independently. During an interview on April 22, 2026, at 2:35 PM, the Nursing Home Administrator and Director of Nursing reviewed the findings and confirmed there was no documentation to support that a quarterly care plan conference had been conducted for Resident 4. The facility failed to ensure Resident 4 was afforded the right to participate in the care planning process by failing to conduct a required quarterly care plan conference and failing to make reasonable efforts to reschedule and complete the meeting. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on observation, review of clinical records, review of hospital records, and resident and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards of practice by failing to follow physician-ordered bowel protocol for one of 26 residents (Resident 75) reviewed, which resulted in hospitalization and actual harm. Additionally, the facility failed to follow professional standards of practice related to medication administration management for one of three closed residents (Resident CR3) sampled.Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine) the primary goal of constipation management should be symptom improvement. The secondary goal should be the passage of soft, formed stool without straining at least three times per week. Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnosis to include, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side (hemiplegia refers to the complete paralysis of one side of the body, while hemiparesis indicates partial weakness on one side. a nontraumatic intracerebral hemorrhage, which is bleeding within the brain tissue itself, typically due to the rupture of a blood vessel). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 2, 2025, revealed that Resident 75 was severely cognitively impaired, required extensive assistance of staff for activities of daily living, and was frequently incontinent of bladder and bowel. Review of the clinical record revealed that physician orders dated July 1, 2023, included the following bowel protocol for Resident 75: Milk of Magnesia (MOM, Magnesium Hydroxide an oral laxative used to treat constipation) Suspension 400 mg (milligrams)/5 mL: Give 30 mL (milliliters) by mouth as needed for constipation if no bowel movement after the third day or nine shifts. Bisacodyl suppository (stimulant laxative) 10 mg: Insert one suppository rectally as needed for constipation if no bowel movement 24 hours after Milk of Magnesia is ineffective. Fleet's Enema (liquid laxative for severe constipation), insert one application rectally as needed for constipation if no bowel movement on the fifth day and no result from the suppository; notify the physician if no bowel movement occurs. Review of Resident 75's bowel movement tracking documentation for December 2025 revealed that 11 shifts passed between December 6, 2025, and December 9, 2025, without a documented bowel movement. The review revealed that 11 additional shifts passed between December 25, 2025, and December 28, 2025, without a bowel movement. A small, liquid, non-formed bowel movement was documented on December 29, 2025. A review of Resident 75's Medication Administration Record (MAR) for December 2025, revealed no documented evidence that nursing staff administered the physician-ordered bowel protocol during the periods when Resident 75 had no bowel movements. A review of the clinical record revealed Resident 75 was transferred to the hospital on December 30, 2025, for evaluation of respiratory symptoms. Review of a hospital diagnostic report dated December 30, 2025, revealed a computed tomography (CT) scan (a diagnostic imaging test that produces detailed cross-sectional images of the body) of the abdomen and pelvis was ordered due to abdominal pain. The CT scan of the resident's abdomen and pelvis completed on December 30, 2025, revealed marked distention (enlargement) of the rectum and distal rectosigmoid colon (part of the large intestine that connects to the rectum) with a large fecal burden (fecal impaction is a hard, immobile mass of stool lodged in the rectum due to prolonged constipation), with bowel wall thickening suspicious for stercoral colitis (a serious inflammatory condition of the colon caused by prolonged fecal impaction that can lead to bowel perforation and life-threatening infection). The report further indicated that the uterus (pear shaped organ in lower abdomen of a woman responsible for nourishing and housing a fetus) was displaced anteriorly and to the right due to severe colonic distention with stool. Review of the hospital record revealed that manual disimpaction (physical removal of impacted stool) was attempted on December 30, 2025, and was unsuccessful. Surgical consultation recommended an aggressive bowel regimen, including multiple enemas. Hospital documentation indicated that the resident received enemas at 3:00 PM and 6:00 PM. on December 30, 2025, after which the resident had a bowel movement. During an interview with the Director of Nursing (DON) on February 6, 2026, at 9:20 AM the DON was unable to provide evidence that the physician-ordered bowel protocol was followed for Resident 75 during the periods without bowel activity described above. The facility failed to implement the physician-ordered bowel protocol for Resident 75, which resulted in actual harm, as evidenced by hospitalization and a large fecal impaction causing marked enlargement of the rectum and colon, stercoral colitis, and displacement of the uterus. A closed clinical record review revealed Resident CR3 was admitted to the facility from the hospital on January 23, 2026, with the primary diagnosis of wedge compression fracture of the first lumbar vertebra (the front of a bone in the back collapses). Review of the facility policy titled Medication Administration, last reviewed January 14, 2026, revealed medications are to be administered in a safe and timely manner as prescribed. The policy stated that if a medication is withheld, refused, or administered at a time other than scheduled, the administering staff member must document this on the Medication Administration Record and provide supporting documentation. Review of the electronic medication administration record revealed an order for Enoxaparin Sodium Injection 90 mg, to be administered subcutaneously once daily (subcutaneous means injected under the skin). Enoxaparin is an anticoagulant medication used to prevent deep vein thrombosis (blood clots in the veins, typically in the legs) that may travel to the lungs and cause a pulmonary embolism (a potentially life-threatening blockage of blood flow to the lungs). The medication was ordered to start on January 24, 2026, at 9:00 a.m., with an end date of January 26, 2026, at 10:31 AM. The medication administration record indicated that the medication was not administered as ordered on January 24, 2026, and directed the reviewer to nursing narrative notes. A review of the narrative nurses' notes did not include any information, rationale, or insight regarding why the medication was not administered or what other measures were taken when the medication was not administered. During an interview with the Director of Nursing on February 5, 2026, at 11:12 AM., the DON confirmed Resident CR3 did not receive the prescribed dose of Enoxaparin due to medication unavailability. The DON was unable to provide evidence that the medication was obtained from the facility's emergency supply, that the physician was notified, or that appropriate documentation was completed to reflect the missed dose. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure a resident was free from neglect by failing to provide care and services in accordance with the resident's plan of care. Specifically, staff failed to utilize the required sliding board with assistance of one staff member during a transfer from wheelchair to bed, as planned to ensure safety and prevent injury. As a result of this failure, one resident (Resident CR147) sustained an acute distal femur fracture that progressed to an above-the-knee amputation, representing actual harm to one resident out of 3 discharged residents sampled. This deficiency is cited as past noncompliance.Findings include: A review of the facility Abuse Policy last reviewed on January 14, 2026, indicated it was the facility's policy for residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility's policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Some examples of individual failures noted in the facility's abuse policy included the following: failure to provide sufficient, qualified, competent staff to meet resident's needs, failure to provide orientation and/or training to staff, failure to provide training on new equipment or new procedures or medications required for the care of a specified resident or required due to changes in acceptable standards, failure of staff to implement resident interventions, even when residents are assessed, and interventions are identified in the care plan. A closed clinical record review revealed Resident CR147 was admitted to the facility on [DATE], with diagnoses that included a history of a right BKA (below-knee amputation, a surgical procedure performed to remove a part of the lower leg that is not viable or healthy), Type II diabetes mellitus (a chronic condition affecting the body's ability to regulate blood sugar), chronic pain syndrome (a complex condition characterized by persistent pain lasting for at least three months, often accompanied by emotional and psychological symptoms such as depression and anxiety), and unspecified lack of coordination (a medical condition that affects the body's ability to coordinate movements and maintain balance). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2025, revealed Resident CR147 had a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition). The assessment revealed the resident required substantial to maximal assistance from staff for bed mobility, transfers, toileting, and movement from sitting to standing positions. A review of Resident CR147's care plan, initiated April 15, 2025, identified an activity of daily living self-care performance deficit related to impaired mobility secondary to right BKA. Planned interventions included transfers using a sliding board (a rigid transfer device placed between two surfaces to allow a resident to move safely from one surface to another while minimizing twisting, weight bearing, and shear forces). The care plan required assistance of one staff member during transfers, use of a wheelchair with positioning supports, and use of a prosthetic limb (an artificial device designed to replace a missing limb and restore some degree of function). A review of investigative documentation and clinical records dated December 31, 2025, revealed that Employee 1, a Registered Nurse (RN), documented that Resident CR147 reported pain in their right leg following a transfer from wheelchair to bed performed by a Nurse Aide (NA) Employee 2. The documentation reflected that the transfer involved a pivot assist (a transfer technique in which a staff member assists a resident to stand, turn or rotate on one or both feet, and then sit on another surface, requiring the resident to bear weight and maintain balance during the movement) while the resident was wearing a prosthetic to the right lower extremity. The resident reported that her right knee twisted during the transfer and stated, My right knee twisted when I was getting into bed. The resident reported a pain level of 7 (a standardized numeric pain scale ranging from 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable. A pain rating of 6 to 7 is considered severe pain and may interfere with concentration and functional ability). Review of the investigative documentation revealed that the Certified Registered Nurse Practitioner (CRNP) assessed Resident CR147 and observed swelling of the right knee. New orders were issued to obtain an x-ray of the right knee, elevate the right leg on a pillow, apply ice for 15 minutes, and medicate for pain as ordered. A review of the resident's x-ray report dated December 31, 2025, at 4:29 PM revealed an acute comminuted distal femur fracture of her right leg (a recent fracture of the thigh bone near the knee involving multiple fracture fragments). The resident's attending physician was notified of the results and ordered transfer to the hospital for further evaluation and treatment of the right leg. A review of a written statement completed by Employee 2, NA, dated December 31, 2025, no time recorded , revealed Employee 2 reported, I was transferring Resident CR147 into bed to change her, she refused the slide board so I put the wheelchair close to the bed, stood her up straight, and pivoted her to a sitting position on the bed, she had her prosthetic on her right leg. When I got her on the bed, she said that her right leg twisted, but when I looked her right leg was straight and while turning her the leg moved the way it should, the prosthetic remained straight. A review of a written statement provided by Resident CR147 dated December 31, 2025, no time recorded revealed the resident reported that Employee 2, NA, did not use the sliding board during the transfer. The resident stated, I didn't refuse it (the slide board), the Nurse Aide said hug me and I put my arms around her neck and she pulled me up, turned me but my foot didn't turn, I said ouch it hurt by my knee, then she went to get the nurse. A review of investigative documentation included a written statement completed by Employee 3, the Occupational Therapist treating Resident CR147, dated January 2, 2026, at 11:27 AM. Employee 3 reported that on December 30, 2025, the day prior to the injury, Employee 2 requested assistance with transferring the resident. The Occupational Therapist documented that the resident expressed a preference to transfer using her prosthetic limb instead of the sliding board. In the presence of Employee 3, Employee 2 transferred the resident from the wheelchair with the right armrest removed using a low pivot transfer with hands-on assistance. Employee 3 documented that both Employee 2 and Resident CR147 were educated on the requirement to continue transfers using the sliding board from the wheelchair to the bed until all staff were trained and educated on alternative transfer methods. The Occupational Therapist documented that understanding was verbally acknowledged by both the staff member and the resident. A review of Resident CR147's hospital records revealed a vascular surgery consultation dated January 1, 2026, at 9:56 PM. The consultation documented that the resident was an established vascular surgery patient with a prior BKA, who presented with a right distal femur fracture. The consulting provider documented that surgical repair was indicated due to the severity of the fracture. However, the resident declined open reduction and internal fixation (ORIF, a surgical procedure used to realign and stabilize broken bones using internal hardware such as plates or screws) and instead elected to undergo an above-the-knee amputation (AKA, surgical removal of the leg above the knee). Hospital records revealed the resident underwent the AKA procedure on January 2, 2026. A review of the facility's investigative documentation dated January 2, 2026, regarding allegations of abuse and neglect, revealed the facility determined Employee 2 failed to follow Resident CR147's plan of care by not utilizing the required sliding board during a transfer from the wheelchair to the bed. The documentation reflected that this failure resulted in Resident CR147 sustaining a right distal femur fracture requiring surgical intervention. The facility substantiated neglect related to this event, and Employee 2 was terminated from employment. During an interview on February 4, 2026, at 1:35 PM the Director of Nursing confirmed the facility failed to ensure staff consistently utilized the care-planned transfer device, specifically the sliding board, to safely transfer Resident CR147 from the wheelchair to bed and prevent physical harm. The Director of Nursing confirmed that Employee 2's failure to follow the resident's plan of care directly resulted in the resident sustaining a right distal femur fracture that required surgical intervention in the form of an above-the-knee amputation. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: Post incident on December 31, 2025, the Employee 2, NA, was suspended due to failure to utilize a slide board to transfer Resident CR147 from the wheelchair to the bed that resulted in the resident experiencing pain in the right knee with an order from the MD to obtain an x-ray. Employee 2 was terminated due to Resident CR147 sustaining a fracture due to the employee neglecting to follow the resident's plan of care. Results of the x-ray were obtained on December 31, 2025, at 4:29 PM and revealed an acute comminuted distal femur fracture. The resident's attending physician was notified of the results with an order to transfer the resident to the hospital for evaluation and treatment of the right leg. Cognitively intact residents in Employee 2's assignment area were interviewed to ensure transfers were done as per their plan of care correctly and no complaints/concerns were reported. To prevent future incidents, all nursing staff were re-educated on the facility's Abuse Policy and educated on the importance of following resident's plan of cares for transfers to prevent injuries. To monitor and maintain ongoing compliance, the Director of Nursing or designee will review a sample of five residents to ensure transfers based on their care plan are followed by direct observation. Audits will continue for thirty days and then re-evaluated. The facility's compliance date was January 6, 2026, and completion of the corrective action plan noted above was confirmed during the survey ending February 6, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 211.10 (a)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services.

Based on review of the Centers for Disease Control and Prevention (CDC) guidance, facility policy, clinical records, observations, and staff interviews, it was determined the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection for one of five residents reviewed (Resident 83) who had an indwelling medical device.Findings include: According to the Centers for Disease Control (CDC) Enhanced Barrier Precautions (EBP) guidance focuses on gown and glove use and other important infection control measures for prevention of multi-drug-resistant organisms (MDRO type of bacteria or microorganism that has developed resistance to multiple classes of antibiotics, making infections harder to treat). EBP are recommended for residents with any of the following: infection or colonization with a MDRO, a wound, or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the facility Enhanced Barrier Precautions (EBP) Policy last reviewed/revised January 14, 2026, indicated EBPs are used to prevent the spread of MDROs. The policy directs the use of EBP during high-contact care activities for residents with chronic wounds (skin ulcers) or indwelling medical devices (medical instrument left inside the body temporarily or permanently to support physiological functions). The procedure includes precautions (gown and gloves) during high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. According to the procedure guidelines, when EBP are in place there will be signs posted in the door or wall outside the resident room and personal protective equipment (PPE) (gowns and gloves) will be readily accessible outside the resident's room. Resident 83 was admitted to the facility on [DATE], with diagnoses including, but not limited to, endocarditis (inflammation of the inner lining of the heart valves and chambers), end stage renal disease (a condition in which the kidneys no longer function well enough to meet the body's needs), and dependence on dialysis (a treatment that performs the function of the kidneys when they are no longer able to work effectively). Review of the admission Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 5, 2026, revealed a Brief Interview for Mental Status score of 15. (BIMS, brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact. Current physician orders dated December 31, 2025, indicated Resident 83 was to receive dialysis treatments three times weekly on Tuesday, Thursday, and Saturday. The orders directed staff to inspect the dialysis access site daily for signs of infection, including localized pain, erythema (redness), warmth, edema (swelling), or abnormal drainage. Review of the clinical record identified that the dialysis access site was a double lumen catheter located in the right upper chest. A double lumen catheter is a type of central venous catheter (a flexible tube placed into a large vein) that contains two separate internal channels or lumens. One lumen allows blood to be removed from the body and sent to the dialysis machine for filtration, while the second lumen allows the filtered blood to be returned to the body. This catheter remains inserted into a large vein for ongoing treatment and is therefore considered an indwelling medical device (a medical instrument that remains inside the body either temporarily or permanently to support normal body functions or deliver treatment). The presence of this double lumen dialysis catheter constituted an indwelling medical device as defined in both CDC guidance and the facility's Enhanced Barrier Precautions policy. Review of the clinical record revealed no documented physician order or care plan intervention indicating implementation of Enhanced Barrier Precautions for Resident 83, despite the presence of an indwelling medical device as outlined in CDC guidance and facility policy.Observation conducted on February 4, 2026, at 10:41 AM, revealed there was no signage posted outside Resident 83's room indicating Enhanced Barrier Precautions. Additionally, no personal protective equipment, including gowns or gloves designated for EBP use, was observed to be readily accessible outside the resident's room.On February 4, 2026, at 1:45 PM, the above findings were reviewed with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, observations, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for two of two residents reviewed who received hemodialysis (Residents 72 and 83), and failed to develop and implement an individualized, person-centered care plan for one of two residents receiving hemodialysis (Resident 83).Findings include: According to the National Kidney Foundation, patients receiving hemodialysis, (a life-sustaining treatment for individuals with kidney failure that removes waste and excess fluids from the blood) and utilize central venous hemodialysis catheters, (tubes placed into large veins to allow blood to flow to and from a dialysis machine), are associated with serious complications including infection and bleeding. The Centers for Disease Control and Prevention further identifies central lines as devices that can result in significant complications such as bloodstream infection and hemorrhage (severe bleeding). Standard dialysis emergency guidance indicates that if a dialysis catheter becomes dislodged (moves out of place) or begins to bleed, immediate firm pressure must be applied to the site and emergency medical care must be obtained to prevent life-threatening blood loss. Therefore, residents who receive hemodialysis through a central venous catheter require immediate access to appropriate emergency supplies, such as clamps and pressure dressings, to ensure prompt intervention in the event of catheter-related complications. A review of the policy Care of Resident with End-stage Renal Disease last reviewed January 4, 2024, indicated that staff caring for residents with ESRD ( End Stage Renal Disease) including residents receiving dialysis care outside of the facility shall be trained in the care and special needs of these residents, including the ability to recognize the signs and symptoms of worsening conditions and /or complications of ERSD. The policy also indicated that the resident's comprehensive care plan will reflect the resident's needs related to dialysis care and ESRD. A review of the clinical record revealed that Resident 72 was admitted to the facility on [DATE], with diagnoses to include End-Stage Kidney Disease with dependence on dialysis (a life-sustaining treatment that removes waste products and excess fluid from the blood when the kidneys no longer function). The record documented the presence of a right chest Tessio catheter (a specialized double-lumen central venous catheter that provides immediate vascular access for hemodialysis). Physician orders dated January 29, 2026, identified dialysis treatments on Tuesday, Thursday, and Saturday at 5:30 AM and included transfer instructions utilizing a Hoyer lift (a mechanical lifting device used to safely transfer individuals with limited mobility). Observations conducted on February 2, 2026, at 11:15 AM and again on February 3, 2026, at 8:43 AM revealed no emergency dialysis supply kit, clamps, pressure dressings, or other catheter-related emergency equipment present at the bedside, mounted on the wall, or otherwise visible and readily accessible in Resident 72's room. During an interview on February 3, 2026, at 8:45 AM, Employee 4, Registered Nurse (RN), stated that an emergency kit with appropriate supplies should have been present and easily accessible in the resident's room. On February 4, 2026, at 9:30 AM, the above findings were reviewed with the Director of Nursing (DON) regarding the absence of required emergency supplies for residents receiving hemodialysis. Clinical record review revealed Resident 83 was admitted on [DATE], with diagnoses including End-Stage Renal Disease and dependence on dialysis. A hospital Discharge summary dated [DATE], documented a dialysis double-lumen catheter located in the right internal jugular vein (a major vein in the neck that carries blood back to the heart), with the external access site observed on the right upper chest. A physician's order dated December 31, 2025, required dialysis treatments three times weekly (Tuesday, Thursday, and Saturday) and daily inspection of the dialysis access site for signs of infection, including localized pain, redness, warmth, swelling, or drainage. Observation on February 4, 2026, at 10:40 AM confirmed the presence of a dialysis access site on the right upper chest. No emergency dialysis supply kit, clamps, pressure dressings, or other catheter-related emergency equipment were present at the bedside, mounted on the wall, or otherwise readily accessible in the resident's room. During an interview on February 4, 2026, at 10:41 AM, Employee 5, Registered Nurse, stated that an emergency kit containing clamps and pressure dressings should have been present and immediately accessible in the resident's room based on the resident's dialysis access needs. Review of Resident 83's comprehensive care plan, initiated January 5, 2026, revealed no individualized interventions addressing hemodialysis treatment, monitoring of the dialysis access site, emergency response measures for hemorrhage or catheter dislodgement, or location of the dialysis access site. There were no documented interventions outlining emergency procedures specific to the resident's dialysis catheter. On February 4, 2026, at 1:45 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON). 28Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, review of facility policies and procedures, observation, and staff interview, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice failed to obtain physician orders for monitoring of the PICC line and failed to ensure physician-ordered intravenous antibiotic therapy was administered as prescribed for one of 3 residents reviewed (Resident 5) who required care and monitoring of a Peripherally Inserted Central Catheter (PICC) line (a long, flexible tube inserted into a vein in the arm and advanced to a large vein near the heart to allow administration of intravenous medications and fluids).Findings include: Review of the facility policy titled Administering Medications last reviewed by the facility on January 14, 2026, revealed that medications are administered as prescribed and in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals). The individual administering the medication initials the resident's electronic medication administration record (eMAR) after each medication is given. Review of the facility policy titled Peripheral and Midline IV Dressing Changes and Central Venous Catheter Care and Dressing Changes last reviewed by the facility on January 14, 2026, revealed the purpose of the procedure is to prevent complications associated with intravenous therapy. Licensed staff, as identified by the State Nurse Practice Act, are responsible to measure the arm circumference (measurement of the arm at the midpoint between the shoulder and the elbow) and compare the arm circumference to the baseline when clinically indicated to assess for edema (swelling caused by fluid buildup) and possible deep-vein thrombosis (a dangerous blood clot that forms deep in the vein). The policy indicated licensed nursing staff are to measure the length of the external central vascular catheter (portion of the catheter visible outside the body) with each dressing change or when catheter dislodgement (unintended movement of the catheter from the original insertion position) is suspected and compare findings to the length documented at insertion.Clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included intraspinal abscess (a rare, dangerous collection of pus within or around the spinal cord) and granuloma (inflamed tissue). Review of a hospital procedure note dated February 18, 2026, revealed that Resident 5 underwent placement of a single-lumen PICC line (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for intravenous fluids and medications) in the right arm for intravenous administration of fluids, including antibiotics. Documentation indicated a catheter length of 42 centimeters (cm) with an external length of 0 cm at the time of insertion.Review of Resident 5's Nursing admission Evaluation dated February 18, 2026, failed to identify the presence of the PICC line. Review of physician orders failed to identify orders addressing PICC line monitoring, including measurement of external catheter length, measurement of arm circumference, or instructions to monitor for catheter migration (movement of the catheter from the original location) or dislodgement. Review of the Medication Administration Record (MAR) for February 2026 and March 2026, and nursing progress notes dated February 18 through March 20, 2026, failed to provide documented evidence licensed nursing staff measured or recorded PICC line external length or arm circumference upon admission or during weekly dressing changes as indicated in facility policy.During an observation on March 20, 2026, at 3:25 PM, Employee 1 (Registered Nurse) measured the external catheter length at 12 cm and the arm circumference at 28 cm. Employee 1 confirmed the hospital documented an external catheter length of 0 cm and was unable to provide documented evidence the current measurement did not reflect catheter migration due to the absence of baseline and ongoing assessments. Review of a physician order dated February 18, 2026, indicated Cefazolin Sodium (an antibiotic medication used to treat bacterial infection) injection solution 2 grams intravenously three times daily for treatment of spinal infection through March 27, 2026. Review of the MAR for February 2026 and March 2026 indicated the medication was scheduled for administration at 6:00 AM, 2:00 PM, and 10:00 PM. Documentation failed to confirm the medication was administered as ordered on the following dates: February 20, 2026, at 2:00 PM dose not documented as administeredMarch 9, 2026, at 10:00 PM dose not documented as administeredMarch 19, 2026, at 10:00 PM dose not documented as administered Interview with the Director of Nursing (DON) on March 20, 2026, at 3:45 PM confirmed the facility failed to obtain a physician order for PICC line monitoring in accordance with facility policy and failed to ensure and document administration of ordered intravenous antibiotic therapy. The DON acknowledged that the absence of documentation indicated the medications were not administered per policy and professional standards. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services.28 Pa. Code 211.10 (a)(c)(d) Resident care policies.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, select facility policies, observations, and staff interviews, it was determined the facility failed to consistently monitor residents' nutritional and hydration status to timely identify declines, failed to implement and document effective non-invasive interventions, and implemented invasive measures (intravenous therapy) without documented evidence that less invasive approaches were attempted or optimized for two of 26 residents reviewed (Resident 58 and Resident 12). Findings include: A review of a facility policy entitled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, last reviewed by the facility on January 14, 2026, indicated the nursing staff will monitor and document weights and dietary intakes of resident in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intakes, and pertinent laboratory values) and identify individuals with anorexia, weight loss/gain, and significant risk for impaired nutrition. The facility staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician will review medical causes for weight changes, anorexia, and weight loss before ordering interventions. A review of Resident 58's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia (a gradually progressive type of brain disorder that causes problems with memory, thinking and behavior) and adult failure to thrive (a process of physical and psychological decline associated with advanced age, manifesting as a pronounced overall deterioration that encompasses a wide range of vague symptoms, including unexplained loss of appetite, weight loss, cognitive and functional decline, and social isolation, complicated by multiple medical comorbidities and psychiatric factors).A review of Resident 58's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 2, 2025, revealed the residents Brief Interview for Mental Status score of 7 (BIMS, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) that indicated severe cognitive impairment. The resident was not on a therapeutic diet and required set-up assistance for meals. Resident 58's nutrition plan of care initiated July 7, 2025, and last revised July 29, 2025, identified the resident at risk for altered nutritional status related to Alzheimer's disease and adult failure to thrive with a history of dehydration (a condition that occurs when the body loses more fluids than it takes in). Goals included maintaining hydration status, laboratory values within physician-determined parameters, and absence of signs and symptoms of dehydration. Interventions included monitoring meal percentages, encouraging fluids, notifying the registered dietitian (RD), family, and physician of changes, obtaining labs, and providing feeding assistance and supplements as ordered. Planned interventions included administering medications and vitamin or mineral supplements as ordered by the physician; encouraging and providing fluids throughout the day, if not medically contraindicated (not advised due to a medical condition); monitoring and documenting meal intake percentages to identify changes in eating habits; notifying the registered dietitian (RD), family, and physician of any signs or symptoms of dehydration; obtaining laboratory tests as ordered that relate to nutritional status and reporting results to the physician while ensuring the RD was informed; initiating referrals to occupational therapy (OT) and speech-language A review of a Certified Registered Nurse Practitioner (CRNP) progress notes dated November 25, 2025, at 3:00 PM, indicated Resident 58 was evaluated for increased shortness of breath, increased confusion, decreased eating and drinking, and progressive decline following a COVID-19 infection in late October 2025. Laboratory results obtained that day revealed a BUN of 44 mg/dL (Blood Urea Nitrogen, a blood test that measures waste products in the blood that are normally removed by the kidneys; normal range approximately 7-20 mg/dL). An elevated BUN may indicate dehydration (not enough body fluid) or impaired kidney function.; a creatinine of 1.2 mg/dL (creatinine is a waste product from normal muscle activity that is filtered by the kidneys; normal range approximately 0.6-1.3 mg/dL). Elevated creatinine levels may suggest reduced kidney function, and a blood glucose of 56 mg/dL (glucose is the amount of sugar in the blood; normal fasting range approximately 70-100 mg/dL). A level of 56 mg/dL is considered low and may cause confusion, weakness, or altered mental status. The CRNP documented stable vital signs, notified the resident's son of the resident's decline, and ordered intravenous (IV) hydration (fluids administered directly into a vein), specifically D5W (dextrose 5% in water, a sterile IV solution used for hydration) 1 liter at 75 milliliters per hour, along with continued encouragement of oral fluids and repeat laboratory testing, BMP (basic metabolic panel measures basic metabolic functions like kidney health and electrolytes) for November 28, 2025 A review of a nutrition progress note completed by the facility's registered dietitian (RD) dated November 26, 2025, at 10:23 AM, indicated meal intake percentages ranged from 26% to 100% of a regular diet with regular texture and thin liquids. The RD documented awareness that the resident was receiving intravenous fluids (IVF, fluids administered directly into a vein) and recommended initiation of a 2.0 supplement (a high calorie, high protein oral nutritional supplement) 120 milliliters twice daily due to inconsistent intake. The note indicated the RD would monitor and follow. Further review of a Certified Registered Nurse Practitioner (CRNP) follow-up progress notes dated November 28, 2025, at 12:20 PM, documented continued decline since late October following COVID-19 infection. Nursing reported that the resident's oral (PO) intake (food and fluids taken by mouth) was very poor, with intermittent shortness of breath and increased confusion. The residents received IV fluids on November 26, 2025. Repeat laboratory results indicated additional IV fluids were appropriate. The CRNP ordered 1 liter of normal saline (NS, a sterile saltwater solution used for hydration) at 75 milliliters per hour intravenously and continued encouragement and assistance with oral intake. Orders were also given for the 2.0 supplement 120 milliliters twice daily. A quarterly nutrition assessment completed by the RD dated December 1, 2025, at 12:44 PM, continued to show meal intake variability of 26% to 100% of a regular diet with thin liquids, supplemented with 2.0 supplement 120 milliliters twice daily with medication administration. Estimated hydration requirements were documented as 1272-1527 milliliters per day. The resident's weight on November 1, 2025, was 112.2 pounds, reflecting no change in one month, a gain of one pound in three months, and a gain of 8.6 pounds since admission. Body Mass Index (BMI, a measurement of body weight in relation to height used to assess nutritional status) was 21.9, which falls within normal range. The plan was to continue the current plan of care and monitor. A review of a Hydration Screening Tool completed by the CRNP on December 16, 2025, identified persistent low fluid intake, decreased perception of thirst, difficulty communicating needs, lethargy (abnormal drowsiness), confusion, recent weight loss, poor appetite, and malnutrition (a condition resulting from inadequate nutrient intake). Physical findings included cracked lips and decline in activities of daily living (ADLs, basic self-care tasks such as eating and bathing). The CRNP ordered IV hydration with 0.9% normal saline 500 milliliters at 250 milliliters per hour via peripheral IV (a small catheter inserted into a vein), along with Hydration Plus (overall hydrational support with supplemental micronutrients)and vitamin supplementation (B-Complex ,Vitamin C 5,000 mg, methyl-cobalamin B12, zinc 10 mg, magnesium chloride 600 mg, and calcium chloride 100 mg, plus Cognitive Support of Taurine 100 mg, glycine 100 mg, and folic acid 5 mg). A review of the December 2025 Medication Administration Record (MAR, the legal record documenting medications and treatments administered) revealed the IV infusion was completed on December 20, 2025, four days after documentation of persistent low fluid intake and visible signs of dehydration. A subsequent Hydration Screening Tool dated January 13, 2026, again documented persistent low fluid intake, confusion, lethargy, poor appetite, cracked lips, and decline in ADLs. IV hydration with supplementation was again ordered. The January 2026 MAR indicated the IV infusion was completed on January 19, 2026, at 8:20 AM, six days after identification of dehydration concerns. Further review of the clinical record failed to reveal documented evidence of additional or intensified oral hydration strategies, structured fluid intake monitoring, increased staff feeding assistance, or alternative non-invasive interventions prior to repeated intermittent (once per month) IV therapy. Further review of Resident 58's clinical record failed to reveal any follow up from the facility's RD with the residents' continued declined oral fluid intake and failed to reveal documented evidence of additional or intensified oral hydration strategies, structured fluid intake monitoring, increased staff feeding assistance, or alternative non-invasive interventions prior to repeated intermittent IV therapy. Observation of Resident 58 on February 5, 2026, at 12:05 PM, revealed the resident in bed with an untouched breakfast tray consisting of a toasted bagel, scrambled eggs, and a 4-ounce yogurt. An interview with Employee 6, a licensed practical nurse (LPN), on February 5, 2026, at 12:15 PM, confirmed the resident did not complete her breakfast and probably needed to be assisted more with meals. The facility was unable to provide documented evidence of alternative, non-invasive measures implemented to improve and maintain Resident 58's nutritional and hydration status prior to reliance on intermittent IV therapy. A review of Resident 12's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia without behavioral disturbance, schizoaffective disorder bipolar type (is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), feeding difficulties (difficulty consuming adequate nutrition and hydration), and anxiety disorder (excessive and persistent worry and fear about everyday situations and often involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes resulting in panic attacks). A review of a quarterly MDS dated [DATE], revealed Resident 12 was severely cognitively impaired and was not on a therapeutic diet. Resident 12's nutrition plan of care initiated on September 9, 2023, last revised December 23, 2025, identified risk for altered nutritional status related to variable intake and psychiatric diagnoses. Interventions included encouraging fluids, providing supplements, notifying the RD and physician of dehydration signs, and providing feeding assistance. A review of a quarterly nutrition assessment completed by the facility's registered dietitian (RD) dated October 21, 2025, at 10:42 AM, indicated Resident 12 consumed 51% to 100% of a regular diet with regular texture and thin liquids. The resident received fortified foods (foods enhanced with additional calories and protein), a 2.0 supplement (a high calorie, high protein oral nutritional supplement) 120 milliliters three times per day with 100% acceptance, and a Magic Cup (a frozen high calorie, high protein supplement) with meals, also documented as 100% accepted. The resident's weight on October 1, 2025, was 112.8 pounds, reflecting a one-pound loss in one month, two-pound loss in three months, and 2.8-pound loss in six months, which was documented as not significant. The RD noted no changes in food or beverage preferences and indicated the current plan of care would continue with monitoring. However, review of the weight record revealed that on November 1, 2025, the resident's weight had decreased to 107.4 pounds, representing a 5.4-pound loss in one month. A subsequent nutrition progress note completed by the RD on November 6, 2025, acknowledged the 5.4-pound weight loss. Meal intake continued to vary between 51% and 100% of meals with supplements accepted. The RD questioned the overall downward weight trend despite documented supplement acceptance and discussed obtaining a TSH (thyroid-stimulating hormone, a blood test used to evaluate thyroid function) to rule out a metabolic cause. The note indicated the RD would monitor and follow. A review of a Hydration Screening Tool completed by the Certified Registered Nurse Practitioner (CRNP) on December 16, 2025, identified persistent low fluid intake, decreased perception of thirst, difficulty communicating needs, lethargy (abnormal drowsiness), recent weight loss, poor appetite, and malnutrition (a condition caused by inadequate intake of nutrients). Physical findings included cracked lips and recent falls or increased fall risk. New orders were issued for intravenous (IV) consisting of 0.9% normal saline (a sterile saltwater solution used for hydration) 500 milliliters at 250 milliliters per hour via peripheral IV (a small catheter inserted into a vein), along with vitamin and micronutrient supplementation (B-Complex ,Vitamin C 5,000 mg, methyl-cobalamin B12, zinc 10 mg, magnesium chloride 600 mg, and calcium chloride 100 mg, plus Cognitive Support of Taurine 100 mg, glycine 100 mg, and folic acid 5 mg). A review of Resident 12's Medication Administration Record (MAR) for December 2025, revealed the IV infusion was completed on December 20, 2025, four days after the CRNP documented persistent low fluid intake and visible signs and symptoms of dehydration. Further review of the clinical record failed to reveal documented evidence that oral hydration strategies were intensified, that structured fluid intake monitoring was implemented, that feeding assistance was increased, or that other non-invasive interventions were trialed or evaluated prior to initiating IV therapy. During an interview on February 6, 2026, at 10:10 AM, the RD reported that resident weight changes and poor oral intake were discussed each morning with the interdisciplinary team. However, the RD was unable to provide documented evidence that the nutritional plan of care for Resident 12 or Resident 58 was revised or intensified to improve hydration status prior to repeated intermittent IV infusions. During an interview on February 6, 2026, at 10:30 AM, the CRNP reported that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) communicated concerns regarding decreased intake to determine the need for additional IV hydration and vitamin therapies. The CRNP further stated that measured fluid intake records were not reviewed to determine actual oral fluid consumption; rather, visual assessment and laboratory results were used to determine the need for IV therapy. During an interview on February 6, 2026, at 11:00 AM, the Nursing Home Administrator reviewed the above findings and acknowledged that less invasive nutrition and hydration measures should have been attempted and documented prior to implementing invasive IV therapy for cognitively impaired residents. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on review of select facility policy and interviews with residents and staff, it was determined the facility failed to review and revise a resident's plan of care in response to a significant weight loss for one resident out 26 residents reviewed (Resident 8).Findings include: Review of the facility policy titled Weight Assessment and Intervention last reviewed January 26, 2026, revealed care planning for weight loss should include identification of the cause of weight loss, goals with measurable time frames for improvement and interventions and approaches. Review of the clinical record of Resident 8 revealed admission to the facility on November 21, 2025, with diagnoses to include dementia (the loss of cognitive functioning; thinking, remembering, and reasoning; to such an extent that it interferes with a person's daily life and activities). On January 5, 2026 the resident weighed 122.5 pounds and on January 21, 2026 the resident weighted 115. 6 which was a 5.63% weight loss in less than 30 days. A nutritional note dated January 21, 2026, revealed the dietitian continued to implement interventions to address the residents weight loss, however a review of the resident's care plan, dated as last revised on December 30, 2025, revealed the resident was nutritionally at risk related to dementia, poor intakes, meal refusals and weight gain, there was no focus on the residents care plan regarding the resident's recent weight loss. Upon review during the days of the survey, February 3-6, 2026, there were no updates or revisions to this resident's care plan related to the resident's nutritional risk and weight status since December 30, 2025. There was no documented evidence that Resident 8's care plan had been reviewed and revised related to current individualized interventions to address the resident's significant weight loss and continued need to monitor the resident's weights. Interview on February 5, 2026, at 2:30 PM the Nursing Home Administrator (NHA) confirmed the facility failed to review and revise Resident 8's plan of care to accurately reflect the resident's current status and needs. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical record review, and staff interview, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and individualized interventions to address a resident's diagnosed medical condition for one of 30 residents reviewed (Resident 13).Findings include:A review of the facility policy titled Care Plans, Comprehensive Person Centered, last reviewed by the facility on January 14, 2026, revealed that a comprehensive person-centered care plan with measurable objectives and timeframes is to be developed and implemented to meet each resident's physical, psychosocial (mental and social), and functional (ability to perform daily activities) needs. Clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses that included Viral Hepatitis C (a contagious infection that causes inflammation or damage to the liver, most commonly spread through contact with infected blood) without hepatic coma (a severe complication of liver failure resulting in decreased brain function due to toxin buildup in the bloodstream). Review of Resident 13's comprehensive care plan, initiated October 25, 2025, revealed there were no identified problems, goals, or interventions addressing the resident's diagnosis of Viral Hepatitis C. The care plan did not include monitoring for potential symptoms or complications, infection control considerations, laboratory monitoring, medication management, or education related to the liver condition. An interview was conducted with the Director of Nursing (DON) on February 5,2026, at 1:45 PM to review the above findings related to the facility's failure to develop a comprehensive care plan related to this resident's specific diagnosis. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on review of clinical records, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS) assessments, and staff interviews, it was determined the facility failed to ensure the MDS accurately reflected the clinical status and services provided for two of 26 sampled residents (Residents 12 and 8).Findings include: A review of Resident 12's clinical record revealed the resident was admitted on [DATE], with diagnoses that included dementia without behavioral disturbance (a chronic disorder affecting memory and thinking) and anxiety (a condition involving excessive worry or nervousness). A physician's order dated December 19, 2025, at 5:22 PM, revealed an order written by the facility's Certified Registered Nurse Practitioner (CRNP) for intravenous micronutrient hydration therapy provided by an outside contracted nursing service. The order included an intravenous infusion (fluid delivered directly into a vein through a catheter) containing the following substances: B-Complex (a combination of B vitamins that support energy metabolism and nerve function)Vitamin C 5,000 milligrams (a vitamin that supports immune function and tissue repair)Methyl-cobalamin (Vitamin B12, a vitamin important for nerve function and red blood cell production)Zinc 10 milligrams (a mineral involved in immune function and wound healing)Magnesium chloride 600 milligrams (a mineral involved in muscle and nerve function)Calcium chloride 100 milligrams (a mineral important for bone strength and muscle function)Taurine 100 milligrams (an amino acid that supports neurological and cardiovascular function)Glycine 100 milligrams (an amino acid involved in protein synthesis and nervous system function)Folic acid 5 milligrams (a B vitamin necessary for cell growth and red blood cell production) These substances are classified as vitamins or micronutrients. Vitamins are organic compounds required in small amounts for normal body function and are typically obtained through diet or oral supplements. They are not considered parenteral nutrition (intravenous feeding that provides calories, protein, fats, carbohydrates, vitamins, and minerals as a primary nutritional source). The micronutrients were added to 500 milliliters (ml) of 0.9 percent normal saline (a sterile saltwater solution commonly used for hydration) and infused at 250 ml per hour on December 20, 2025. A review of the December 2025 Medication Administration Record (MAR) revealed the infusion was administered and completed on December 20, 2025, at 8:30 AM. The Resident Assessment Instrument (RAI) Manual is the federally issued instruction manual that provides specific coding guidance for each item on the Minimum Data Set (MDS). Facilities are required to code the MDS exactly as instructed in the RAI Manual to ensure accuracy, consistency, and regulatory compliance. The RAI Manual for Section K0520 (Nutritional Approaches, Parenteral/IV Feeding) instructs that parenteral feeding refers to intravenous nutrition that provides calories and nutrients when a resident cannot receive adequate nutrition by mouth or through the gastrointestinal tract. The Manual specifically states that IV fluids administered only for hydration or IV fluids used to reconstitute or dilute medications must not be coded as parenteral/IV feeding. The RAI Manual for Section O0110H1 (Special Treatments, Procedures, and Programs, IV Medications) instructs that this item includes drugs or biological agents administered intravenously by IV push (direct injection into a vein), continuous infusion (drip), or through a central or peripheral IV line (a catheter inserted into a vein). The Manual further clarifies that IV fluids without medication and flushes used only to maintain IV line patency (to keep the line open) must not be coded in this item. A review of Resident 12's annual MDS dated [DATE], revealed that: Section K0520 (Parenteral/IV Feeding) was coded yes, indicating the resident received IV feeding during the seven-day look-back period (the seven days preceding the assessment reference date).Section K0710 (Percent Intake by Artificial Route) was coded 25 percent or less of total calories received through parenteral or tube feeding during the seven-day look-back period.Section K0710B (Average fluid intake per day by IV or tube feeding) was coded 500 milliliters per day or less during the seven-day look-back period.Section O0110H1 (IV Medications) was coded yes.However, review of Resident 12's clinical record revealed documentation of a one-time intravenous micronutrient hydration infusion consisting primarily of vitamins, minerals, and amino acids added to normal saline. The record did not contain documentation that the infusion provided calories as a primary nutritional source, replaced oral intake, or constituted artificial nutritional support as defined under parenteral feeding in the RAI Manual. Additionally, the clinical record did not contain documentation supporting that the infusion met RAI criteria for coding under Section O0110H1 as IV medication therapy consistent with the Manual's definition. The infusion primarily consisted of vitamins and micronutrients added to IV fluids for hydration. Based on review of the RAI Manual instructions and the clinical documentation, Sections K0520, K0710, and O0110H1 on the December 25, 2025, MDS were not supported by the clinical record. A review of Resident 8's clinical record revealed the resident was admitted on [DATE], with diagnoses that included Alzheimer's dementia (a progressive brain disorder affecting memory, thinking, and behavior) and mild protein-calorie malnutrition (a condition in which the body does not receive adequate protein and calories). A review of a physician's order dated December 19, 2025, at 5:17 PM, revealed an order given by the facility's Certified Registered Nurse Practitioner for intravenous micronutrient hydration therapy provided by an outside contracted nursing service consisting of the same micronutrient hydration infusion described above, administered on December 20, 2025, with 500 ml of normal saline. A review of Resident 8's Medication Administration Record (MAR) for December 2025, revealed the IV infusion was administered and completed on December 20, 2025, at 9:25 AM. Resident 8's quarterly MDS dated [DATE], revealed: Section K0520 (Parenteral/IV Feeding) coded yes.Section K0710 coded 25 percent or less calories and 500 ml per day or less of fluids.Section O0110H1 (IV Medications) coded yes. Review of Resident 8's clinical record failed to reveal documentation that the IV micronutrient hydration constituted parenteral feeding or met criteria for IV medication coding as defined by the RAI Manual. There was no documentation that the infusion provided primary nutritional support or that it was medically necessary IV drug therapy consistent with RAI definitions. During an interview on February 5, 2026, at 11:15 AM, the facility's Registered Nurse Assessment Coordinator stated that the contracted IV therapy service provided information indicating that MDS Sections K and O could capture administration of IV micronutrient therapies. During an interview on February 6, 2026, at 10:10 AM, the facility's Registered Dietitian stated that Sections K and O were believed to capture IV micronutrient therapies and that coding was based on information provided by the contracted IV service. The facility provided educational material from the contracted intravenous hydration service titled Documentation Guidance: Establishing Medical Necessity. The document indicated that IV fluids may be coded under Section K0520A (Parenteral/IV Feeding) when needed to prevent dehydration, provided there is supporting documentation reflecting a specific nutrition and/or hydration need. The document outlined four areas to establish medical necessity for IV hydration support: The resident has a chronic fluid deficit despite interventions to support adequate oral fluid intake; and/orThe resident has documented diagnoses, conditions, or medications that interfere with or predispose the resident to difficulty maintaining normal fluid balance; and/orThe resident has documented diagnoses or conditions known to be caused by, contributed to, or complicated by dehydration; andThe resident has no contraindications (medical reasons not to receive treatment) for intravenous hydration, and any special considerations have been addressed.The Resident Assessment Instrument (RAI) Manual requires that IV fluids be coded under Section K0520 only when there is supporting clinical documentation in the medical record demonstrating a need for additional fluid intake specifically addressing a nutrition or hydration need. Prevention or treatment of dehydration must be clinically indicated and supported by documentation in the resident's record.Review of the clinical records for both Resident 12 and Resident 8 failed to reveal documentation supporting medical necessity for intravenous hydration consistent with the criteria outlined in the vendor's documentation guidance or the RAI Manual requirements. Specifically, the clinical records for both residents did not contain documentation of: A chronic or acute fluid deficit despite interventions to promote adequate oral intakeClinical signs, symptoms, or laboratory findings consistent with dehydrationA diagnosis, condition, or medication interfering with the resident's ability to maintain normal fluid balanceDocumentation that oral hydration interventions were attempted and unsuccessfulA documented plan of care addressing hydration needs requiring intravenous therapy Additionally, the records did not demonstrate that the intravenous infusion provided artificial nutritional support (intravenous feeding supplying calories as a primary source of nutrition), as defined under Section K0520 of the RAI Manual. Although the contracted service's educational material suggested the therapy could be coded under Section K0520A, the RAI Manual requires that coding decisions be based on the resident's clinical condition and supporting documentation in the medical record. In the absence of documentation demonstrating medical necessity for hydration consistent with RAI criteria, the coding of Sections K0520, K0710 (Percent Intake by Artificial Route), and O0110H1 (IV Medications) on the respective MDS assessments was not supported by resident-specific clinical documentation. During an interview with the facility's Nursing Home Administrator (NHA) on February 6, 2026, at 11:30 AM, the above findings were reviewed. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on clinical record review, review of facility policy, investigative documentation, and staff interviews, it was determined the facility failed to thoroughly investigate an incident involving a resident being left unattended while at an outside medical appointment to determine whether neglect occurred for one of 22 sampled residents (Resident 1).Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on April 8, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated it is the expectation that any allegation of abuse or neglect is to be reported to the Nursing Home Administrator and other officials. The policy further indicates that an investigation into the allegation will be initiated immediately and include complete statements and interviews from staff and residents involved in the allegation within time frames required by federal regulations. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life, and heart failure (a condition in which the heart does not pump blood effectively, leading to fatigue and difficulty with daily activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 22, 2025, revealed that Resident 1 had severely impaired cognition with a BIMS score of 4 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; (a score of 0-7 indicates severe cognitive impairment). A review of the resident's comprehensive person-centered care plan initiated on August 25, 2025, revealed Resident 1 was identified as at risk for elopement (leaving the facility without staff awareness or supervision). The care plan directed that Resident 1 would not leave the facility unattended. An interview with Employee 1NA (Nurse Aide) conducted September 24,2025, at 9:39AM, revealed on September 12, 2025, revealed that on September 12, 2025, she accompanied Resident 1 to an outside cardiology appointment. Employee 1 stated that after the appointment, she wheeled the resident to a lobby area, closed the door, and went to use the restroom, leaving the resident unattended. Employee 1 stated that when she exited the restroom, Resident 1 was no longer in the lobby. She reported she then ran outside and observed Resident 1 with a [NAME] driver, who was questioning the resident about where her caregiver was. The interview further revealed that upon return to the facility, Employee 1 verbally reported the incident to Employee 2, an LPN (licensed practical nurse). Employee 1 stated that Employee 2 provided her education not to leave residents who were identified as elopement risks unattended at any time. An interview with Employee 2, conducted on September 24, 2025, at 9:58 AM, confirmed that Employee 1 NA reported the incident. Employee 2 LPN stated she verbally educated Employee 1NA and wrote a witness statement, which she provided to Employee 3, an RN (registered nurse) Supervisor. Employee 2 LPN stated she followed her chain of command. An interview with Employee 3, RN Supervisor, conducted on September 24, 2025, at 10:35 AM, confirmed she was the RN Supervisor on duty on September 12, 2025. Employee 3 stated she was told about the incident by Employee 4, the transportation driver, later that evening at the end of her working shift around 7:00PM). Employee 3 stated she believed the information was a rumor and did not report it to the Nursing Home Administrator (NHA) or the Director of Nursing (DON). Employee 3 further stated she was not directly informed by Employee 2 about the incident. An interview with Employee 4 (Transportation Driver) conducted September 24, 2025, at 11:16 AM revealed on September 12, 2025, Employee 4 arrived at the outside cardiology facility to transport Resident 1 back to her facility. Employee 4 stated upon arrival at the cardiology office he witnessed Resident 1, Employee 1 NA, and the [NAME] driver outside of the facility. Employee 4 stated the [NAME] driver informed him Resident 1 was witnessed to be propelling herself out of the facility when the [NAME] driver asked her where she was going. While the [NAME] driver was questioning the resident, Employee 1 NA came running out of the building to the resident. The [NAME] driver stated Employee 1 NA was using the restroom when the resident began to wheel herself out of the facility but was stopped. Employee 4, transportation driver further stated upon return to the facility he told Employee 3 RN Supervisor about the incident but did not report the information to the NHA or the DON. An interview with the DON on September 24, 2025, at 11:30 AM, revealed she was not made aware of the incident involving Resident 1 until the survey team's investigation. Despite staff interviews and statements, the facility failed to implement its written abuse policy by not ensuring the incident was reported to administration, by not initiating an immediate investigation, and by not collecting statements from all parties involved. The failure to investigate whether neglect (defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress) occurred placed Resident 1 at risk for further neglect, elopement, or harm. 28 Pa. Code 201.14 (a)(c) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care policies. 28 Pa. Code 211.12 (c)Nursing Services

Based on clinical record review, interview, and policy review, it was determined the facility failed to provide residents and/or their representatives with the required written notice of Medicare coverage termination, including an explanation of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) and the right to appeal, prior to the end of Medicare Part A services for two of three sampled residents reviewed for Medicare coverage notices (Resident 1 and Resident 2).Findings Include: A review of Resident 1's clinical record revealed admission to the facility on May 14, 2025, with diagnoses to include Parkinsons disease (a progressive, neurological disease), muscle weakness and diabetes. Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was June 5, 2025. Further review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form dated June 3, 2025, which is a standardized written notice that facilities are required to issue to a Medicare beneficiary when services are expected to end or coverage will be denied. The notice must explain the reason for non-coverage; the date coverage will end and inform the resident or their representative of their right to appeal the decision. The form indicated Resident 1 requested the form be reviewed with her responsible party, her daughter. The facility social worker documented the responsible party's name and telephone number, the date June 3, 2025, and noted no appeal. There was no evidence that the resident or her responsible party received the notice, reviewed the form, or were informed of the opportunity to appeal the coverage termination. During a telephone interview conducted on August 12, 2025, at 12:00 P.M., Resident 1's daughter stated that the facility did not contact her regarding the SNF-ABN and that she was not advised of her right to appeal the denial of coverage. A review of Resident 2's clinical record revealed admission to the facility on July 14, 2025, with diagnoses to include Parkinson's disease (a progressive, neurological disease) and a history of falls. The clinical record indicated the resident was his own responsible party. A review of an admission minimum data set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 17, 2025 revealed a BIMS score of 10 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information. A score between 8 and 12 indicates moderate cognitive impairment). Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was July 31, 2025. Further review of the SNF-ABN form dated July 29, 2025, revealed the resident signed the form, and the social worker documented no appeal. There was no evidence that the resident was provided with an explanation of the form or informed of the right to appeal. During an interview on August 12, 2025, at 12:30 P.M., Resident 2 stated that he was asked by someone to sign the form. He stated he was not given an explanation about the SNF-ABN and was not advised that he could appeal the denial of coverage. An interview with the Nursing Home Administrator (NHA) on August 12, 2025, at 1:30 PM the aforementioned information was reviewed with the NHA. The NHA acknowledged the information which was provided by the surveyor. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights.

Based on review of clinical records and select facility investigative reports and staff interview it was determined the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized toileting and safety needs of two residents (Residents 18 and 11) out of 27 sampled. Findings included: A review of Resident 18's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness that occurs due to disruptions in brain, spinal cord, or the nerves that connect to the affected muscles) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain (cerebral infarct) that is caused by disrupted blood supply (ischemia) and restricted oxygen supply), abnormalities of gait (walking [NAME]) and mobility, lack of coordination, and narcolepsy (a neurological condition that disturb the sleep wake cycles and characterized by excessive sleepiness in the daytime and may also suddenly fall asleep during any activity). A review of a Resident 18's quarterly-Day MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 9, 2024, revealed the resident was cognitively intact, used a wheelchair as primary mobility devise, required supervision or touching assistance with transfers and toilet use, and required partial to moderate assistance with walking on the unit. Additionally, the resident's assessment indicated the resident was occasionally incontinent of bowel and bladder without a toileting program. The resident's care plan, initiated on November 10, 2023, and revised on January 13, 2025, indicated the resident was at risk for falls related CVA with left hemiparesis/hemiplegia, decreased strength and endurance, history of falls, impaired cognition with decreased safety awareness, and gait dysfunction. Planned fall prevention/safety interventions were to educate the resident and family to call for assistance before transferring and add visual reminders and implement preventative fall interventions/devices. Additionally, Resident 18's care plan also indicated the resident had episodes of bladder and bowel incontinence with planned interventions to assist the resident with toileting needs, periodically evaluate resident's pattern of urination and episodes of incontinence, and scheduled toileting upon rising, after meals, and at 10:00 PM. A review of Resident 18's clinical record revealed that the resident had a fall in the bathroom on October 29, 2025, at 10:36 PM, and sustained a laceration to the left forehead. The resident was placed on temporary every fifteen minute checks and neurological checks. On January 13, 2025, at 4:50 AM, nurse aides found Resident 18 sitting on the floor of her bathroom. The resident stated that she went to the bathroom on her own while trying to get back into her chair. No injuries. Further review of the clinical record for Resident 18 revealed documentation of a fall in the resident's bathroom, during which the resident was found seated on the floor in front of the toilet. A small hematoma was noted to the back of the head. Documentation indicated that the resident reported falling while attempting to stand and pull up pants after toileting. Fall interventions noted at that time included a reminder for the resident to call for staff assistance and to initiate a three-day bowel and bladder tracking assessment. Further review of the clinical record failed to reveal documentation that the three-day bowel and bladder assessment had been completed or implemented following the fall. Review of the resident's person-centered plan of care failed to reveal timely revisions to reflect post-fall interventions or the inclusion of bowel and bladder assessment results. An interview conducted with the Director of Nursing (DON) on April 24, 2025, at 9:45 AM confirmed the fall-related interventions, including the three-day bowel and bladder assessment, were not implemented and that the comprehensive care plan was not revised in a timely manner to address the post-fall needs of Resident 18. A review of the clinical record revealed Resident 11 was admitted to the facility on [DATE], with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time, and Congestive heart failure (a long-term condition where the heart cannot pump blood effectively causing a build up of fluid in the lungs and legs). A review of the clinical record revealed Resident 11's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated for January 31,2025, revealed Resident 11 had a BIMS (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) score of 12 (a score of 8 to 12 indicates moderate cognitive impairment). A review of the clinical record reveals a progress note dated for January 24,2025, revealed documentation of a fall with injuries in the resident room while trying to go to the bathroom. A review of Resident 11's care plan initiated on November 9,2023 and revised on January 24,2025, revealed Resident 11 was at risk for falls related to bladder and bowel incontinence, decreased strength and endurance, generalized weakness, history of self-transfers, history of falls, obesity, pain and unsteady gait. Planned interventions were to educate resident to call for assistance prior to transferring, a 3-day bowel and bladder tracking assessment and a bed alarm to alert staff of unsafe transfers. Further review of the clinical record failed to reveal the facility completed the implemented fall intervention to complete a 3-day bowel and bladder assessment. An interview with the Director of Nursing on April 25 ,2025, at approximately 10:50 AM confirmed the facility failed to implement the planned fall interventions and 3-day bowel and bladder assessment for Resident 11. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on clinical record and select facility policy review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed (PRN) basis for one resident out of twenty-seven sampled (Resident 52). Findings include: Review of the facility policy titled Pain Assessment and Management, last reviewed by the facility on April 8, 2025, revealed non-pharmacological interventions may be appropriate alone or in conjunction with medications to manage pain. Examples of non-pharmacological interventions included environmental adjustments (such as adjusting room temperature or providing pressure-reducing surfaces), physical interventions (such as ices packs or warm compresses), exercise (such as range of motion exercises), and cognitive or behavioral strategies (such as relaxation techniques, music, or diversional activities). The policy indicated that while pharmacological interventions (such as analgesics) may be prescribed to manage pain, they do not usually address the underlying cause of the pain and can have adverse effects on the resident, including drowsiness, increased risk of falling, and loss of appetite. A clinical record review revealed Resident 52 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis of the right knee (a chronic joint disease that causes the breakdown of cartilage). A review of a Quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2025, revealed Resident 52 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact. Review of physician's orders dated March 19, 2025, revealed an order for Oxycodone HCl Capsule 5 MG, give 1 tablet by mouth every 8 hours as needed for moderate to severe pain 4-10 (pain scale of 1-10 indicates 1 no pain and 10 as worst amount of pain). A review the resident's medication administration record (MAR) dated March 1, 2025, through April 24, 2025, revealed Oxycodone HCL Oral Tablet 5mg, give 1 tablet by mouth every 8 hours as needed (PRN) for pain - Moderate (4-6) or Severe (7-10) was administered without documented attempts of nonpharmacological interventions on the following dates as follows: March 26, 2025, at 08:15 AM, administered an opioid PRN pain medication for a reported pain level at 6 (moderate pain) without attempted nonpharmacological interventions. March 28, 2025, at 01:42 AM, administered an opioid PRN pain medication for a reported pain level at 7 (severe pain) without attempted nonpharmacological interventions. March 29, 2025, at 09:11AM, administered an opioid PRN pain medication for a reported pain level at 5 (moderate pain) without attempted nonpharmacological interventions. March 30, 2025, at 03:02 AM, administered an opioid PRN pain medication for a reported pain level at 6 (moderate pain) without attempted nonpharmacological interventions. March 31, 2025, at 08:00PM, administered an opioid PRN pain medication for a reported pain level at 6 (moderate pain) without attempted nonpharmacological interventions. April 1, 2025, at 11:00AM, administered an opioid PRN pain medication for a reported pain level at 4 (moderate pain) without attempted nonpharmacological interventions. April 2, 2025, at 02:02 AM, administered an opioid PRN pain medication for a reported pain level at 7 (severe pain) without attempted nonpharmacological interventions. April 2, 2025, at 10:00AM, administered an opioid PRN pain medication for a reported pain level at 5 (moderate pain) without attempted nonpharmacological interventions. April 3, 2025, at 08:59 AM, administered an opioid PRN pain medication for a reported pain level at 6 (moderate pain) without attempted nonpharmacological interventions. April 4, 2025, at 3:26 PM, administered an opioid PRN pain medication for a reported pain level at 5 (moderate pain) without attempted nonpharmacological interventions. April 5, 2025, at 12:10AM, administered an opioid PRN pain medication for a reported pain level of 9 (severe pain) without attempted nonpharmacological interventions. April 8, 2025, at 09:37 AM, administered an opioid PRN pain medication for a reported pain level of 6 (moderate pain) without attempted nonpharmacological interventions. April 12, 2025, at 09:43AM, administered an opioid PRN pain medication for a reported pain level of 5 (moderate pain) without attempted nonpharmacological interventions. April 13, 2025, at 11:48PM, administered an opioid PRN pain medication for a reported pain level of 8(severe pain) without attempted nonpharmacological interventions. April 14, 2025, at 5:23 PM, administered an opioid PRN pain medication for a reported pain level of 5 (moderate pain) without attempted nonpharmacological interventions. April 15, 2025, at 01:49 AM, administered an opioid PRN pain medication for a reported pain level of 5 (moderate pain) without attempted nonpharmacological interventions. April 16, 2025, at 12:55 AM, administered an opioid PRN pain medication for a reported pain level of 7 (severe pain) without attempted nonpharmacological interventions. April 17, 2025, at 5:51 PM, administered an opioid PRN pain medication for a reported pain level of 8 (severe pain) without attempted nonpharmacological interventions. April 18, 2025, at 02:07 AM, administered an opioid PRN pain medication for a reported pain level of 8 (severe pain) without attempted nonpharmacological interventions. April 18, 2025, at 3:48PM, administered an opioid PRN pain medication for a reported pain level of 5 (moderate pain) without attempted nonpharmacological interventions. April 19, 2025, at 03:30AM, administered an opioid PRN pain medication for a reported pain level of 6 (moderate pain) without attempted nonpharmacological interventions. April 20, 2025, at 08:42 AM, administered an opioid PRN pain medication for a reported pain level of 4(moderate pain) without attempted nonpharmacological interventions. April 20, 2025, at 9:40PM, administered an opioid PRN pain medication for a reported pain level of 7(severe pain) without attempted nonpharmacological interventions. April 21, 2025, at 08:23 AM, administered an opioid PRN pain medication for a reported pain level of 4(moderate pain) without attempted nonpharmacological interventions. April 22, 2025, at 1:07 PM, administered an opioid PRN pain medication for a reported pain level of 7 (severe pain) without attempted nonpharmacological interventions. April 23, 2025, at 09:51 AM, administered an opioid PRN pain medication for a reported pain level of 8 (severe pain) without attempted nonpharmacological interventions. An interview with the Director of Nursing (DON) on April 24, 2025, at 11:00 AM, confirmed there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of opioid pain medication to Resident 52. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on observation, a review of select facility policy, review of clinical records and staff and resident interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses follow physician's orders and ensure accurate medication administration as prescribed for one resident (Resident 31) out of one sampled. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated the registered nurse is responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.14 Functions of the RN (Registered Nurse) requires the following: The RN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The RN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (a) A licensed RN may administer a drug ordered for a patient in the dosage and manner prescribed in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. A review of Facility Policy Labeled Administering Medications last reviewed on April 8, 2025, revealed insulin pens are clearly labeled with the resident's name and other identifying information. Prior to administering insulin with an insulin pen, the nurse is to verify the correct pen is used for that resident. A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnosis to include Type 2 Diabetes Mellitus (a condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) and parkinsonism (a neurological condition causing movement problems). A review of a quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 15, 2025, revealed Resident 31 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). On April 24, 2025, at 8:10 AM, during a medication administration observation, Employee 1, Registered Nurse (RN), checked Resident 31's blood sugar, which registered 169 mg/dL. Employee 1 then administered 10 units of Novolog Flex Pen Reli On (insulin aspart), a short-acting insulin which replaces the insulin that is normally produced by the body by helping move sugar from the blood into other body tissues where it is used for energy), to Resident 31. Review of physician orders revealed an active order dated March 19, 2025, for Basaglar Kwik Pen (insulin glargine a long-acting insulin) to be administered 10 units subcutaneously once daily. Additionally, a separate sliding scale order for Novolog dated December 8, 2024, required administration only when blood glucose readings exceeded 200 mg/dL (201-250 = 2 units; 251-300 = 4 units, 301-350= inject 6 units; 351-400= inject 8 units). Resident 31's blood glucose of 169 mg/dL did not meet criteria for Novolog administration under the physician's sliding scale. The insulin administered was not the ordered long-acting Basaglar, nor was it indicated by the blood glucose reading. At 11:15 AM on April 24, 2025, inspection of the facility medication cart revealed Basaglar insulin was not available for Resident 31 for the daily scheduled injection. A medication usage analysis of the Novolog Flex Pen, opened on March 19, 2025, showed that 64 units had been administered, without qualifying blood sugar levels per the sliding scale order. During an interview with Employee 1 at approximately 12:00 PM on April 24, 2025, the RN stated she administered Novolog insulin, but documented Basaglar was given. She acknowledged failing to verify the medication type against the physician's orders prior to administration. An interview with the Director of Nursing (DON) on April 25, 2025, at approximately 9:00 AM, confirmed that Employee 1 failed to verify the insulin type, administered an incorrect medication, and failed to provide nursing services in accordance with professional standards of practice. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 27 residents reviewed (Resident 76). Findings include: According to the RAI User's Manual dated October 2023 a Significant Change in Status MDS assessment is required within 14 days of the determination of the significant change when: A resident enrolls in a hospice program; or A resident changes hospice providers and remains in the facility; or A resident receiving hospice services discontinues those services; or A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS). A review of the clinical record revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia and hyperlipidemia. A review of the clinical record revealed that Resident 76 had experienced a significant decline in condition and elected Hospice Services/Care (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, attending to their emotional and spiritual needs) on July 1, 2024. There was no documented evidence a significant change MDS was completed to reflect that Resident 76's hospice services were initiated. Interview with the Director of Nursing on April 24, 2025, at approximately 1:45 PM, confirmed that a comprehensive significant change MDS assessment was not completed as required. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening two of five employees for employment (Employee 2 and 3). Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility April 2025, revealed the requirement for screening potential employees included obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 2 (Dietary Manager): Hired on March 3, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Housekeeping): Hired on January 10, 2025. The application listed prior employers, yet no evidence was found to verify that the facility obtained references or employment information from previous employers. Interview with the Nursing Home Administrator (NHA) on April 25, 2025, at 12:15 p.m. the NHA verified there was no evidence that previous employers were contacted for information regarding the employees' past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c)Resident Rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.19 (1) Personnel records

Based on a review of clinical records, information submitted by the facility, and select incident reports and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms displayed by one resident (Resident CR1) which, resulted in one resident (Resident 4) out of 6 residents sampled sustaining a serious injury, a fractured hip, caused by Resident CR1's dementia-related behavioral symptoms. Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). An admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment completed periodically to plan resident care) dated November 22, 2023, revealed that the resident was severely cognitively impaired. A review of the resident's current plan of care initially dated November 15, 2023, revealed a care plan in place for behaviors related to care, wandering into resident's rooms, refusal of care, yelling out or striking staff, resistive to going to the bathroom, cursing at staff, residents, and inanimate objects, striking out at others, and initiating arguments revealed interventions such as attempt to redirect when resident is experiencing behaviors and keep resident safe during episodes of behaviors. However, the resident's plan of care failed to address person specific interventions designed to address the resident's aggressive behaviors and the approaches staff should implement to deescalate the resident's behaviors to maintain the safety of both the resident, and other residents residing on the unit. A review of a nursing note dated November 15, 2023, at 9:49 PM revealed the resident self ambulates up and down the hallways in the facility. Staff redirected the resident back to her room, several times, but she will not lay down. The nursing documentation did not identify the approaches used to re-direct the resident or that staff had attempted other diversional activities designed for the resident to manage the resident's wandering behavior. A nursing note dated November 17, 2023, at 10:13 PM revealed that the resident became aggressive when staff was providing care. Staff were able to complete the task but with difficulty. This nursing documentation did not identify the approaches used by staff to de-escalate the resident's aggressive behaviors and to allow the staff to safely provide the nursing care. Nursing notes dated November 18, 2023, at 2:52 AM indicated that the resident was pacing the halls of the nursing unit and attempting to enter other resident rooms. Nursing noted that the interventions offered were snacks and toileting, which the resident refused. A nursing note dated November 21, 2023, at 4:45 AM revealed that the resident was combative with staff. The resident was kicking, hitting, scratching, and yelling at staff. The entry did not identify the behavior modification or management interventions staff attempted in response to the resident's combative behavior. A nursing note dated December 18, 2023, at 5:59 PM indicated that the resident was ambulating in the hallways of the unit, yelling, swearing, and getting into other residents' personal space. Resident CR1 was raising her fists to other residents and staff. There was no documented evidence of the individual person centered non-pharmacological interventions attempted to divert the resident's attention and redirect her from her intrusive wandering and aggressive behavior towards other residents. The facility administered a dose of Ativan (anti-anxiety medication) to manage her behavior. A nursing note dated December 19, 2023, at 2:32 PM revealed that the resident was ambulating in the hallways of the nursing unit and was verbally aggressive towards staff. Nursing noted that staff tried to redirect the resident with food and fluids with no effect. This intervention was attempted on November 18, 2023, and was ineffective in diverting the resident's behavior at that time as well. Nursing noted on December 26, 2023, at 5:54 PM that the resident was continually walking up and down the hallways, stopping and yelling at the residents, yelling I'll f**k you up. The resident would walk away from one resident, and then approach another resident yelling at them. Staff noted that the resident was observed clenching her fist, motioning at another resident. Nursing noted that attempts were made to redirect the resident but the resident then continued to pace the hallways and dining room yelling at other residents. A review of a nursing note dated December 27, 2023, at 4:34 AM revealed that the resident saw staff in the bathroom of the resident's room, with her roommate. The resident blocked the doorway of the bathroom and began punching towards staff members. Staff stood in front of the resident's roommate who was sitting on the toilet at that time. Nursing indicated that they tried to redirect the resident, which was ineffective. The entry did not identify the interventions used in an attempt to redirect the resident. The resident began to seek out any person in the halls or in rooms and tried to {physically} attack anyone within her reach. A medication administration note dated December 31, 2023, at 1:00 AM indicated that staff administered Ativan to the resident in response to resident's pacing, up and down the halls, cursing under her breath. The resident was observed, stopping at any person, residents and staff, in the common area and tell them to, F**k off. The entry noted that staff continued to redirect the resident but she continued to pace the hallways of the unit. A review of a nursing note dated December 31, 2023, at 3:01 AM revealed the resident was ambulating in the hallway and approached a male resident sitting in a chair at the nursing station who was yelling and agitated. The resident began yelling at the male resident in the hallway and the male resident swung at Resident CR1. The facility failed to identify, address and/or obtain necessary services for the dementia care needs of this resident and develop and implement a person-centered care plan that included and supported the dementia care needs. The facility failed to develop individualized interventions related to the resident's aggressive behaviors, including designing specialized activities and/or environmental modifications in an attempt to manage, modify or respond to the resident's behaviors. A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses to include dementia. An admission MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired. A nursing note dated January 2, 2024, at 2:07 AM reveled that Resident CR1 was ambulating in the hallways cursing at any person she came in contact with. At approximately 1:00 PM Resident CR1 was yelling out obscenities directed towards Resident 4 who was yelling out for help. Staff responded and found Resident 4 lying on the floor and Resident CR1 yelling at her. According to information dated January 3, 2024, submitted by the facility upon RN assessment, Resident 4 noted with external rotation to lower extremity. Neuro checks WNL. MD/RP made aware. Orders received to send to ER for eval and treatment for suspected injury. Investigation into unwitnessed incident immediately initiated. Per staff, a thump and yelling out was heard. When staff arrived on the scene around the corner, {Resident 4 -BIMs 00} was on the ground. {Resident 4} was transported to the hospital due to external rotation of RLE upon discovery and assessment. {Resident CR1 - BIMs 2} was witnessed to be wandering hall in vicinity at the time of incident exhibiting behaviors and was also transferred to the hospital for change in mental status. Facility investigation completed. Investigation revealed {Resident CR1} had quickly approached {Resident 4} and pushed her to the ground. Staff interviewed states {Resident CR1} was agitated per her norm, and made multiple attempts to redirect and provide safe environment. Resident CR1 was on q 15 minute checks related to behaviors, which were maintained without concerns. Staff was observing and redirecting residents throughout time prior to incident. Staff interviewed denies any circumstances at the time that Resident CR1 turned and approached Resident 4 that would have been a trigger. AAA, PDA and [NAME] PD made aware. MDs and RPs made aware of incident and updated on investigation. Resident CR1 returned to the facility at approximately 9:10AM 1/2/24 with no recommendations from ER visit. Resident received follow-up visit from NP and Psychiatric CRNP, with recommendations noted and implemented. Resident CR1 was placed on 1:1 supervision and placed in a private room due to behaviors. Resident 4 was admitted with right hip fx, and had surgical repair to same on 1/2/24. A review of a facility incident report dated January 2, 2024, revealed Resident CR1 was seen wandering the hallways exhibiting aggressive behaviors. Staff heard a thud and screaming. Resident 4 was found lying on the floor in pain with her right lower extremity externally rotated. Both residents were transferred out to the hospital for evaluations. Further review of the facility investigation revealed a security camera timeline of the incident. which was indicated that at 12:06 AM through 12:09 AM {on January 2, 2024}. Resident CR1 and Resident 4 were seen on camera passing by each other on multiple occasions. At 12:07 AM Employee 6, a nurse aide, walked down the hall and interacted with the residents out of camera view. At 12:09 AM Employee 6 was observed walking up the hall with both Resident CR1 and Resident 4 in view. At 12:11 AM Resident CR1 was walking down the hall from the nursing station. At 12:16 AM Resident 4 walks into her room then comes out of her room and begins walking down the hall during the nursing station. At 12:16 AM Resident CR1 walked directly towards Resident 4 and then pushes Resident 4, and Resident 4 falls to the floor. A review of Employee 6's witness statement dated January 6, 2023, revealed prior to the incident Resident CR1 was being aggressive, pacing the halls, and wandering into other resident rooms. A written statement from Employee 7, a nurse aide, dated January 2, 2024, revealed the employee stated she was not assigned Resident CR1 on that date. The employee stated prior to the incident Resident CR1 was agitated during the shift. When asked what the staff do for the resident when she is like that, the employee stated they attempt to redirect her. When asked what redirect means the employee stated to give her something to eat or drink and direct her in another direction. The employee stated that resident will still swing out after those attempts are made however. An undated follow up statement was obtained from Employee 6, which revealed that the employee checked in with both Resident CR1 and Resident 4 multiple times leading up to the incident. Employee 6 stated that prior to the incident Resident CR1 had been yelling at Resident 4 and she had approached the residents to redirect them. The employee further indicated that as soon as Resident CR1 got out of bed, she she began yelling and every time she walked past Resident 4, she would yell at her and yell into other resident rooms. Employee 6 indicated that she tried to redirect her, but she was just angry. Employee 6 indicated that she went around the nursing station, and Employee 7 went to the bathroom, and at that time, Resident CR1 was unsupervised and hit Resident 4. A review of Resident 4's hospital documentation dated January 2, 2024, revealed that Resident 4 had sustained an impacted femoral neck fracture (broken hip) as a result of Resident CR1 pushing the resident, which caused Resident 4 to fall to the floor. The facility failed to develop and implement interventions to effectively address Resident CR1's dementia care needs and behaviors. Resident CR1 seriously injured Resident 4 during an altercation, initiated by Resident CR1. An interview with the Nursing Home Administrator on January 25, 2024 at approximately 3:10 PM failed to provide evidence that an effective individualized person-centered plan was developed and implemented to address and manage the resident's dementia-related behaviors. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident rights

Based on a review of clinical records, select investigative reports and information submitted by the facility and staff interview, it was determined that the facility failed to timely implement effective safety interventions including necessary staff supervision of resident with known unsafe behaviors that increased the resident's risk for falls to prevent a fall with serious injuries, a fractured hip and tail bone, for one resident out of six sampled (Resident 365). Findings include: Clinical record revealed that Resident 365 was admitted to the facility on [DATE], with diagnoses including history of falls, lack of coordination, muscle weakness, unsteadiness on feet, senile degeneration of the brain, and dementia. A review of an admission/readmission evaluation dated July 18, 2023, indicated that the resident was at moderate risk for falls. A review of the resident's baseline care plan initiated July 18, 2023, indicated that the resident was at risk for falls related to not paying attention while ambulating, with planned interventions to include the placement of bed and chair alarms, non-skid footwear, a low bed, clutter- free environment, and the resident's call bell within reach. An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 21, 2023, revealed that the resident was severely cognitively impaired with a BIMS score of 05 and required staff supervision with bed mobility, transferring, walking in his room, toileting, and limited assistance with dressing. A review of a nurses note dated July 19, 2023, at 2: 44 AM revealed that the resident was walking into other residents' rooms and throughout halls for first part of shift. Nursing noted that the resident was easily redirected and put back to bed after several times of redirecting resident back to bed. A nurses note dated July 23, 2023, at 4:25 PM revealed that nursing placed a call to resident's family related to increase in the resident's agitation and that the resident was demanding to walk home. A physician order was noted August 4, 2023, for the resident to transfer and ambulate independently on unit and with supervision off unit. Nursing noted on August 13, 2023, at 1:41 PM that the resident was exit seeking this day and stating he is going home. Nursing progress notes dated August 21, 2023, at 4:33 AM revealed that the resident was awake most of this shift, pacing hallways and attempting to close other residents doors. According to the entry, close supervision was provided and the resident was redirected, as needed, with short term effect . Nursing documentation dated September 1, 2023, at 4:31 AM revealed that the resident was awake thus far this shift, and pacing the hallway off and on throughout tour. A nurse's note dated September 19, 2023, at 1:55 AM revealed that the resident's bed alarm was sounding and the resident was found sitting upright on the side of his bed attempting to self-transfer to the bathroom, staff assisted. Staff identified that the resident had an unsteady gait. According to the resident's clinical record and select reports the resident incurred six falls, occurring on August 26, and 31, 2023, and September 15, 16, 17, and 27, 2023, which resulted in no serious injury. A review of a fall risk evaluation dated September 27, 2023, indicated that the resident was now at high risk for falls. Nursing documentation dated from October 11, 2023, through November 4, 2023, revealed that the resident continued to display, on an almost daily basis, increased restlessness, agitation, and anxious behaviors, with numerous and repeated attempts to self-rise from the chair and bed. Nursing also noted that the interventions attempted by staff were ineffective. A late entry, dated October 20, 2023, at 5:30 PM, and incident report dated October 20, 2023, at 5:07 PM revealed that as the nurse turned around, the nurse witnessed the resident stand up while leaning on a table. He grabbed another resident's wheelchair and lowered himself to the floor. The resident did not hit his head with no injuries noted upon assessment. Non-skid socks were in place. The resident stated that he unclipped his chair alarm because he did not want it on him. MD and RP made aware. The resident's chair alarm was changed a clip alarm to a pad alarm. A review of a nurses note dated October 20, 2023, at 7:01 PM revealed that the resident's family expressed concern with resident's increased anxiety. In response the physician ordered 0.5 alprazolam (antianxiety medication) three times a day (TID) as needed (PRN). A review of a fall occurrence note dated October 21, 2023, at 3:50 PM and incident report dated October 21, 2023, at 3:45 PM revealed that the resident was in day the room. Staff heard the alarm on the resident's broda chair sound and found the resident on the floor in the supine position (lying on their back, with their face and abdomen facing upwards). No injuries were noted. The planned intervention was to change the resident's medication administration time. On October 23, 2023, the physician discontinued the order for the resident to transfer and ambulate independently on unit and with supervision off unit. A review of a nurses note dated November 4, 2023, at 3:35 AM revealed that the RN was called to the unit for a fall the resident incurred. Staff observed the resident lying on right side between the bathroom and his neighbor's door. The resident stated that he was going to the bathroom and lost balance. Non-skid socks were in place. The resident's call bell was not activated, but staff reported that the resident's bed alarm was sounding when they found him. The resident complained of pain to the right thigh and was medicated with Tylenol for pain. Skin tears were noted to the resident's right elbow and right hand. Q 15 minute safety checks were now initiated as a result of this fall. The physician ordered xrays of the resident's right hip, femur, tibia, and fibula (leg bones). An incident report dated November 4, 2023, 3:30 AM, indicated that a predisposing factor contributing to the event was the resident's confusion, gait imbalance, and impaired memory. The planned intervention was a 3 - day bowel and bladder upon the resident's return from the hospital. Nursing documentation dated November 4, 2023, at 4:14 PM revealed that the xrays revealed that additional diagnostic testing, a nuclear scan, was recommended. The physician ordered that the resident be sent to the ER for evaluation. Subsequent nursing documentation dated November 4, 2023, at 9:33 PM revealed that the resident was admitted to the hospital with a fracture of his right femur (leg bone). An Employee Statement, dated November 4, 2023, from Employee 5, Nurse Aide indicated the the employee had last seen the resident prior to the fall at 1:30 AM, and he was sleeping. A further follow-up interview with Employee 5, revealed that the employee observed the resident in bed, sleeping at 1:30 AM. According to the employee she offered him toileting, and he accepted, then afterwards went back to bed without incident. A review of information dated November 4, 2023, submitted by the facility and hospital documentation dated November 4, 2023, indicated that the resident sustained a mildly displaced comminuted fractures of the coccygeal bones (tail bone), and comminuted displaced fracture of the right greater trochanter bone (leg-hip) as a result of the fall. The facility's information noted that a nurse aide saw the resident at 1:30 AM, approximately 2 hours prior to the fall, and provided bathroom -toileting assistance. A review of hospital Discharge Summary dated November 7, 2023, indicated that based on the location of the fracture and discussion with the resident and family, it was decided to not pursue surgery and the resident returned to the facility on [DATE] Nursing documentation dated November 8, 2023, at 10:23 PM revealed that the resident exhibited numerous attempts to self rise after dinner, redirected and interventions were ineffective. A nurse's note dated November 10, 2023, at 4:30 AM revealed that the resident's bed alarm was sounding and staff found the resident seated upright on the floor in front of bathroom door in the resident's room. According to this nursing documentation, staff conducted rounds shortly before and the resident denied needing care or the bathroom. The resident was brought to nursing station to sit with staff as a safety intervention and noted that staff will continue to monitor the resident with the safety measures in place. The resident was admitted to the facility with a history of falls, was identified to be at risk for falls, incurred multiple falls without injury, and the facility was aware of the resident's ongoing displays of unsafe, anxious and restless behaviors beginning August 2023 and regularly documented throughout the months of September 2023, and October 2023. Nursing repeatedly documented the resident's displays of anxiety, anxiousness, confusion and lack of safety awareness and ineffective interventions, occurring prior to the resident's fall with multiple fractures on November 4, 2023. The facility did not initiate every 15 minute checks of the resident until after the resident's fall with serious injury on November 4, 2023. During an interview December 15, 2023, at approximately 10:30 AM, the Nursing Home Administrator confirmed that the facility was aware that Resident 365 displayed restless behaviors, anxiety, confusion and lack of safety awareness and falls in the two months leading up to the resident's fall with fractures and there was no documented evidence that the facility had increased the level and frequency of staff supervision of the resident until after the resident's fall with serious injuries occurred on November 4, 2023. 28 Pa Code 211.12(a)(c)(d)(3)(5) Nursing Services

Based on review of clinical records, select facility policy and incident reports and staff interview it was determined that the facility failed to provide necessary supervision and assistance with activities of daily living for a resident with known unsafe behaviors and poor safety awareness to prevent repeated falls and serious injury, a fractured hip, for one resident out of eight sampled residents (Resident 4). Findings include: Review of the current facility policy entitled Falls and Fall Risk, Managing provided during the survey ending September 20, 2023, (no facility review date noted on the policy) indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include cognitive impairment and incontinence. The staff, with the input of the attending physician, will implement a resident-centered fall preventions plan to reduce the specific risk factor(s) of fall for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of fall, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have identified. A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the pancreas [cancer of pancreas, an organ which is behind the lower part of the stomach], adult failure to thrive [occurs when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal]. The resident was noted to be unsteady on feet, lacking coordination and had a history of falling according to the admission documentation. Review of Resident 4's annual Minimum Data Set (MDS - federally mandated standardized assessment process completed periodically to plan resident care), dated August 6, 2023, revealed that the resident was moderately cognitively impaired, required extensive assistance with support of one-person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene, required limited assistance of one-person physical assistance for walking in room, walking in corridor, and for locomotion on the unit and was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, surface-to-surface to surface transfers. Resident 4 used both a walker and wheelchair for mobility according to the assessment. A review of Resident 4's plan of care initiated August 19, 2022, and revised on August 20, 2023, identified that the resident was at risk for falls due to impaired mobility with a goal to minimize risk for injury related to falls with planned interventions to have call bell in reach, maintain bed in low position, non-skid shoes/slippers, provide assistance to transfer and ambulate as needed, and to reinforce the need to call for assistance. An incident report dated August 17, 2023, at 11:27 PM, revealed that a nurse aide (NA) and the licensed practical nurse (LPN) noticed that the resident's shoes were not fitted correctly and found Resident 4 with a bump on her left forehead and dried blood. Resident 4 stated I fell in the bathroom and hit my head. Predisposing physiological factors were identified as gait imbalance and impaired memory. Immediate actions taken were that the supervisor was notified and a full resident assessment completed. No additional fall prevention measures were noted. A nursing progress note completed by Employee 1, RN, dated August 17, 2023, at 11:30 PM, revealed that a nurse aide observed Resident 4 sitting in bed with blood-tinged shirt. When questioned, the resident stated she wiped her blood on her shirt after she fell in the bathroom. The nurse aide then observed a bruise and small open area to the resident's left forehead and the LPN provided wound care. RN assessed the resident, whose vital signs were within normal limits and neurological assessment intact. The resident had no complaints of pain with vital signs stable. The resident stated that she tripped coming out of the bathroom but was ok now. The attending physician and resident representative notified. Nursing noted that the resident's call bell was in reach, bed in a low position, and the resident was educated on calling for assistance and not self-ambulating. The entry noted that the resident care plan was updated, and staff would continue to monitor. Review of a witness statement completed by Employee 3, a nurse aide, dated August 17, 2023, no time indicated, revealed that the last time she saw the resident at 10:30 PM and the resident was laying in her bed. Employee 3 indicated that the resident toilets self with no documented time that the resident {assist of 1 person for toileting} was last toileted by staff. The resident was assessed to require extensive assistance with support of one-person physical assistance for bed, toilet use, required limited assistance of one-person physical assistance for walking in room, walking in corridor, and for locomotion on the unit and was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, surface-to-surface to surface transfers according to the resident's annual MDS dated [DATE], but there was no evidence that staff were consistently providing the resident the assistance needed with transfers and toileting to promote the resident's safety, prevent falls and deter the resident's attempts at self-transfers, unassisted ambulation and unassisted toileted A review of a Fall Risk Evaluation dated August 18, 2023, at 9:43 AM, indicated that Resident 4's assessed Morse Fall Scoring [(MFS) is a rapid and simple method of assessing a resident's likelihood of falling] indicated that the resident was at high risk for falling. A progress note dated August 18, 2023, at 9:47 AM, revealed that the interdisciplinary team (IDT) reviewed Resident 4's fall of August 17, 2023, and noted that the resident had non-skid socks in place and the resident's bed was in the lowest position and locked. It was noted it was observed that the resident's bed alarm was not sounding as it had been unplugged and that the resident was non-compliant with use of her call bell. The resident was also noted to have been non-compliant with transfer status of assistance of one-person and was educated related to the use of call bell as an immediate intervention to prevent further falls. IDT team recommends placing a reminder picture to utilize call bell and the resident's bed alarm was discontinued. The resident was receiving therapy services. The resident's attending physician and responsible party, her daughter, were made aware of fall, assessment, and the interventions. An incident report completed by Employee 2, a LPN, dated August 31, 2023, at 9:14 PM, revealed Employee 2 was alerted by the resident's roommate that resident {Resident 4} needed help. Upon entering room, Employee 2 found Resident 4 lying on the floor, on the resident's left side, near the doorway in between the bed and door. RN supervisor was made aware, and the resident was assessed immediately. Resident 4 stated that she was on her way back from her closet trying to get a red sweater. The resident stated that she turned off the bed alarm while getting up from bed (noted as discontinued after the IDT review of the resident's fall of August 17, 2023, but still in use). The facility noted that the predisposing physiological factors for the resident's fall included confused, gait imbalance, impaired memory, and that the resident was non-compliant with treatment/transfers/overall care. Further follow-up actions were noted to initiate staff education on anticipating the resident's needs due to impaired cognitive status and to complete a 3-day bowel and bladder assessment. A witness statement completed by Employee 3, a nurse aide, dated August 31, 2023, no time noted, indicated that she found the resident lying on her floor in her room and that she last saw the resident at 8:35 PM. Resident 4 was assessed and complained of pain rated 7 out of 10 to right hip. No noted internal or external rotation. Hip was in normal alignment. PRN (as needed) pain medication given as ordered. Neuro checks started and within normal limits and vital signs stable. The attending physician was made aware and new orders noted for a STAT (immediate) x-ray to the right hip. The resident's responsible party was made aware. Nursing progress notes dated September 1, 2023, at 1:06 AM, revealed that the x-ray result was positive for fracture and the physician ordered the resident to be sent to the hospital for an evaluation and treatment. A review of hospital records dated September 1, 2023, revealed that the resident sustained a right displaced femoral neck fracture with need of surgical repair. A review of the clinical record revealed that Resident 4 was readmitted to the facility on [DATE], at approximately 1:00 PM, post fall and sustaining a right hip fracture with surgical repair. Upon returning from the hospital, fall interventions included bed clip alarm and staff were to check function and placement each shift and as needed and bilateral fall mats. There was no documented evidence that the facility had conducted the 3-day bowel and bladder assessment as noted as a follow-up measure after the resident's fall. The facility also continued the use of the bed alarm, which proved ineffective in preventing the resident's falls and alerting staff of the resident's unassisted transfers as the resident was known to turn the alarms off. An incident report completed by Employee 4, a RN, dated September 18, 2023, at 5:00 PM, revealed that they were called to the resident's room and found the resident on the left side of her bed, on the floor on her left side, with her legs straight out in front of her. Her bed alarm was sounding, non-skid socks in place, continent at the time of fall, and her bed was in the lowest position. Her call bell was in reach, but not activated. The resident denied pain and no injuries were assessed, or deformity, full range of motion (ROM), and the resident was assisted times 3 staff back into bed. Resident 4 stated I gently plopped myself on the floor to get my jewelry out of my bag. While resident was lying on the floor she was dipping in two bags that were on the floor but there wasn't any jewelry inside of the bags. The attending physician and RP were notified and X-rays of both hips and pelvis were obtained with negative results. The facility failed to provide Resident 4 with the necessary supervision, at the level and frequency required and failed to consistently provide the resident with necessary staff assistance with activities of daily living, transfers, ambulation and toileting, to prevent repeated falls and injury to the resident. Interview with the Nursing Home Administrator (NHA) on September 20, 2023, at approximately 2:00 pm, confirmed that the facility failed to provide Resident 4 with adequate supervision and assistance, and sufficient efforts to meet and anticipate her needs as care planned to prevent falls and serious injury, a right hip fracture. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, staff interviews, and select facility policy and documentation it was determined the facility failed to consistently store perishable (foods likely to spoil, decay or become unsafe to consume if not kept refrigerated at 40 F or below, or frozen at 0 F or below. Examples of foods that must be kept refrigerated for safety include meat, poultry, fish, dairy products, some fruits and vegetables and all cooked leftovers) and potentially hazardous foods (Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens, such as bacterial or viral organisms capable of causing a disease or toxin formation) at safe temperatures to prevent potential food borne illness. This food safety failure placed 102 of 103 residents residing (one resident NPO) in the facility in immediate jeopardy due to their risk for serious complications from potential foodborne illness as a result of their compromised health status. Findings included: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Regulatory guidance defines a Danger Zone meaning temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. A review of the facility's undated Refrigerator Temperature Logs policy revealed the procedure that an internal hanging thermometer is placed inside the refrigeration cooler and the temperature is to be maintained at 40 degrees Fahrenheit or below. It is the facility policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. The Dining Services Director/Cook(s) ensures that all perishable foods will be maintained at temperature of 41 F or below except during necessary periods of preparation and service. The Dining Services Direct/Cook(s) monitors that all frozen foods will be stored at temperature to maintain frozen state, target temperature is 10 F or below. The Dining Services Director/Cook(s) insures that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures is recorded. The Dining Services Director/ Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Observation upon arrival at the facility on August 7, 2023, at 9:45 AM revealed a 16 foot refrigerated truck running in the facility parking lot. A tour of the facility's dietary department and kitchen on August 7, 2023, at approximately 9:50 a.m. with Employee 1, dietary manager, revealed one thermometer inside the walk-in refrigerator, which registered a temperature of 62 degrees Fahrenheit. Employee 1 stated that this walk-in cooler was out of order since July 25, 2023. However, continued observation revealed that foods intended for service to the residents were stored inside this non-functioning refrigerated cooler to include the following: approximately 48 souffle cups of butter slices, 3 packages of pancakes (6 pancakes in each), 3 packages of 12 slices of French toast dated as opened 7/31/2023 along with an unknown quantity of plastic wrapped French toast slices dated as opened 8/4/2023, a box, which read keep frozen containing 3 large center cut pork loins, a cart containing one gallon of milk, multiple small cartons of individual milk cartons, 7 pitchers containing various juices/juice blends, one opened 28 ounce container of mustard, one gallon of teriyaki marinade sauce with half remaining in container, a two quart container of low sodium soy sauce with approximately half left for use, one opened cardboard box containing approximately 19 one pound blocks of margarine, one gallon container of Italian dressing opened on 7/14/2023 with approximately one quarter left, plastic bin containing loose onions, a 29 ounce bottle of opened barbecue sauce, a 6.5 lb container of 6.5 of sliced strawberries, a metal pan containing cooked pierogi dated 8/6/2023 (menu indicated served for dinner on 8/6/2023), a half a case of liquid whole eggs and a case of cabbage in a box with the instructions to keep refrigerated at 33 degrees Fahrenheit to 40 degrees Fahrenheit. Interview with Employee 1 during this tour revealed she was unaware that these potentially hazardous and perishable foods were stored in the non-functioning cooler in the dietary department. Employee 1 stated that dietary staff were to store all food items requiring refrigeration in the refrigerated truck located in the parking lot. According to facility provided documentation a quote was obtained from a vendor on July 25, 2023, for replacement of the entire cooling system of the main walk in cooler in the dietary department. The quote was approved by the facility's corporation on July 27, 2023. A review of the rental agreement for the refrigerated truck revealed that it was obtained by the facility at 12:20 PM on July 27, 2023. The dietary manager, Employee 1, stated during interview on August 7, 2023, at approximately 10 AM that the food stored in the in the walk-in cooler between July 25, 2023 and July 27, 2023 was disposed of, but she was unable to state the specific foods and beverages that were discarded. Interviews with facility maintenance staff on August 7, 2023, at approximately 10:20 AM revealed the refrigerated truck ran out of gas on August 3, 2023. The maintenance staff employee stated that on that date he had to obtain gas in a container to restart the truck and then it was driven to gas station to fill. The facility was unable to provide evidence as to the time the truck ran out of gas, how long the truck was not running and the temperature of the unit. The facility had not developed a functional procedure to ensure consistent monitoring of the fuel status and temperatures inside refrigerated truck to ensure perishable food items were stored at safe temperatures. Interview with Employee 2 on August 7, 2023, revealed that the refrigerated truck was not running on the morning of Sunday August 6, 2023. Employee 2 stated he went to the truck to retrieve an item at approximately 4:00 PM and the truck was not running and the inside of the truck was hot. The food items stored inside the truck were not chilled. Employee 2 retrieved margarine and liquid eggs in an attempt to remove them from the warm environment, but placed them in the non working cooler, where they were observed by the surveyor on August 7, 2023. Employee 2 stated that the broken walk-in color was at least not has warm as the truck. Employee 2 stated that Employee 1, the dietary manager and the lead dietary assistant obtained fuel for the truck at approximately 10 PM on August 6, 2023. A review of the walk-in cooler refrigerator temperature log for July 2023 revealed temperatures between 34 degrees to 38 degrees Fahrenheit. Temperatures noted from July 26, 2023 through August 7, 2023, were for the refrigerated truck in the parking lot which were between 34 degrees Farenheit and 35 degrees Fahrenheit. The refrigerated truck temperature was set at 36 degree Fahrenheit when observed during the survey. An observation of the contents of the truck at 10:09 AM on August 7, 2023, reveled very few items such as box of lemons, box of diced potatoes, bag of onions, box of fresh vegetables and a bag of Tater tots. After observing the contents of the truck for approximately five minutes of keeping the door open, the truck temperature rose to 40 degrees Fahrenheit The facility failed to ensure that perishable foods were consistently stored at refrigerated temperatures below 41 degrees Fahrenheit. When the facility's walk-in cooler became non-functional on July 25, 2023, and the facility obtained a refrigerated truck for cold food storage as interim measure until the unit was repaired/replaced, the facility failed to establish procedures to ensure staff consistently monitored the the fuel status and temperatures inside the unit to assure proper temperatures for safe cold food storage. This failure placed residents in immediate jeopardy to their health due to the risk of food borne illness. The facility was notified of the Immediate Jeopardy on August 7, 2023 at 11:15 AM and the IJ template provided to the facility at 11:29 AM. An immediate plan of correction was requested and received on August 7, 2023. The plan included: Food from the non-operable cooler in the dietary department was discarded immediately. Sign placed on cooler door to notify staff that cooler is non-operable. Refrigerated Truck gas was filled on 8/6/23. Refrigerated Truck temperature checked at 36 degrees at 12:45 pm Food stored in refrigerated truck temperature checked at 37.4 degrees at 12:45 pm. Interruption of refrigerator cooler reported to the Department of Health on 8/7/23. Dietary staff in-serviced on 8/7/23 by Dietary Manager to store perishable food items in the refrigerated truck, completing temperature logs on perishable food three times a day, monitoring the fuel levels in the refrigerated truck three times a day and refueling the truck at or before a quarter tank of fuel remains. Dietary staff members not on the schedule will be in-serviced prior to beginning their next scheduled shift. The Immediate Jeopardy was lifted on August 7, 2023 at 3:15 PM when completion of the implementation of the plan of correction was verified. Refer F800 28 Pa. Code 201.18 (e)(1)(2)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide adequate supervision and effective safety measures to prevent falls for a resident identified at high risk for falls with known restless and unsafe behaviors resulting in a fall with serious injuries, a fractured hip and ribs, for one resident out of 19 sampled (Resident 249). Findings include: A review of the clinical record revealed that Resident 249 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and history of falling. A review of a fall risk evaluation dated August 7, 2022, revealed the resident was assessed at a high risk for falling. A review of an Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated August 10, 2022, revealed that the resident was moderately cognitively impaired and required extensive assistance of two staff for bed mobility, transferring, and toileting. The resident required supervision of one staff member when moving about on the nursing unit according to the MDS. The resident's care plan, initially dated August 4, 2022, noted the resident's problem of being at risk for falls related to impaired mobility. The resident's goal was to minimize injuries related to falls. Interventions planned were to provide assistance with transfers, have the bed in the lowest position, and have commonly used items in reach. A progress note dated August 6, 2022, at 12:43 AM revealed that the resident was found on the floor of his room, seated three feet away from his wheelchair. The resident stated at that time he wanted to walk. A review of an incident report dated August 7, 2022, at 12:10 AM, revealed the resident was found on the floor sitting on his buttocks three feet away from his wheelchair. The resident at that time stated he wanted to walk. No injuries were noted. A new intervention of a clip alarm check for functioning and placement was added to the resident's plan of care on August 7, 2022. A review of a skilled note dated August 9, 2022, at 12:33 PM, revealed that the resident was restless and balance was unsteady. A nursing note dated August 13, 2022, at 5:42 AM, indicated that the resident was attempting to self-transfer himself out of bed at 4:10 AM. The resident was screaming and yelling for his wife that he needed to leave. The resident was assisted in his wheelchair to the nurse's station. Review of a nursing note dated August 16, 2022, at 7:55 AM, revealed that the resident was restless and awake at times. A review of a skilled note dated August 18, 2022, at 8:23 PM, revealed that the resident was anxious and fidgety. A review of a skilled note dated August 19, 2022, at 8:23 PM, revealed that the resident was a safety concern due to his unsteady gait. A nursing note dated August 20, 2022, at 2:28 AM, revealed that the resident was having difficulty sleeping and was sitting on the side of the bed. The resident would reposition to laying and then sitting numerous times. The resident had increased confusion according to this nursing documentation. On August 20, 2022, at 6:25 AM, the resident had difficulty sleeping all shift. The resident was confused and unable to follow directions. The resident was attempting to get out of bed and out of his wheelchair without assistance multiple times. Nursing noted on August 20, 2022, at 1:35 PM, that the resident's safety remained a concern due to unsafe self-transfers and being a fall risk. A nursing note dated August 21, 2022, at 3:03 AM, revealed that the resident was very restless throughout the night. The resident appeared to be unable to relax and continuously moving from lying position to sitting position with legs dangling on the side of the bed. The resident was brought out to the nurse's station in his wheelchair, but remained restless and attempted to stand independently. Review of a nursing note dated August 22, 2022, at 2:51 AM, revealed that the resident was restless and anxious at times throughout the night. A nursing note dated August 22, 2022, at 11:05 AM, indicated that the resident was self-propelling in his wheelchair on the unit was confused and forgetful. Review of a skilled note dated August 22, 2022, at 9:20 PM, revealed the resident was anxious and fidgety. A review of a nursing note dated August 26, 2022, at 6:22 AM, indicated the resident was awake all night in his wheelchair. On August 26, 2022, at 9:54 PM, nursing noted that the resident has safety concerns due to him trying to get up by himself. Review of a skilled note dated August 29, 2022, at 2:17 PM revealed that the resident's balance was unsteady and displayed unsafe self-transferring. A review of a nursing note dated August 30, 2022, at 3:30 AM, indicated that the resident was awake all night trying to self-transfer. The resident was consistently sitting on the very edge of the bed asking what time it was every 15 minutes. A note entered at 3:33 AM revealed that the resident was being monitored at the nurse's station as a safety precaution due to the resident being a fall risk and attempting to self-transfer. On August 30, 2022, at 12:03 PM, nursing noted that the the resident's safety was a concern due to self-transferring. Review of a skilled note dated August 31, 2022, at 6:43 PM, revealed the resident was still a safety concern due to self-transferring. A review of a nursing note dated September 4, 2022, at 12:40 AM revealed that the resident will only lay down for a short period of time and was mostly in his wheelchair. Skilled notes dated September 6, 2022, at 2:01 PM, September 7, 2022, at 9:05 AM and September 8, 2022, at 9:08 AM revealed the resident was restless, anxious, and fidgety and his safety was a concern due to attempts to self-transfer and risk for falls. A review of a progress note dated September 8, 2022, at 11:52 PM, indicated the resident was sitting in front of the nurse's station and is verbally yelling out. A review of a nursing note dated September 9, 2022, at 12:45 AM, revealed the resident was sitting at the nurse's station constantly self-rising and subsequently fell near the nurse's station The resident hit his head. A laceration was noted to the left part of the forehead with a large hematoma. A review of the incident and accident report dated September 9, 2022, at 1:11 AM, revealed that at 12:45 AM the resident was found on the floor lying near the nurse's station on his left side with his knees bent. The resident was found next to his wheelchair with the alarm sounding. Staff assisted the resident back to his wheelchair. He had a red area to the left side of the head and pain to his left leg, head and buttocks. He was transferred to the hospital for evaluation. A review of hospital records dated September 9, 2022, revealed that the resident sustained a fracture of the left and right femoral neck and a fracture of the right lateral 8th rib. A review of a witness statement from Employee 2 NA (nurse aide) dated September 9, 2022, revealed the employee stated that it was just her and another nurse on the floor to care for the residents at the time of the resident's fall on September 9, 2022. Employee 2 stated that she and the nurse were helping put another resident in bed when she heard an alarm sounding alerting staff that Resident 249 had fallen out of the wheelchair. A review of a witness statement from Employee 3 LPN (licensed Practical Nurse) dated September 9, 2022, revealed that Employee 3 stated that she was in a resident's room providing care with Employee 2, a nurse aide. When Employee 3 left that other resident's room, she noticed Resident 249 on the floor next to his wheelchair in front of the nurse's station with the alarm going off. Employee 3 stated that there was only one other nursing staff member besides herself on the nursing unit that night. Employee 3 stated that Resident 249 had been awake and confused constantly that night and required staff assistance. The facility failed to review and revise the adequacy of the resident's fall prevention care plan in response to the resident's ongoing restlessness and repeated attempts at unsafe self-transferring. The resident's care plan also failed to identify the resident's behaviors of being awake frequently during the night and needing increased supervision due to unsafe and restless behaviors. On the night of the resident's fall on September 9, 2022, staff brought the resident to the nurse's station for supervision for restless behaviors and unsafe behaviors. However, due to the staffing levels the resident was left unattended at the nurse's station, while staff were in a resident room providing care to another resident. Resident 249 fell while unsupervised and sustained fractures. An interview with the Nursing Home Administrator on December 2, 2022, at approximately 2:00 PM confirmed the facility failed to provide effective safety interventions and sufficient and timely staff supervision to Resident 249 to prevent falls and injury. Refer F725 28 Pa. Code 211.11(d) Resident care plan 28 Pa Code 211.12(a)(d)(5) Nursing services 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(3) Nursing services

Based on a review of clinical records, select facility policies, and incident/accident reports and observations and staff interviews it was determined that the facility failed to ensure that one resident (Resident 2) out of six sampled was free from sexual abuse and harassment perpetrated by another resident (Resident 1). The failure of the facility to prevent Resident 1 from repeatedly sexually abusing Resident 2 placed Resident 2 and other female residents residing on the dementia unit in immediate jeopardy to their safety due to the potential for future episodes of sexual abuse and harassment to occur. Findings include: A review of the facility's current Abuse policy, no review date noted, revealed that Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility's goal is to achieve and maintain an abuse free environment. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. Clinical record review revealed that Resident 1 was admitted to the facility May 12, 2022. Pre admission hospital documentation dated December 30, 2021, revealed that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital documentation noted that he has been wandering out of his house and made a neighbor touch him inappropriately. His wife does not feel she can keep him safe. She is power of attorney and believes he needs to be placed in a home. Review of Resident 1's admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2022, revealed that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a screening tool to assess cognitive function) score of 3 (a score of 0-7 indicates severe impairment) and was independent with ambulation. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's quarterly MDS assessment dated [DATE], revealed that she was severely cognitively impaired and was also independent with ambulation. According to nursing documentation throughout the month of May 2022, both Resident 1 and 2 displayed wandering behavior and independently ambulated on the dementia unit. Both Residents 1 and 2 resided on the same hallway of the locked dementia unit at the time of the survey ending June 23, 2022. Nursing documentation since Resident 1's admission on May 12, 2022, indicated that Resident 1 was frequently seen ambulating around and/or near Resident 2 on the dementia unit. A review of nursing documentation and information received from the local Area Agency on Aging, on May 31, 2022 at 11 AM Resident 1 was observed fondling Resident 2's breasts in the day room. The residents were separated and every 15 minute watches of Resident 1 were initiated. A review of a facility incident investigation, information submitted by the facility dated June 14, 2022, and a Pennsylvania Department of Health report form for investigation of alleged abuse, neglect and misappropriation of property dated June 14, 2022 at 12:55 PM revealed that Employee 2 (nurse aide) came out of a resident room and saw Resident 2 playing with the privacy curtain in a resident room. Employee 2 then observed that Resident 1 was standing behind Resident 2 with his hands down the front of her pants. Employee 2 immediately separated the residents and took Resident 2 to the activity room. Both residents were assessed by licensed nursing staff and placed on every 15 minute observation. However, Resident 1 had been on an every 15 minute observation by staff at the time of the incident, which proved to be an ineffective intervention. There was no documented evidence at the time the survey ending June 23, 2022, that staff had performed the every 15 minute observation of Resident 1 on June 14 2022. There was no record of the every 15 minute checks of Resident 1 conducted on June 14, 2022, available at the time of the survey ending June 23, 2022. An observation on June 23, 2022 at 8 AM, revealed that Resident 1 was awake and lying in his bed in his room. Resident 2 was observed ambulating in her room on the same hallway. At 8:10 AM, Resident 1 was observed leaving his room. He found Resident 2 in her room and took her by the hand and walked her into his room. When staff observed this surveyor following the residents back into Resident 1's room, a staff member then also followed the surveyor into Resident 1's room. The staff member then removed Resident 2 from Resident 1's room. An observation of the every 15 minute watch sheets for June 23, 2022, revealed that a watch sheet had not been completed for the prior 11 PM to 7 AM shift. The 7 AM to 3 PM sheet had not been started as of 8:45 AM when the surveyor reviewed the record. There was no documented evidence that facility staff were consistently conducting the every 15 minute observations of Resident 1. During an interview conducted on June 23, 2022, at 8:45 AM with Employee 3 (LPN), Employee 3 confirmed that Resident 1's every 15 minute watch sheet had not been completed for the prior 11 PM to 7AM shift and also had not been completed from 7 AM to the time of the interview. Employee 3 stated that the nurse aide staff assigned to Resident 1 was responsible for monitoring the resident every 15 minutes and to document completion of the task. During an inteview June 23, 2022 at 8:50 AM Employee 1 (nurse aide) stated that he was assigned to Resident 1 during this shift. He further stated that Resident 1 was on an every 15 minute watch. Employee 1 stated that he was busy getting other residents out of bed and ready for breakfast. He confirmed that as of 8:45 AM, he had not yet monitored Resident 1's whereabouts and did not start or complete the every 15 minute watch sheet since his shift began at 7 AM. A review of Resident 1's care plan for inappropriate sexual behavior, inappropriate touching related to cognitive impairment initiated June 16, 2022, after the second incident of inappropriate sexual contact with Resident 2 revealed interventions to administer medications as ordered, avoid conversations/television/radio that could encourage/or initiate inappropriate behavior and supervise in social gathering/recreation programs. There was no documented evidence at the time of the survey that Resident 1's pre admission inappropriate sexual behavior was identified and addressed on the resident's baseline or comprehensive care plan immediately upon the resident's admission or after the resident's initial inappropriate sexual behavior towards Resident 2 on May 31, 2022. The approach of every 15 minute checks of the resident was not included on the resident's care plan. An interview with the director of nursing (DON) at 1:30 PM on June 23, 2022, confirmed that the facility was aware of Resident 1's history of inappropriate sexual behavior that occurred prior to his admission to the facility at the time of his admission on May 12, 2022. She confirmed that this sexual behavior was not identified on the resident's plan of care. She further confirmed that the facility did not report Resident 1's sexual abuse of Resident 2 on May 31, 2022, to the State Survey Agency. She also confirmed that the facility was unable to demonstrate that staff had consistently performed the every 15 minute observations of Resident 1 as planned after the incident of sexual abuse on May 31, 2022, which was also verified by the incomplete records, surveyor observations during the survey and staff interviews. Immediate Jeopardy was called on June 23, 2022, due to the facility's failure to ensure that residents on the locked dementia unit were protected from the potential for further sexual abuse by Resident 1 with a known history of repeated sexual assault of a female resident on the dementia unit. The facility staff failed to sufficiently supervise Resident 1's whereabouts and activities to prevent sexual abuse and harassment of Resident 2, which placed Resident 2 and other residents residing on the unit in immediate jeopardy due to the potential for abuse to continue to occur. The facility was notified of the Immediate Jeopardy on June 23, 2022, at 12:15 PM and the IJ template provided to the facility at 12:15 PM. An immediate plan of correction was requested and received on June 23, 2022. The plan included: Resident 1 was placed on 1:1 supervision, documentation sheets will be completed by the staff providing the service. The sheets will be checked every shift by the charge nurse and monitored for compliance. The RN supervisor will complete random observations to assure that 1:1 and Q15 minutes are completed as assigned. Completion date June 23, 2022 Education initiated on sexual abuse to all facility staff while they arrive on shift (days, evenings and nights), implementation of baseline care plan, updating care plan post event and execution of intervention of 1:1 and every 15 minute observation. Completion date June 23, 2022 The Immediate Jeopardy was lifted on June 23, 2022, at 4:30 PM when implementation of the plan of correction was verified. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(a)(b)(d) Resident rights 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.5 (f)(g)(h) Clinical records

Based on a review of select facility policy, standards established by the Centers for Medicare and Medicaid Services and the facility's employee vaccination data and staff interviews, it was determined that the facility failed to fully develop and implement policies and procedures to ensure that all staff were vaccinated for COVID-19. Review of facility employee vaccination status information revealed, that as of February 5, 2022, the facility's staff vaccination rate was 98.3 % and there were four COVID resident infections since January 27, 2022 (Residents 29, 57, 73, and Resident 12) Findings include: According to the CMS Memorandum QSO-22-07 On November 5, 2021, CMS published an IFC with comment period (86 FR ), entitled Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination, revising the infection control requirements that most Medicare- and Medicaid-certified providers and suppliers must meet to participate in the Medicare and Medicaid programs. These changes are necessary to protect the health and safety of patients and staff during the COVID-19 public health emergency. At the time of the survey ending February 5, 2022, the facility did not meet the requirement of staff vaccinated; and one or more components of the policies and procedures had not been developed and implemented. Review of the facility policy entitled CMS Vaccine Mandate-COVID-19, dated November 11, 2021, revealed that effective December 5, 2021, all individuals must receive their first vaccine (either the single dose vaccine or the first dose of the two-step vaccine) against Covid-19 as a condition of employment and complete the vaccine course by January 4, 2022, unless there is a valid reason for exemption or accommodations. Review of facility employee vaccination status information revealed, that as of February 5, 2022, the facility's vaccination rate of employees fully vaccinated was 98.3 %. The facility failed to provide evidence that Employee 7 (contracted phlebotomist) and Employee 8 (contracted transportation aide/ambulance) were vaccinated or had a qualifying exemption. The facility's vaccine policy failed to include procedures for defining and implementing the necessary mitigation and additional precautionary measures that would be taken for those employees that were unvaccinated with a qualifying exemption to ensure the implementation of the additional precautions used to accommodate these staff members and intended to mitigate the transmission and spread of Covid-19, for all staff who are not fully vaccinated for Covid-19 and failed to include a contingency plan for unvaccinated employees without a qualifying exemption, including deadlines and timeframes for resolution. At the time of the survey, ending February 5, 2022, and based on a review the previous 9 days since the effective date of January 27, 2022, there was a current COVID-19 outbreak of among residents which included a total of 4 residents positive for Covid-19 on these dates (Residents 29, February 2, 2022, Resident 57, February 2, 2022, Resident 73, February 2, 2022, Resident 12, and February 10, 2022) Interview with the Nursing Home Administrator (NHA) on February 5, 2022, at 1:00 PM, confirmed that not all staff were vaccinated against the COVID-19 virus required by the CMS mandate and that there were omissions in the facility's policy and procedures. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(d)(e)(1) Management

Based on review of clinical records and staff interview, it was determined that the facility failed to accurately assess skin impairments and timely implement treatment and services designed to promote healing and prevent worsening of an existing pressure sore, which resulted in deterioration of the resident's pressure wound and related pain, for one resident out of 15 sampled residents ( Resident 11). Findings include: A review of the clinical record revealed that Resident 11 was readmitted to the facility on [DATE], with diagnoses, which included Morbid (severe) obesity due to excess calories, diabetes mellitus due to underlying condition with diabetic [CONDITION(S)], unspecified, pneumonia and unspecified abnormalities of gait and mobility. A review of Resident 11's 5-day MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process completed periodically to plan resident care) dated July 11, 2021, revealed that the resident required extensive assistance of staff for transfers and bed mobility (moving to and from lying position, turning side to side and positioning body while in bed). A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated July 7, 2021, re-admission from an acute care hospital, revealed that the resident received a score of 12, indicating that the resident was at high risk for pressure sore development. A review of Resident 11's current plan of care initially dated July 2021 revealed that Resident 11 was identified as at risk for alteration in skin integrity related to impaired mobility with a goal of will decrease/minimize skin breakdown risks with the following interventions planned: pressure reduction device on bed/chair, administer preventative skin treatment per physician orders, and administer treatments as ordered. Review of an Admission/Re-admission skin evaluation dated July 7, 2021 at 9:04 p.m. , the initial skin evaluation conducted upon the resident's return from the acute care hospital, identified four (4) areas/sites of skin impairment: a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) pressure area on the Resident 11's natal cleft (the deep groove which runs between the two buttocks from just below the sacrum to the perineum) with measurements of 6 centimeters (cm) x 4 cm x 0.1 cm; a Stage II pressure area on the left buttocks measuring 4 cm x 3 cm x 0.1 cm; an excoriation of the left gluteal fold with measurements of 3 cm x 1 cm x 0 cm, and an excoriation on the labia with measurements of 3 x 2 x 0 (no measurement metrics provided). Review of Resident 11's July's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that treatments were in place for these areas at the time of the above readmission evaluation on July 7, 2021. Further review of the July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a wound care specialist documentation revealed that Resident 11 was seen on July 13, 2021, and two wounds were identified, one on the resident's sacrum and another on the resident's left gluteus. Review of the wound care specialist documentation dated July 13, 2021, identified the resident's sacrum wound as an unstageable full-thickness ulceration (Full thickness tissue loss in which the base of the ulcer is covered by slough ( yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed measuring 5.5 cm x 4.4 cm x 4.0 cm wound base 90% slough and 10% granulation tissue with moderate non-odorous serosanguineous (thin, pink, watery) drainage, wound edges adherent to wound base, periwound without [CONDITION(S)] (redness), induration (deep thickening), [CONDITION(S)] (swelling), or crepitus (crackling sensation due to the presence of air in the subcutaneous tissue). The wound on the resident's left gluteus was identified as a unstageable full-thickness ulceration measuring 4.0 cm x 2.5 cm x 0.1 cm wound base 60% slough and 40 % granulation tissue with moderate non odorous serosanguineous drainage, wound edges adherent to wound base, periwound without [CONDITION(S)], induration, [CONDITION(S)] or crepitus. Review of Resident 11's current plan of care revealed a care plan was initiated for actual skin breakdown on July 7, 2021. The resident's care plan, for the problem of at risk for skin integrity related to mobility impairment was initiated on July 8, 2021, to include a treatment to the natal cleft, which was then revised on July 14, 2021, to reflect the approach of treatment to sacrum. The resident's care plan did not specifically address an unstageable wound to the sacrum until August 3, 2021. Review of Resident 11's nursing progress notes revealed a late entry on July 8, 2021, at 8:26 AM, written on July 14, 2021 at 8:27 AM, noting Clarification the resident has an unstageable wound to the sacrum. Wound bed is with slough present and noted in wound documentation. Review of Resident 11's wound evaluation dated July 8, 2021, revealed that the resident's sacral pressure sore wound was identified on July 7, 2021, as an unstageable wound measuring 6 cm x 4 cm x 0.1 cm. However, this facility wound evaluation documentation was not created until July 14, 2021, after the wound specialist identified this area on July 13, 2021. The facility documentation on the wound evaluation noted under the comments pre admission unstageable pressure area to natal cleft with 100% slough to wound bed. However, the admission/re-admission skin evaluation completed by the facility indicated that the area described as the natal cleft was a Stage II presure ulcer upon admission July 7, 2021. Interview with Resident 11 on August 24, 2021 at approximately 4:00 p.m. revealed that the resident indicated that she presently was no longer in pain, but that she experienced excruciating pain related to her pressure wounds after her readmission to the facility on [DATE]. Resident 11 allowed for observation of her wounds at this time, but the depth of the sacral pressure wound could not be observed because the resident opted not to have the current treatment (packing) removed for surveyor observation. A review of the wound specialist documentation dated August 24, 2021, revealed that the current measurements of the sacral pressure wound were 6 cm x 4 cm x 3 cm. The measurements of the left gluteus area were 3.5 x 2 cm x 0.1 cm. Review of Resident 11's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2021, at which time she was transferred to an acute care hospital. Review of nursing notes revealed an entry on July 19, 2021, at 8:46 PM that the facility received a call from 911 that the resident was on the floor and no one was taking care of her. The entry further noted that the resident was found sitting on the floor in front of her wheelchair, lift pad on the chair, left knee fully flexed and askew with heel towards door side of room. Absolutely refused staff to move her or in any way reposition her. Nursing noted an entry dated July 20, 2021, at 12:54 AM , indicating that the resident was admitted to the acute care hospital with a Stage III sacral decubitus ulcer. Review of hospital documentation dated July 19, 2021, revealed that Resident 11's presenting problem was her sacral wound. According to hospital documentation Resident 11 relayed that she returns (to the hospital) complaining of pain in her buttocks. Subsequently, the patient was admitted and was scheduled for the operating room for surgical debridement (procedure for treating a wound in the skin. It involves thoroughly cleaning the wound and removing all hyperkeratotic (thickened skin or callus), infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material from dressings). Resident 11 remained at the acute care hospital until July 27, 2021, when she returned to the skilled nursing facility. The facility provided documentation at the time of the survey ending August 24, 2021, indicated that the facility concluded that the admitting nurse's classification of natal cleft is indeed the same area as subsequently documented as sacrum. Due to the resident's exceptional size, bony landmarks are not palpable and there may have been differing opinions regarding anatomical location. After the initial documentation stating natal cleft all further mention of said wound is referred to as sacrum. However, the facility provided no additional information related to the two other identified areas, the natal cleft and left gluteus, that were identified as Stage II on July 7, 2021, which upon evaluation by the the wound specialist 6 days later were identified as Full-thickness pressure wounds. Interview with the Director of Nursing (DON) on August 24, 2021 at approximately 4:30 p.m. also confirmed that treatments were not provided timely upon identification and evaluation of the wounds on readmission on July 7, 2021. Resident 11's skin impairment worsened from a Stage II pressure sore to an unstageable full thickness wound causing the resident severe pain for which the resident requested transfer to the hospital where she her wound was surgically debrided. 483.25 Quality of Care - Treatment/Services to Prevent/Heal Pressure Ulcers Previous cited 4/9/21 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/13/19, 4/9/21, 6/9/21 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services. Previously cited 12/13/19, 1/15/20, 12/14/20, 4/9/21, 6/9/21 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/15/20, 12/14/20, 4/9/21, 6/9/21 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/15/20, 12/14/20, 4/9/21, 6/9/21

Based on observation, a review of clinical records, information submitted by the facility, select resident incident/accident and investigative reports and video surveillance footage and staff interview it was revealed that the facility failed to ensure that one resident out of 20 sampled was free from physical abuse, which caused injuries and psychosocial harm to the resident (Resident 310). Findings include: A review of the facility policy entitled Abuse Policy reviewed by the facility July 13, 2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property corporal punishment, and involuntary seclusion. Abuse is defined as the willful infliction of injury, resulting in physical harm, pain, or mental anguish. A review of Resident 310's clinical record revealed admission to the facility on [DATE], with diagnoses, which included [CONDITION(S)] (buildup of fluid in the cavities deep within the brain) and [CONDITION(S)] disorder (disorder that is marked by a combination of [CONDITION(S)] symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of Resident 310's quarterly MDS ( Minimum Data Set assessment - federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2020, indicated the resident had a BIMS (Brief Interview for Mental Status - a required screening tool used in nursing homes to assess cognition) score of 14 (a score of 13-15 indicates the resident is cognitively intact). It further indicated the resident did not display any behavior symptoms. Review of information submitted by the facility on September 3, 2020, revealed that during the facility's morning meeting staff reported that Resident 310 fell the on September 2, 2020, at approximately 10:20 PM. The facility reviewed the video footage to observe the circumstances of the resident's fall. When the video footage was viewed, it revealed Employee 4, LPN (license practical nurse) engaged in what appeared to be a normal conversation with the resident. However, after a few minutes, both Employee 4 and the resident appeared to be gesturing and leaning towards each other. The resident moved using the wheelchair, when Employee 4 turned towards the resident and used both hands to push him in the upper chest, causing the resident to tip backward in his wheelchair. A review of a resident incident abuse investigation and Pennsylvania Department of Health, PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property report dated September 3, 2020, at 9:45 AM revealed Employee 4 claimed the resident fell from his wheelchair. When video footage was observed it was revealed that Employee 4 physically pushed the resident causing the resident to fall backwards out of his wheelchair. A body assessment was completed revealing that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee 4 was suspended at that time. Review of a nursing progress note dated September 3, 2020, at 10:27 AM revealed that the resident was identified to have a change in his baseline mental status. The resident was noted to have confusion and pain in his wrist along with right shoulder pain. The physician was notified and the resident was transferred to the hospital for further assessment. The resident returned to the facility at 5:20 PM with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee 4 did not submit a written statement to the facility regarding the incident, but the Director of Nursing (DON) and Nursing Home Administrator (NHA) conducted a verbal interview over the phone with Employee 4 on September 3, 2020 at 1:34 PM. The employee stated that the resident was verbally irate and upset with her. The employee stated she was getting ice and told the resident she was not his nurse. She further stated that Resident 310 then turned around rose from his chair and fell back. The employee denied having a verbal altercation or making physical contact with the resident. A review of a witness statement from Employee 5 NA (nurse aide) dated September 3, 2020, at 3:06 PM indicated that this employee heard a verbal altercation between Employee 4 and Resident 310. The employee stated she did not witness the altercation, but when she went to help with the resident who was on the floor, Resident 310 stated you are going to take me by my throat and throw me to the floor. A review of a witness statement from Employee 6, LPN on September 3, 2020, at 1:00 PM revealed that the employee stated that she asked the resident what happened. He started to tell her, but looked up and saw Employee 4 and then stopped and refused to say what happened. An interview was conducted with Resident 310 on September 3, 2020. The resident at that time indicated he did not recall what happened the night of September 2, 2020. Interview with the NHA on April 8, 2021, at 8:30 AM revealed that the NHA informed Employee 4 of the video footage of her physically abusing the resident. Employee 4 did not provide any explanation for the video footage captured at that time, but continued to stand by her verbal statement describing her account of the incident. Observation of video footage conducted by surveyor in the presence of the Nursing Home Administrator on April 8, 2021 at 8:35 AM, revealed a date September 2, 2020, but no time stamp was on the footage. It was determined through the facility's investigation the time was approximately 10:20 PM. The video footage showed Employee 4 by the nursing station next to the ice cooler. Employee 4 and the resident were seen to be talking to each other. Within seconds, Employee 4 and the resident appeared to be having a verbal altercation. Employee 4 lunged at the resident while appearing to be yelling. The resident appeared to be yelling back at the employee. Continuing viewing revealed the resident then turned his wheelchair towards the employee and started to wheel his wheelchair towards her. Employee 4 forcefully took her two hands and pushed the resident in the chest. The resident was seen falling backwards out of his wheelchair and his legs flung up into the air. The resident could not be seen any further in the video footage after the fall. Employee 4 was seen picking up the wheelchair and placing it upright and then alerting staff. Review of Employee 4's personnel record revealed she was employed by a nurse staffing agency and was working in the facility on an as needed basis. The employee was last trained on abuse on August 12, 2020. The facility concluded their abuse investigation on September 3, 2020, of the alleged physician abuse of Resident 310 by identified perpetrator Employee 4 LPN. The facility substantiated the abuse and the employee was not allowed back in the facility as of September 3, 2020 The facility reported the employee to the nurse licensing board, the PA State Board of Nursing. The facility's completed an abuse investigative report (PB-22) dated September 3, 2020, and it was submitted to the State Survey Agency. A police investigation was performed by the local police. A review of Magisterial District Judge Criminal Docket initiation date September 4, 2020 revealed Employee 4 was arraigned on charges of strikes, shoves, kicks, or attempts/threatens care-dependent person, simple assault, recklessly endangering another person, and harassment other to Physical Contact. Employee 4 had a pre-trial conference hearing on February 9, 2021 and is awaiting trial. A review of the State Board of Nursing final adjudication and order dated April 6, 2021, indicated the State Board of Nursing revoked Employee 4's license to practice nursing beginning April 6, 2021. Interview with the NHA on April 8, 2021, at approximately 8:45 AM, confirmed the facility failed to protect one resident from physical abuse. This deficiency is cited as past non-compliance. The facility's corrective action plan was as follows: 1. Resident 310 was assessed by nursing staff and supportive visit was completed. 2. A baseline audit was completed with all other residents in the facility to determine if any other resident was abused or had any care concerns 3. Staff was re-educated on the facility's abuse policy, how to identify physical abuse, how to care for behavioral residents. 4. Staff development will audit five staff members weekly for four weeks to ensure staff can properly define, identify, and report abuse. Further staff development will audit five staff members weekly for four weeks are providing care and interacting appropriately with residents The facility's immediate corrective action plan was completed September 4, 2020. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.18 (e)(3) Management 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12 (a) Nursing services 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records, facility provided documentation and select investigative reports and staff interview, it was determined that the facility failed to provide necessary staff assistance as planned for assistance with activities of daily living, bed mobility, to prevent a fall resulting in a fractured right knee and right hip for one out of five sampled residents (Resident 358). Findings include: A review of the clinical record revealed that Resident 358 was most recently admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)], dependence on [CONDITION(S)], peripheral vascular disease (circulatory problem in which narrowed arteries reduce blood flow to your limbs), cerebral infarction (stroke), [CONDITION(S)] and [CONDITION(S)] left side ([CONDITION(S)] is weakness of one entire side of the body, [CONDITION(S)] is, in its most severe form, complete paralysis of half of the body), heart failure, diabetes and right below the knee amputation. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 24, 2020, revealed that Resident 358 was cognitively intact, required extensive assistance with activities of daily living including bed mobility, dressing, toileting, and personal hygiene and was total dependent with transfers. A review of the resident's care plan revealed a problem of risk for falling initially dated April 11, 2017, with planned approaches for the resident to be transferred in and out of bed with a mechanical lift. The resident's care plan also included the problem of ADL (activities of daily living) self-care performance with an intervention of the use of two staff for bed mobility initially dated July 30, 2020. A review of facility incident investigation, nursing documentation, and facility provided documentation revealed that on September 19, 2020, at approximately 4:45 AM revealed that one staff member was providing incontinence care to Resident 358, while the resident was in bed when the resident rolled out of bed onto the floor landing on her right side. Review of Employee 3 witness statement dated September 19, 2020, stated I was providing incontinent care to resident, rolled her on L (left) side. I then asked resident if she was ok resident stated yes. I took care if resident, resident rolled out if bed, incontinent care. Nursing documentation revealed that Resident 358 had complained of pain in the right leg. The physician was notified, and orders obtained to transfer Resident 358 to the hospital for evaluation and treatment. At approximately 5:40 AM Resident 358 was transferred to the hospital on September 19, 2020, and the family was made aware. Radiology report dated September 19, 2020, indicated that Resident 358 sustained a comminuted (a break or splinter of the bone into more than 2 fragments) fracture of the distal right femur (leg bone) and an impacted (broken ends of the bone are jammed together by a force), angulated intertrochanteric right femur fracture (a type of hip fracture). Resident 358 was admitted to the hospital on September 19, 2020 and had returned to the facility on [DATE]. A review of hospital surgical documentation dated September 20, 2020 at 10:27 AM revealed that Resident 358 had a fracture involving right proximal and distal femur and had underwent surgical intervention of the right femur, right distal femur traction pin and right hip IM nailing, (a type of surgery in which a permanent nail or rod is placed into the center of the bone to keep it stable). During an interview on April 8, 2021, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed the circumstances of the fall. The NHA verified that Employee 3 did not follow the resident's care plan for bed mobility during the resident's care on September 19, 2020, and the facility failed to provide two staff members for assistance with the resident's bed mobility resulting in a fall from bed and serious injury to the resident. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, a facility wide review of resident's bed mobility care plans was completed, and as necessary therapy evaluations were completed, and care plan updated. Residents with assist of two for bed mobility were interviewed to ensure they receive their bed mobility assistance according to the plan of care. To prevent this from recurring, the resident's with assist of two for bed mobility will have an identifying marker placed on the headboard of their bed to cue staff. Facility provided education to the nursing staff regarding the necessity and risks with failure to follow the residents unique Plan of Care as documented and proper bed mobility safety with residents that are assist of 2. To monitor and maintain ongoing compliance the Facility Administrator/Designee will audit residents with an assist of two for bed mobility to ensure their headboard had the indicator markers in place; daily for two weeks, weekly for two weeks and monthly for two months. The facility's staff development nurse will observe staff performing bed mobility assistance on residents with an assist of two for bed mobility to ensure the plan of care is being followed; daily for two weeks, weekly for two weeks and monthly for two months. The facility's immediate corrective action plan was completed September 22, 2020. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services

Based on observation, a review of clinical records and facility documentation and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 128) was free from physical abuse, which resulted in a [MEDICAL CONDITION] and failed to implement sufficient measures necessary to protect residents from abusive behavior perpetrated by one resident (Resident 117) out of 13 sampled residents. Findings include: A review of Resident 117's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 16, 2019, indicated that the resident was severely cognitively impaired with a BIMS score of 6 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). Further review of Resident 117's comprehensive plan of care dated July 28, 2019, revealed that the facility identified the resident's risk of resident-to-resident abuse related to being unaware of boundaries, striking/shoving/scratching others, cursing profanities and unaware of personal space and boundaries. The planned interventions were limited to staff offering emotional support as needed and social services to provide supportive visits as needed. A review of Resident 128's clinical record indicted the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 13, 2019, indicated that the resident was severely cognitively impaired with a BIMS score of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). A review of Resident 128's current care plan, in effect at the time of the survey ending January 15, 2020, revealed that she was at risk of resident-to-resident abuse related to risk of being the recipient of abuse. The planned interventions prior to an incident on January 12, 2020, indicated that staff were to maintain an environment that provides safety, provide comfort and reassurance and attempt to respect Resident's personal space. Further review of the care plan revealed the resident was also at risk for exhibiting non-compliant behavior as evidenced by taking other resident's belongings. The planned interventions prior to an event on January 12, 2020, indicated that staff were to offer resident alternatives if able, re-direct resident and to encourage resident to verbalize (if able) reason for non-compliant behavior. A review of documentation in the clinical record dated January 12, 2020, at 1:37 p.m., revealed that Resident 117 had episode of screaming and using foul language toward staff in day room at lunch time. Resident was re-directed to quiet area. No further behaviors noted at this time. Resident is in her room resting at this time. Facility documentation further noted that on January 12, 2020, Resident 117 had an episode of increased behavior at lunch time was screaming at staff but was re-directed at that time and calmed. Information dated January 12, 2020, at 2:30 p.m., submitted by the facility indicated that Resident 128 was walking down the hallway of the resident unit. Resident 128 was about to enter the room of Resident 117, when Resident 117 pushed Resident 128 to the floor. Documentation submitted by the facility dated January 12, 2020, at 3:12 p.m., indicated that Resident 128 was found lying on the floor on her right side after being struck by another resident, 911 notified for pickup due to extreme pain to left hip area. The facility's investigative report dated January 13, 2020, indicated that at approximately 1430, Resident 128 was walking down the hallway. She went to enter Resident 117's room and Resident 117 pushed her causing her to fall. Resident 128 landed on her left side. According to the facility's investigative report dated January 13, 2020, the facility's conclusion was that the facility confirmed the altercation occurred between both residents. A statement by Employee 1, a housekeeper, indicated that she saw Resident 128 standing in the doorway to Resident 117's room. Resident 117 was yelling at Resident 128. Employee 1 then witnessed Resident 117 push Resident 128 right across the hall. {Resident 128} fell and hit her head on the baseboard molding and was screaming. The facility interviewed Resident 117 on January 12, 2020, in response to the incident and Resident 117 stated that she {Resident 128} was coming into my room and I pushed her. Review of information dated January 12, 2020, submitted by the facility indicated that on January 12, 2020, Resident 128 was ambulating down the hallway and attempted to enter another resident's room. Resident {128} was then pushed by the resident {117} of that room. A statement by Employee 2, a nurse aide, indicated that prior to the incident, Resident 128 was walking the hall as she normally does. Employee 3, a nurse aide assigned to Resident 128's care during that shift had last seen Resident 128 walking the hallway at approximately 2:15 p.m. according to the statement provided. A review of documentation in the clinical record dated January 12, 2020, at 4:02 p.m., revealed that Resident 128 was sent emergently to the hospital due to extreme pain to the left leg/hip area. Further review of documentation revealed that Resident 128 was admitted to the hospital with [REDACTED]. The facility implemented 1:1 staff supervision of Resident 117 and placed a STOP sign across Resident 117's doorway to prevent other residents from entering her room. Observation of Resident 117 on January 15, 2020, at approximately 10:30 a.m., revealed that the resident was in her room with a staff member providing 1:1 supervision. The resident was yelling at the staff member to change her diaper. Interview with the Director of Nursing and Administrator on January 15, 2020, at 3 PM failed to provide evidence that the facility had implemented effective measures to prevent Resident 117, a resident with known physically and verbally abusive behavioral symptoms, from physically abusing Resident 128, a resident with known wandering and intrusive behaviors, which resulted in serious physical injury to Resident 128. 28 Pa. Code 201.18(e)(1) Management Previously cited 11/2/18 28 Pa. Code 201.29 (a)(c)(d) Resident rights 28 Pa. Code 211.12 (a) Nursing services Previously cited 12/13/19, 11/19/19, 10/8/19, 7/3/19, 11/2/18 28 Pa. Code 211.12 (c) Nursing services Previously cited 12/13/19, 11/19/19, 10/8/19, 7/3/19, 11/2/18 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 12/13/19, 11/19/19, 10/8/19, 7/3/19, 11/2/18 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 12/13/19, 11/19/19, 10/8/19, 7/3/19, 11/2/18 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 12/13/19, 11/19/19, 10/8/19, 7/3/19, 11/2/18 28 Pa. Code 211.11(d)(e) Resident care plan

Based on a review of clinical records, facility documentation and select facility policy, observation and staff interview, it was determined that the facility failed to provide sufficient staff supervision of one resident (Resident 64) with a known history of falls to prevent an accident resulting in serious injury and failed to implement interventions planned and/or necessary to maintain resident safety and prevent falls for two of 25 residents reviewed (Residents 64 and 9). This failure placed residents at high risk for falls and requiring increased supervision to prevent accidents in Immediate Jeopardy of sustaining further serious injury. Findings included: The facility's policy and procedure entitled, Fall Risk Assessment and Management, reviewed by the facility February 29, 2016, indicated that it is the policy of the facility to evaluate each resident for fall risk factors on admission, quarterly and after a fall. An individualized care plan is developed for each resident at risk for falls in an attempt to reduce the falls or injury, while maximizing dignity and independence. A licensed nurse evaluates residents at the time of each fall and the care plan is reviewed and revised on a quarterly basis and following each fall. The purpose is to ensure appropriate medical and multidisciplinary assessment of falls and fall risk factors, to coordinate management of acute and recurrent falls and to provide measures to help prevent falls. All staff in all departments assist with the identification of fall risk factors, by reporting observations to the Charge Nurse/Unit Manager/Nursing Supervisor. The fall evaluation and plan of care shall be completed or revised when a resident experiences a fall. The interdisciplinary team members shall update the plan of care and approaches within their area of expertise. A review of the clinical record revealed that Resident 64 was admitted to the facility on [DATE], following a fall and hospitalization . The resident's admitting [DIAGNOSES REDACTED].{thigh bone}fits), osteoarthritis (a degeneration of joint cartilage and the underlying bone), Schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real), abnormalities of gait and mobility, a cardiac pacemaker (a surgically implanted device to regulate the heart beat), anxiety, major depression (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), right eye cataract (clouding of the normally clear lens of the eye) and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated June 3, 2016, and the quarterly MDS assessment dated [DATE], revealed that the resident was cognitively intact and required staff assistance for activities of daily living (ADLs - the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring) including the assistance of two staff for transfers and ambulation. Review of Resident 64's initial care plan dated May 27, 2016, revealed that one of his problematic areas was falls (due to a history of falls). A Fall Risk Evaluation completed on admission indicated that he was at high risk for falls. The facility's planned safety measures for the resident included fall mats to the sides of the resident's bed, safety alarms, a helmet to protect the resident's head, call (tap) bell in reach and to try to anticipate the resident's needs. According to a review of resident incident/accident reports the resident incurred falls, without injuries and/or serious injuries, on May 27, 2016, at 4:55 p.m. May 30, 2016, at 1:10 p.m. May 31, 2016, at 8:05 p.m. June 3, 2016, at 5:00 p.m. June 3, 2016, at 8:25 p.m. June 4, 2016, at 4:00 p.m. June 15, 2016, at 7:30 a.m. July 2, 2016, at 5:30 a.m. July 4, 2016, at 5:20 p.m. July 21, 2016, at 3:20 p.m. July 30, 2016, at 10:50 a.m. August 6, 2016, at 11:15 a.m. August 22, 2016, 7:30 a.m. August 22, 2016, 11:45 a.m. August 22, 2016, at 4:45 p.m. August 24, 2016, at 4:20 p.m. September 4, 2016, at 11:48 a.m. October 3, 2016, 6:40 p.m. October 12, 2016 and October 19, 2016, at 1:53 p.m. Review of the Resident 64's clinical record revealed that the resident had sustained 28 falls in the facility from admission to the time of the survey ending November 18, 2016, the last occurring on November 15, 2016, at 8:30 p.m. During the course of the resident's stay the facility provided intervals of 1:1 supervision of the resident, as well as, every 15 minute checks of the resident. These supervisory measures to promote the resident's safety were provided sporadically following the resident's multiple falls according to review of incident/accident reports, facility follow up investigation and the resident's care plan. Fall Risk Evaluations conducted throughout the resident's stay continued to identify him at high risk for falls. The resident sustained [REDACTED]. The resident fell forward out of his chair, to the floor and sustained a 4 cm (centimeter) x 2 cm laceration to his forehead. The facilty noted that every 15 minute checks of the resident were in place at the time of fall. However, there was no documented evidence that the staff conducted the every 15 minute checks between the hours of 3:00 p.m. through 10:45 p.m. on that date, the time frame during which this fall had occurred. On August 22, 2016, the resident fell three times (7:30 a.m. 11:45 a.m. and 4:45 p.m.) and due to the resident's frequent falls, the resident was placed on one to one observation while awake x 24 hours. A review of the clinical record revealed that he was placed on 1:1 supervision on August 24, 2016, 3:00 p.m. through August 27, 2016, at 4 p.m. when this degree of supervision ended. An interview with the Director of Nursing (DON) on November 16, 2016, at 10:00 a.m. revealed that the resident was gradually, weaned off the 24 hour 1:1 supervision as the facility, deemed appropriate. From August 28, 2016 through September 9, 2016, the facility's plan was to provide every 15 minute checks of the resident. However, there was no documented evidence that the facility staff had consistently performed these every 15 minute checks as planned on August 28, 2016, August 29, 2016, August 31, 2016, September 1, 2016, September 2, 2016, September 4, 2016, September 6, 2016, September 8, 2016, and on September 9, 2016, at the time the resident experienced a fall with serious injury. A review of documentation submitted by the facility on September 12, 2016, indicated that on September 9, 2016, at approximately 2:15 p.m. the resident was found on the floor, at the foot of his bed, in the prone position (a body position in which one lies flat with the chest down and the back up). There was some blood noted in the area of the resident's head. The nursing staff assessed the resident and rendered first aid to control the bleeding. The resident had a nose bleed and his nose appeared somewhat deviated (shifted away from the middle of the face). The facility's submitted documentation further noted that the resident had a laser alarm (an audible alarm that triggers when the laser beam is broken by movement) at the foot of his bed, but on the opposite side from which the resident had exited the bed. Therefore, the alarm did not sound when the resident exited the bed. The overbed table was at the foot of the bed. As the resident got to the foot of the bed, he lost his balance, while reaching for the overbed table, causing the table to move and the resident to fall forward. The resident fell and ended up face down on the floor. The physician was contacted and directed that the resident be sent to the emergency room at that time for an evaluation. Following the resident's transport to the hospital, the facility placed a call to the hospital for an update on the resident and was informed that the resident was admitted to the facility with a traumatic (traumatic refers to a brain injury that might be sustained in an accident or a fall) subarachnoid hemorrhage (bleeding in the area between the brain and the thin membrane that covers the brain). The resident returned to the facility on [DATE], at approximately 2:00 p.m. The facility added an additional laser alarm to the other side of the bed and placed the resident on 1 to 1 observation upon the resident's return. A review of the incident/accident report dated September 9, 2016, at 2:15 p.m. revealed, Resident was found (unwitnessed) at the foot of his bed, on the floor, laying face down in front of the bed. Resident noted to have large laceration of left eyebrow, epistaxis (nose bleed), skin tear lower left arm and left hand. The nursing progress notes revealed resident stated he was trying to turn on TV. The tap bell was within his reach while the resident was in bed. The resident's laser alarm was not sounding at the time, but the alarm was checked and working. The resident's responsible party and physician were notified. He was transported to the hospital and admitted with a traumatic subarachnoid hemorrhage. Review of the resident's clinical record revealed that the resident sustained [REDACTED]. or all of the way through, but does not move and maintains its proper alignment) fracture of the frontal process of the left maxilla and left occipital condyle fracture (the bone of the skull that forms a joint with the first cervical vertebra {neck}, enabling the head to move relative to the neck). The resident was readmitted to the facility, wearing a cervical collar (neck brace) on September 12, 2016, at 2:00 p.m. and he was placed on 24 hour 1:1 supervision. The 1:1 supervision continued through September 30, 2016, at 12:00 a.m. at which time the 1:1 supervision was discontinued during the 7:00 a.m. to 3:00 p.m. shift. The resident had five additional falls, without injury, after his hospitalization on [DATE], and return to the facility on [DATE], according to a review of incident/accident reports and the resident's clinical record. Observation of this resident on November 18, 2016, at 11:18 a.m. in the resident's room revealed that he did not have a tap bell available at his bedside and within reach in his room as noted on the resident's current care plan. An interview with the DON on November 16, 2016, at approximately 11:40 a.m. indicated that the facility frequently reduced and/or eliminated the resident's 24 hour 1:1 supervision and the resident did sustain multiple falls, both with and without injuries. The DON also verified that the existing safety interventions planned were not effective in preventing the resident's multiple falls. An interview with the Nursing Home Administrator and the DON on November 16, 2016, at 12:00 p.m. failed to provide evidence that the facility consistently provided this resident with the type and degree of supervision necessary to maintain the resident's safety and prevent falls and injuries. A review of the clinical record revealed that Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an admission MDS assessment dated [DATE], the resident was cognitively intact and required extensive assistance of two for bed mobility and extensive assistance of one for transfers and ambulation. The resident's balance was noted as unsteady during transitions (from seated to standing) and walking. The resident was also identified as having a fall in the last 2-6 months prior to admission to the facility. The resident's comprehensive plan of care dated October 8, 2016, indicated that the resident was identified at risk for falls related to a new environment, confusion and dementia. Interventions planned to address this fall risk dated October 8, 2016, included keeping assistive/adaptation equipment within reach of the resident, keeping frequently used items within easy reach, keeping the resident's bed in the lowest position and locked and to maintain a hazard free environment. The resident was also placed on every 15 minute safety checks from October 8, 2016 through October 18, 2016, according to a review of safety check records maintained by the facility. Review of nursing progress notes dated October 31, 2016, revealed that at approximately 7:15 p.m. a nurse aide found the resident on the floor of his room. The resident was going to pick up his clothes off the table. The resident stated that he forgot to call for help. The resident was educated to call for assistance. Every 15 minute checks were initiated. Review of a corresponding incident/accident investigation completed by the facility dated October 31, 2016, revealed that the resident was found on the floor in his room. The resident was sitting in his wheelchair watching television and was last seen at 6:30 p.m. The resident was noted to be confused. The resident sustained [REDACTED]. The wheelchair brakes were locked and he had non-skid socks on at the time of the fall. Interventions to prevent a reoccurrence included re-instituting every 15 minute checks. However, there was no evidence that the facility's interdisciplinary team had evaluated the resident for the use of other interventions after this fall from the wheelchair on October 31, 2016, in addition to re-instituting the every 15 minute checks. A review of documentation submitted by the facility on November 2, 2016, revealed that at approximately 4:50 p.m. on November 2, 2016, Resident 9 was in the first floor dayroom with another resident and was found on the floor. The documentation indicated that he attempted to stand from the wheelchair and fell . The resident told the other resident in the dayroom that he was going to go home. As the result of this fall, Resident 9 sustained a hematoma (a collection of blood under the skin that may occur because of an injury allowing blood to leak out into tissues where it does not belong) to the forehead and a skin tear to the left hand. The resident had non-skid socks on at the time of the fall and chair brakes were locked. There was no clutter or debris on the floor. A new physician's orders [REDACTED]. The resident returned to the facility on that same day with all testing being negative. A chair alarm was added to the wheelchair. Therapy planned to evaluate the resident's current status and the care plan was to be updated to reflect any new changes. The IDT (interdisciplinary team) will monitor the resident for pain and safety. Nursing progress notes dated November 2, 2016, at 6:32 p.m. indicated that at approximately 4:45 p.m. that day the staff were summoned to the day room. The resident was noted to be lying on the left side, on the floor next to a table. A moderate amount of blood was noted on the floor coming from the resident's forehead. The resident was very confused and unable to explain what happened or what he was trying to do. Pressure was applied to the forehead. The Registered Nurse assessed the resident. The resident's pain was rated as a five out of 10 (with 10 being the highest), but was unable to state if the pain was of new onset. The physician, family member and the ambulance were notified. Review of a corresponding fall incident/accident investigation dated 4:50 p.m., on November 2, 2016, indicated that the resident was sitting in the day room and he attempted to self-transfer. The resident was found on the left side on the floor. It was noted that he was last seen sitting in his wheelchair. The resident incurred a head laceration and skin tears to the left hand. The incident/injury occurred due to the resident standing up and then attempting to walk. The resident stated to another resident that he was going home, stood up and attempted to ambulate and fell . The resident sustained [REDACTED]. The resident was confused and only oriented to person. The interventions to prevent a reoccurrence of this fall were to implement a chair alarm. The interventions that were already in place at the time of this fall were a bed alarm and every 15 minute checks. Review of an Interdisciplinary team note dated November 4, 2016, at 7:48 a.m. addressing the fall on November 2, 2016, revealed that the resident had increased confusion, stated the resident was going to go home and stood and fell . The note indicated that care had been provided to the resident at 3:45 p.m. and the resident was seen in the dayroom approximately 5 minutes prior to the fall. Therapy will evaluate seating and a chair alarm was now added. There was, no documented evidence that the 15 minute checks had been completed on November 2, 2016, as planned following the fall on October 31, 2016. The facility was unable to provide the documented every 15 minute checks completed on that date at the time of the survey ending November 18, 2016. Review of progress notes dated November 5, 2016, at 12:48 p.m. revealed that the resident had increased lethargy that afternoon, increased confusion and was very stiff and staff were unable to reposition the resident due to stiffness. The physician was called and 1:05 p.m. and the resident was transferred to the hospital at 2:18 p.m. for an evaluation due to the recent fall. The resident returned to the facility on [DATE]. The hospital records dated November 5, 2016, indicated that the resident was seen in the emergency room due to the resident's mental status becoming more altered since the fall this week. A comparison was made to a prior CT scan (commonly known as a CT or CAT scan, is a diagnostic medical test that, like traditional X-rays, produces multiple images or pictures of the inside of the body) dated November 2, 2016. The impression was that there was no acute intracranial (within the skull) abnormality identified and that the resident has frequent falls. The resident's comprehensive plan of care was revised after the resident's fall on October 31, 2016, which resulted in an abrasion to the right outer eyebrow, skin tear to the left elbow, and hematoma to the occipital (back of the head) area to address treatment to the area, after the fall on November 2, 2016, which resulted in a hematoma, a chair alarm was instituted as an additional safety measure in addition to the every 15 minute checks, which had been in place, but ineffective in preventing the resident's fall. An interview with the Director of Nursing on November 18, 2016, at 1:30 p.m. confirmed that the facility's interdisciplinary team did not add an alarm to this resident's wheelchair, as an additional safety measure, until November 2, 2016, after the resident sustained [REDACTED]. As the result of the facility's failure to demonstrate that residents with a known history of falls and identified to be at high risk for future falls were consistently provided with the type and degree of supervision necessary to prevent repeated accidents and injuries, Immediate Jeopardy to the health and safety of residents was identified on November 17, 2016, at 1:15 p.m. On November 17, 2016, at 3:00 p.m. the facility provided an action plan that included the provison of 1:1 supervision of Resident 64 and a review of the resident's care plan by the interdisciplinary team for the appropriateness of interventions. The facility also reviewed other residents identified at high risk for falls on their most recent fall risk assessments for appropriate interventions and effectiveness and updated their care plans. All nursing staff were educated on the 1:1 and every 15 minute check policy and re-educated on proper placement and functionality of alarms. The Director of Nursing and Designee as well as the interdisciplinary team audited recent falls for proper interventions in place and for new interventions to prevent future falls. Following the implementation of the above action plan, the Immediate Jeopardy was lifted on November 18, 2016, at 11:45 p.m. 28 Pa. Code 211.10 (a) Resident care policies Previously cited 8/19/16, 5/12/16 28 Pa. Code 211.10 (d) Resident care policies Previously cited 8/19/16, 5/12/16 28 Pa. Code 211.12 (a) Nursing services Previously cited 7/5/16, 5/12/16 28 Pa Code 211.12 (c) Nursing services Previously cited 7/5/16, 5/12/16 28 Pa Code 211.12 (d)(1) Nursing services Previously cited 5/12/16 28 Pa Code 211.12 (d)(3) Nursing services Previously cited 7/5/16, 5/12/16 28 Pa Code 211.12 (d)(5) Nursing services. Previously cited 7/5/16, 5/12/16

Based on a review of clinical records and select facility policies and procedures and staff interview, it was determined that the facility failed to provide timely and necessary services to promote adequate hydration status and prevent dehydration for one resident out of 25 sampled residents (Resident 16). Findings include: A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses, which included advanced dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). During the resident's stay in the facility, on May 3, 2012 the resident was hospitalized with acute kidney injury (an abrupt loss of kidney function that develops within 7 days, the most common cause is dehydration) prerenal azotemia (high level of nitrogen waste products in the blood) secondary to volume depletion (loss of water and salts from the body). The resident was dehydrated (a dangerous lack of water in the body resulting from inadequate intake of fluids or excessive loss through sweating, vomiting, or diarrhea) and admitted to the hospital for fluid replacement. The resident returned to the facility on [DATE], with recommendation to be maintained on a pureed diet with feeding assistance, nutritional supplements and close monitoring of pre-[MEDICATION NAME] levels (blood test used as a marker for protein stores in the body and adequacy of nutritional status). According to review of the resident's clinical record, and verified by the director of nursing during interview at the time of the survey ending June 11, 2015, no pre-[MEDICATION NAME] levels were obtained for this resident as recommended following hospitalization in 2012. A review of the resident's lab studies following the 2012 hospitalization revealed the following: March 19, 2014: BUN 9.0 mg/dl (within normal range) CRT 0.7 mg/dl (within normal range) NA 144 mEq/l (within normal range) September 26, 2014: BUN 27 mg/dl (elevated) CRT 1.0 mg/dl (n) NA 145 mEq/l (n) October 3, 2014: BUN 30 mg/dl (elevated) CRT 1.0 mg/dl (within normal range) NA 143 mEq/l (within normal range) A review of the resident's daily meal consumption revealed that from January 31, 2015, through March 21, 2015, the resident consumed less than 75% of her meals on forty (40) out of fifty (50) days. The resident's weight documented on March 4, 2015, at the facility was 123 pounds and when hospitalized on [DATE], the resident's weight was documented as 110 pounds. The resident's most current weight on June 3, 2015, was 116.4 pounds. The resident had an order to receive a house supplement three times a day (120 cc three times a day) and a juice supplement of 210 cc three times a day (for a total of 990 cc of supplements) along with the fluids she received on her meal tray, which usually consisted of 240 cc of milk, 240 cc of coffee/tea and 120 cc of juice for a total of 600 cc on each meal tray or 1800 cc per day. According to the facility, the resident was being offered 2790 cc of fluid per day. A nutrition assessment dated [DATE], indicated the resident's fluid requirements were to be 1350-1680 cc per day; the resident's assessed nutritional needs were 1690 kcal with 78 g of protein. The resident's intake record on March 16, 2015, revealed that she consumed 0% at breakfast, lunch and dinner, but that she accepted 752 cc of fluid from her meal trays as documented in the electronic medical record by the nurse aides and accepted 990 cc of her supplements as documented on the treatment record by the professional nursing staff. Nursing assessed the resident on this date, which revealed that she was accepting adequate fluids, her skin was intact and she had moist mucus membranes, which indicated sufficient hydration at this time. The following meal intakes were noted on subsequent days: March 17, 2015 breakfast 50% lunch 75% dinner 25% March 18, 2015 breakfast 50% lunch 50% dinner 0% March 19, 2015 breakfast 50% lunch 25% dinner 0% March 20, 2015 breakfast 25% lunch 25% dinner 50% March 21, 2015 breakfast 0% lunch 0% dinner 0% Fluid intake was documented for the aforementioned days between 120 cc and 1444 cc along with the documentation of 100% acceptance of her supplements (990 cc). Interview with the dietitian on June 9, 2015, at 11:00 AM revealed that the facility does not have a specific hydration assessment, but she stated that when she noticed the resident's intakes were poor on March 16, 2015, she asked the nurse to assess the resident and that entry would be considered a hydration assessment. There was no evidence that the dietician assessed the adequacy of the resident's fluid intake and meal intake during this time period of decreased meal intake to timely intervene as necessary to prevent dehydration. A review of the resident's bowel and bladder record from March 8, 2015 through March 11, 2015, indicated that the resident was incontinent of urine, but there was no documentation of the volume or amount of urine output. The record also indicated that the resident had 10 extra large sized stools (bowel movements) with three occasions of loose stools. The resident's Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 25, 2105, indicated that the resident was severely cognitively impaired, rarely speaks and rarely understands others. This assessment was confirmed upon observation and review of the resident's medical record history. A physician's progress note dated as dictated March 21, 2015, from a visit of March 18, 2015, indicated that the resident reported abdominal pain, however the assessment indicated that the resident's abdomen was soft, non-tender, and non-distended without guarding or tenderness. The physician also indicated she was well-nourished and well developed and was oriented to person, place and time and had an intact recent and distant memory. There was no documented evidence that the physician had noted the resident's decreased appetite or loose stools. A review of the resident's clinical record revealed nursing documentation dated March 21, 2015, at 6:00 PM, which indicated that the resident's appetite remained poor, the resident's temperature was elevated at 102.6 degrees Fahrenheit, as obtained axillary (under the armpit) and blood pressure of 136/113 (elevated blood pressure, normal 120/80). The resident was shivering. The physician was notified and Tylenol (fever reducer) was ordered to be given rectally, due to the resident spitting out pills, and an antibiotic Bactrim DS twice a day by mouth, breathing treatments and a chest x-ray were also ordered by the physician. The chest x-ray showed no acute [MEDICAL CONDITION] disease, but showed slight atelectasis (complete or partial collapse of a lung or lobe of a lung - develops when the tiny air sacs (alveoli) within the lung become deflated) in the left lower lung area. The resident's temperature was rechecked at 9:54 PM and it was 99 degrees Fahrenheit axillary. Nursing documentation at 10:00 PM indicated that the resident's blood pressure was further elevated 186/144 and she was yelling. The resident was transferred to the hospital at 10:40 PM on March 21, 2015. A review of the emergency department admission record revealed that the resident appeared dehydrated and borderline hypotensive (low blood pressure), which required two liters of fluids intravenously (IV) to improve the blood pressure to around 110 systolically (the top number in the blood pressure reading, is the pressure the blood exerts in the artery when the heart muscle is beating A low systolic blood pressure can be indicative of fluid or blood loss or infection in the body). The resident's vital signs at 2:30 AM were blood pressure 107/60 and temperature 97.3 degrees Fahrenheit. The resident's BUN was 81 (blood urea nitrogen-measures nitrogen waste in the blood, normal 6-20 mg/dl) and Creatinine (waste product in blood) was 3.0 (normal 0.5-1.2 mg/dl) {lab indicators of hydration status, dehydration generally causes BUN and Creatinine levels to rise}. The resident's Sodium level was 176 mmol/l (how much sodium is in the blood. Sodium is both an electrolyte and mineral. It helps keep the water {the amount of fluid inside and outside the body's cells} and electrolyte balance of the body). The resident had [MEDICAL CONDITION], high sodium level. The diagnostic impression of this resident in the emergency department was that the resident was to be admitted to the hospital with [REDACTED]. Throughout the resident's hospital stay the resident received IV fluids and antibiotic. The resident was discharged from the hospital and returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. Upon discharge from the hospital the resident's laboratory values were as follows: BUN 23 mg/dl; CRT 1.6 mg/dl and Sodium 160 mmol/l on March 24, 2015, was Sodium 143 mmol/l. A review of the acute care clinical dietitian's note from the resident's hospital stay dated March 23, 2015, at 11:18 AM revealed that the Resident was 110 pounds on admission to the hospital with a thin overall appearance. The note indicated that the resident was severely malnourished related to illness as evidenced by less than 75% of estimated energy requirements for one month and greater than a 5% weight loss for one month and moderate fat and muscle loss. On June 9, 2015, at approximately 10:30 AM the facility's Medical Director stated that this resident was not his patient, but he read the record and stated that the resident was elderly and had a history of [REDACTED]. During an interview with the facility's dietitian on June 9, 2015, at 11:00 AM, she stated that the resident was elderly and could possibly dehydrate very quickly. When asked about intervention in response to the resident's declining meal intake beginning on March 16, 2015, the dietitian stated that she asked the nurse to do a hydration assessment. The dietitian further stated that when the nurse indicated that the resident did not appear dehydrated, nothing further was done to increase the resident's fluid intake and prevent dehydration.

Based on a review of clinical records, select facility policies and procedures and injury of unknown origin investigations, observations and staff interview, it was determined that the facility failed to timely identify skin impairments and implement adequate measures to prevent pressure sore development and promote healing for one resident out of 25 sampled (Resident 118). Findings include: According to the facility's policy entitled Skin Prevention reviewed by the facility March 2015 the facility must ensure each resident receives adequate supervision and assistive devices to prevent skin breakdown. All residents will be assessed for skin integrity risk. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize the potential of skin breakdown. Braden scales (tool used to evaluate risk of skin breakdown) are completed on admit, re-admit, quarterly, annually, with any significant change in condition and any time a resident experiences a new or recurring skin issue. The facility is then to develop an individualized plan of care for all residents that includes general and specific interventions to reduce skin breakdown. This includes long sleeves, geri-sleeves, pressure reducing cushions, padding, specialty transfer equipment, turning and repositioning schedules. The facility is to review assessments to identify any causes that may have contributed to skin breakdown. (Incontinence, decreased appetite, increased confusion, weight changes, talking or communicating less than usual, tires, weak or confused). Preventative measures are then to be implemented to prevent a re-occurrence. The care plan is to be updated with all new interventions. A a review of Resident 118's clinical record revealed that the resident has multiple [DIAGNOSES REDACTED]. An annual Minimum Data Set Assessment (MDS -a standardized assessment process for facilitating care management in nursing homes) dated February 6, 2015, indicated that the resident requires extensive assistance of two staff for mobility, transfers, bathing and hygiene. This assessment also indicated that the resident is at risk for pressure sore development. According to the resident's comprehensive plan of care, which was initiated on February 5, 2015, the resident was at risk for impairment to skin integrity related to fragile skin, decreased mobility, incontinence and [MEDICAL CONDITION]. Interventions planned to address this risk included a pressure reducing mattress to the bed and cushion to the wheelchair as preventative measures, therapy evaluation for seating and positioning and turning and repositioning every 2 hours. The plan of care failed to identify the resident's habit of continually moving her leg up and down and the need to monitor the application and position of geri-sleeves used on the resident's legs for skin protection as a result of the resident's frequent leg movements. Braden Scales (an assessment tool that identifies risk for pressure sore development) dated May 17, 2015 and June 6, 2015, revealed that the resident was identified at risk for pressure sore development. The resident had physician's orders [REDACTED]. According to an interview with the Director of Therapy during the survey ending June 11, 2015, the resident was to be using geri-sleeves for skin protection and not the Derma-Savers. According nursing documentation dated June 6, 2015, at 2:11 AM, at 8:00 PM on June 5, 2015, the Charge Nurse called Employee 5, a registered nurse into the resident's room. The resident was lying in bed with alterations in the resident's skin noted by these nursing staff members. The resident's left posterior knee presented with a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure area measuring 4.0 cm x 6.0 cm x .75 cm with an open red base, minimum yellow to serous drainage. No odor was present. The resident's right posterior knee presented with an unstageable (full thickness tissue loss in which actual depth of an ulcer is completely obscured by slough yellow which is tan, gray, green, brown tissue or eschar which is tan, brown, or black tissue in the wound bed ) pressure area 2.0 cm x 4.0 cm. The surrounding wound had a red open bed and surrounding intact skin which was [DIAGNOSES REDACTED]. The area was dry with no drainage. After the above pressure ulcers were identified physician's orders [REDACTED].(narcotic pain medications) and place a pillow to be placed between the knees at all times when in bed and remove for hygiene. Doppler studies were ordered on June 8, 2015, which were negative. On June 9, 2015, a low air loss mattress was ordered. Review of an injury of unknown origin investigative report into these open areas dated June 6, 2015, included a written statement provided by Employee 6, a nurse aide, which revealed that when she was giving the resident a bed bath she noticed both knees with a red area and she told the nurse. However, during a telephone interview with Employee 6 on June 11, 2015, at approximately 1:15 PM, she stated that when she was giving the resident a bed bath on June 5, 2015, she observed red areas behind the resident's knees, which were opened and she reported it to the nurse. She also relayed that the resident has a habit of constantly rubbing her legs on her chair prior to skin breakdown, stating that it was hard for staff to see behind her knees. According to this investigation the facility concluded that these pressure areas were unavoidable based on the resident's pre-[MEDICATION NAME] level of 8 mg/dl (normal 10-40 mg/dl), her age and decline in condition. However, the facility failed to demonstrate that the risk factor related to the resident's use of geri-sleeves in conjunction with the constant movement of the resident's legs, that resulted in the bunching/wrinkling of the geri-sleeves, had been ruled out as a causative factor in the development of these pressure sores, which were located in the area which the geri-sleeves were used for skin protection. During an observation of the resident's open areas on June 11, 2015, at approximately 11:30 PM, the resident was observed in bed with her legs bent. The resident was moving her legs up and down. She was observed to be contracted (unable to straighten out) at the knees. She had geri-sleeves on her legs at the time of this observation, which were observed to be bunched up behind the resident's knees and were loose. Upon removal of the geri-sleeves, an approximately lime sized, deep, open areas were observed behind the resident's knees bilaterally with significant tendon exposure observed. During a subsequent observation of the resident, at the request of the facility on June 11, 2015, at approximately 2:10 PM, the resident was observed seated in a reclining Broda chair (specialized chair for those at risk for pressure sore development). She was observed again with geri-sleeves on her legs, which were bunched up at the knees and she was moving her legs up and down in the reclining Broda chair. This observation was brought to the attention of the Assistant Director of Nursing. There was no documented evidence available for review by the end of the survey on June 11, 2015, that the facility had timely identified and acted upon the resident's risk factors of contracted knees and habit of up and down leg movements along with the ineffectiveness of the geri-sleeves in providing adequate skin protection to prevent pressure sore development and progression to Stage IV and unstageable areas along with tendon exposure.

Based on a review of clinical records, an event report and incident/accident report and staff interview, it was determined that the facility failed to provide required safety measures to prevent a fall with serious injury to one resident out of seven sampled residents (Resident 71). Findings include: A review of the clinical record revealed that Resident 71 had [DIAGNOSES REDACTED]. A March 20, 2015, annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) indicated that the resident had a BIMS (Brief Interview for Mental Status - a tool to measure cognitive function) score of 10 (score equates to moderate cognitive impairment) and required supervision for most Activities of Daily Living. The nurses' notes from May 1, 2015, through May 5, 2015, indicated that the resident had episodes of nausea, vomiting, loose stools, decreased appetite and weight loss. In addition, on May 5, 2015, a nursing referral was made to Physical Therapy due to the resident's declining mobility and weakness. A physical therapy communication form completed on May 5, 2015, and an interview with the Physical Therapy Director (Employee 4) on May 12, 2015, at 11:05 AM, revealed that as of May 5, 2015, the resident's ambulation status was changed from independent to the assist of one staff with a rollator walker (device that provides support during ambulation) and a gait belt (a device used to transfer people from one position to another, from one thing to another or to be used while ambulating people that have problems with balance). The resident's transfer status was also changed to the assistance of one with the use of a gait belt. According to nursing documentation on May 9, 2015, at approximately 7:55 PM, the nurse was called to the resident's room. Upon entering the room, the resident was observed on the floor in the bathroom doorway with her back leaning against Employee 1's, (a Nurse Aide) bilateral lower extremities (both lower legs), with the resident's right leg extended and left knee rotated outwards. The Nurse Aide reported that while she was assisting the resident back to bed from the bathroom with the rolling walker, the resident's knees buckled, the resident lost her balance and fell back landing on the nurse aide's feet. The resident complained of pain in the left knee, displayed facial grimacing and was unable to move due to the pain. The physician was immediately notified and a new order was received to send the resident to the emergency room for an evaluation at that time. The resident was admitted to the hospital on May 9, 2015, with a [DIAGNOSES REDACTED]. Review of the corresponding Event Report submitted to the State Survey Agency on May 9, 2015, and the Incident/Accident report completed by the facility following the event, also dated May 9, 2015, revealed that the resident fell while ambulating between her bedroom and the bathroom. These reports indicated that the resident was transported to the hospital with a [DIAGNOSES REDACTED]. Review of the current nurse aide care card (a reference guide for individual care required by the resident utilized by direct care staff) conducted on the day of the survey, May 12, 2015, revealed that the resident was to be ambulated with a rollator walker, assist of one and a gait belt and was to be transferred with the assist of one with a gait belt. The date of initiation of these transfer and ambulation services was not noted on the nurse aide care card when reviewed during the survey. Interview with the Director of Nursing on May 12, 2015, at 11:20 AM, revealed that Employee 1 did not use a gait belt when ambulating the resident at the time of the fall. The Director of Nursing confirmed that Employee 1 should have used a gait belt when ambulating Resident 71. An interview with Employee 1, on May 12, 2015, at 1:45 PM, revealed that she was not aware that the resident now required the use of a gait belt. A telephone interview with the 3 PM to 11 PM Charge Nurse (Employee 2) on May 12, 2015, at approximately 2:15 PM, revealed that she was not made aware that the resident's ambulatory status was changed and that the resident now required a rollator walker, the assistance of one and a gait belt. Employee 2 further relayed that there was no mention of this status change in the 24 hour nursing report she received from the previous shift to indicate that the resident was now to be ambulated with a rollator walker, assist of one and a gait belt. She also stated that she had instructed Employee 1, that when Resident 71 was done in the bathroom, to call for additional assistance to take the resident back to bed. During an interview with the 7 AM to 3 PM Charge Nurse (Employee 3) on May 12, 2015, at 2:30 PM, stated that she documented on the above referenced nurse aide care card that the resident required the assistance of one and a gait belt for ambulation and transfer. When asked when she made the entry on the care card, since it was observed to be undated, she stated that she documented it on the same date that the changes were initiated. Upon review of the 24 hour nursing report records (utilized as a method of communication between shifts regarding resident status/changes) from May 5, 2015, there was no documentation to indicate that a change in the resident's ambulation requirements, necessitating the use of a rollator walker, assist of one and a gait belt, or the transfer status with the assist of one and a gait belt had been communicated to the subsequent shifts. This absence of documented evidence of communication of the change in the resident's transfer and ambulation status was confirmed during interview with the Director of Nursing on May 12, 2015, at 2:45 PM. The resident's current comprehensive plan of care, which was initiated on July 12, 2013, revealed that the resident was at risk for falls related to gait/balance problems and syncopal episodes. There was no documented evidence that the May 5, 2015, physical therapy recommendations for the resident to be ambulated with a rollator walker, assist of one and gait belt or to transfer the resident with the assistance of one with the gait belt were incorporated into this resident's current comprehensive plan of care. 28 Pa Code 211.11(c)(d)Resident care plan. 28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services. Previously cited 4/15/15

Based on review of clinical records, an Event Report submitted to the State Survey Agency, select resident incident/accident reports, ambulance and hospital records, and the facility's diet manual and staff interviews it was determined that the facility failed to consistently serve food in a form to meet individual resident needs for a finely chopped diet resulting in a choking episode for one resident out (Resident CR1) of fourteen residents sampled. Findings include: Review of an Event Report submitted to the State Survey Agency on January 23, 2015, revealed that on January 23, 2015 at 3:45 PM Resident CR1 requested a peanut butter and jelly sandwich and a nurse aide provided the sandwich (on white bread) to the resident. Prior to giving the resident the sandwich, the Nurse Aide asked the Licensed Practical Nurse what was the resident's current diet consistency (diet order). The Licensed Practical Nurse checked the PCC (Point Click Care- computerized record system) and indicated that the resident's diet was finely chopped with thin liquids. Shortly, thereafter the resident was provided a drink of juice, but was unable to clear her throat and began to couch. The Nurse Aide and Licensed Practical Nurse rushed to the resident as she began choking. The resident expelled a small amount of food, but was unable to breathe. The Licensed Practical Nurse performed the [MEDICATION NAME] Maneuver on the resident without effect. A Code Blue was initiated and the resident was taken to her room in an upright position. The Nursing Supervisor came onto the unit and immediately 911 was called. The paramedics arrived and took over the emergent care. The resident was admitted to the hospital with [REDACTED]. A crustless finely chopped peanut butter and jelly sandwich was provided to the resident according to the facility. Also noted in the Event Report was that per speech therapy and dietary (staff), a peanut butter and jelly sandwich was not necessarily the appropriate choice at that time. The facility's investigation into this occurrence conducted on January 23, 2015, revealed that Employee 4, a nurse aide provided Resident CR1 a peanut butter and jelly sandwich (on white bread) after Employee 5, the Licensed Practical Nurse informed the aid that the resident could have it, but that the aide should chop it finely. The facility's findings concluded that the bread was was soft, not crispy, and not allowed on finely chopped textured diet, but nursing staff did not know this food was unallowable at the time of the incident. Upon review of Resident CR1's clinical record it was revealed that the resident was admitted to the facility on [DATE]. She had multiple [DIAGNOSES REDACTED]. According to an Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 17, 2014, the resident is understood by others and understands, requires supervision - oversight, encouragement or cueing and one person physical assistance for eating. The was on a mechanically altered diet and therapeutic diet per the MDS assessment. Review of nursing progress notes dated December 19, 2014 at 12:13 PM indicated that the resident was coughing on waffles at breakfast and a referral was sent to therapy (speech) regarding diet consistency. On December 22, 2014, at 1:00 PM, it was noted in the resident's clinical record that the consistency of the resident's diet was decreased to pureed, which the resident was accepting well being fed by staff. Clinical record documentation revealed that on December 28, 2014 at 8:47 PM, during dinner the resident was having difficulty swallowing thin liquids; the resident was coughing and was given nectar thick liquids. A referral was sent to (speech) therapy. Review of the resident's Speech Therapy evaluation and treatment notes dated December 19, 2014, revealed that the referral was made for a speech evaluation secondary to exacerbation of dysphagia as evidenced by coughing on waffles at breakfast. No difficulty was noted with liquids. The resident indicated that she is coughing on food. Speech therapy recommendations were made to change the resident's diet from a Mechanical Soft Diet to a Puree Diet with thin liquid consistency. Speech Therapy treatment was initiated on that date for three times a week x 30 days. The resident was initiated on a pureed diet on December 22, 2014. Subsequent Speech Therapy evaluation and treatment notes dated January 12, 2015, noted that the resident was to have assistance in eating with verbal cues. On January 12, 2014, the swallowing treatment plan for analysis of diet texture was to increase safe oral intake and therapeutic trial feedings to increase resident safety. On January 16 and 19, 2015, speech therapy noted that the resident has good tolerance of finely chopped texture trials. On January 22, 2015, therapy noted that the resident has an excellent tolerance of finely chopped textures. She was initiated on a finely chopped diet with extra moisture and thin liquids on January 22, 2015. During an interview with the Speech Therapy Director (Employee 1) and Assistant Speech Therapy Director (Employee 2) on February 4, 2015, at approximately 11:00 AM and 10:30 AM respectively, both Speech Therapists confirmed that the resident was not provided the appropriate food items for a finely chopped texture diet. These employees indicated that soft bread and peanut butter would not be allowed on a finely chopped texture diet. The speech therapists presented the facility's diet manual and diet texture policies, which listed foods allowed and not allowed on various therapeutic mechanically altered diets. Peanut butter was not present anywhere on either list (allowable/not allowable) on this list for a finely chopped diet. However, bread was allowed if it was toasted and with no crust. Interview with the facility's dietitian on February 4, 2015, also confirmed that soft bread as well as peanut butter were not allowed on a finely chopped diet. A telephone interview conducted on February 4, 2015, at approximately 1:50 PM with Nurse Aide (Employee 3) revealed Employee 4 (nurse aide) summoned her to assist when the resident experienced this choking episode. When asked if she knew what foods would be allowed/not allowed on a finely chopped diet at the time of this event, stated that did not know. Employee 3 further stated that she did no receive in-service education on that subject. On February 5, 2015, at approximately 8:50 AM and 11:10 AM, telephone interviews were conducted with Employee 4 (nurse aide) and Employee 5 (licensed practical nurse) who were not available to be interviewed during the survey on February 4, 2015. When interviewed neither of these employees (Employee 4 and Employee 5) were able to specify foods that would be allowed/not allowed on a finely chopped diet and preceding this choking event both were unaware of any facility reference to identify these foods. Employee 5 (LPN) stated that she thought soft bread could be provided on a finely chopped diet. Documentation in the resident's clinical record indicated that on January 23, 2015, at approximately 3:50 AM, the resident began choking on a snack she had been provided. A nurse aide and nurse attended to the resident; a small piece of food was dislodged from the resident's airway, but the resident was not able to breathe. The [MEDICATION NAME] Maneuver (emergency technique utilized to assist in the dislodgement of an obstruction of a choking victim) was performed twice with no result. The resident's lips were turning cyanotic (blue due to lack of oxygen). She was immediately transferred to her room and a Code Blue (alert for the need for CPR) was initiated. 911 was called. CPR was initiated. The resident was suctioned several times and her airway was not able to be cleared. The ambulance arrived and took over the code. The resident was transported out of the facility at 4:25 AM with color to return and pulse. Review of the ambulance records of the resident's transport dated January 23, 2015, indicated that the ambulance was dispatched to the facility at 3:54 AM in response to the report of a resident choking, resulting in [MEDICAL CONDITION]. When the ambulance arrived at 3:59 AM the resident was without respirations and was pulseless. The resident was suctioned and intubated and absent sounds over the epigastric region. Circulation and a pulse returned at 4:15 AM. Review of hospital records records dated January 23, 2015, until the resident's death on January 26, 2015, indicated that the resident was brought to the hospital after apparently aspirating a peanut butter sandwich and going into cardiopulmonary arrest. She was admitted to the hospital's Intensive Care Unit and placed on a ventilator. She was subsequently transferred to Hospice and expired. The hospital discharge [DIAGNOSES REDACTED]. There was no evidence that the resident was served appropriate food items consistent with the resident's individualized needs for a finely chopped diet. Interview with the Administrator on February 4, 2015, confirmed that the resident was not served an acceptable food item. 28 Pa Code:211.6 (c)(d)(e) Dietary services. 28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services. Previously cited: 11/07/14, 1/08/15

Based on a review of clinical records, including hospital and ambulance records, and select facility policy, observations and staff interview, it was determined that the facility failed to demonstrate ongoing assessment of a resident's change in condition and prompt provision of necessary care and treatment for one resident sampled (Resident CR1), failed to administer a medication as ordered by the physician for one resident out of four observed during medication administration (Resident 12) and failed to carry out a physician's orders [REDACTED]. Findings include: According to the facility's policy and procedures for "[DIAGNOSES REDACTED]," which was reviewed/revised by the facility on March 19, 2014, insulin shock (also known as [DIAGNOSES REDACTED]-low blood sugar) is a condition that occurs in diabetic residents when they receive too much insulin, miss a meal or when they have too much physical activity. If you observe a diabetic resident or if a diabetic resident complains of any of the following symptoms, report it to your staff/charge nurse immediately: perspiring or sweating excessively, weakness, dizziness, hunger or excessive eating, not able to wake up or appears to be in a coma, unconscious or partially conscious (stupor). The CBG {capillary blood glucose; a measurement of the glucose (sugar) content in the blood, which is done on a regular basis in diabetes patients to determine their glucose level} will be performed. If the CBG is lower than 70, the CBG should be rechecked. The resident is to be assessed for any needs which include safety concerns. If the CBG is below 40, administer 1 tube of glucose via [MEDICATION NAME] cavity (mouth). Repeat the CBG in 15 minutes or as per physician order [REDACTED]. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], following a hospitalization for a stroke. The resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The staff were to call the physician with the results of the Accucheck testing. The physician also ordered [MEDICATION NAME] Flex Pen-Injector-Inject 10 units (a pre-filled, dial-a-dose insulin pen) subcutaneously (applied under the skin) before meals and at bedtime. Oxygen at 2 Liters per minute via a nasal cannula (a device used to deliver supplemental oxygen, which consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) continuous on every shift and to obtain an Oxygen Saturation (SPO2-amount of oxygen in the blood, normal is 100%) every shift was also ordered by the physician. The nursing documentation on October 18, 2014, at 9:25 AM, revealed that the resident was uncooperative at meal time. The staff attempted to assist, but the resident refused most of his meal, but accepted thickened liquids. The resident was non-compliant with his No Concentrated Sweets diet and was observed eating a candy bar that was supplied by the family. The resident's Accucheck result at 11:00 AM, was 180, his skin was warm, dry to touch and there were no signs/symptoms of hypo/[MEDICAL CONDITION] (low/high blood sugars) documented. The resident refused to keep the oxygen on and his oxygen saturation was steady at 95% on room air. A review of the nursing documentation entered by the 3 PM to 11 PM, Registered Nurse Supervisor (Employee 1) dated October 18, 2014, at 5:45 PM, indicated that the resident was assessed at this time. The resident was noted to be lying in bed with his eyes open. The resident was not responding to verbal, tactile (touch) or painful stimuli (sternum which is the flat bone in the middle of the chest was rubbed to try to elicit a response). The resident's pupils were non-reactive to light accommodation (did not respond to a light shined in eyes). The resident's SPO2 (oxygen saturation level) was 84% on 2 liters of oxygen via a nasal cannula. The resident's skin was warm, diaphoretic (increased perspiration) and his lung sounds were diminished in bilateral (both) upper lobes (upper part of the lung). The physician was made aware of the resident's condition and new orders were received to send the resident to the emergency room for an evaluation. According to nursing documentation entered by Licensed Practical Nurse (Employee 2) on October 18, 2014, timed at 6:36 PM, it was noted that a Nurse Aide reported that the resident was unresponsive. Upon the nurse entering the room, the resident was in bed and unresponsive to verbal and tactile stimuli. His oxygen saturation was 84% on 2 liters of oxygen delivered via a nasal cannula. The resident's blood sugar was noted as 100 (as previously stated in the prior nursing note at 5:45 PM). The resident's skin was pale and warm and the mucous membranes were pink and moist. The nurse applied 2 liters oxygen via a mask and the resident's oxygen saturation increased to 91%. The Registered Nurse was also present and assessed the resident. The nursing documentation again noted that a call was placed to the physician and the on-call physician indicated to send the resident to the emergency room for an evaluation. This entry indicated that the ambulance was notified. The nurse also noted in this entry that the resident's son called the facility and stated, "my sister just called me and said she was just in visiting dad and he was unresponsive, she was there for about an hour and that she didn't notify staff." The nursing note indicated that the facility staff were aware and are sending the resident out for an evaluation. Review of the resident's October 2014, MAR (Medication Administration Record) revealed that Accuchecks were scheduled for 7:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The 4 PM, results on October 18, 2014, were 289. The [MEDICATION NAME] Flex Pen Solution Pen Injector, 100 units/ml was scheduled for administration at 7:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. On October 18, 2014, this medication was documented as administered to the resident at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the resident's meal consumption records indicated that on October 18, 2014, the resident had refused most of the breakfast, lunch and dinner meals on that date. The resident became unresponsive on October 18. 2014, at 5:45 PM, but there was no documented evidence that the facility's nursing staff had monitored the resident's blood glucose level from the time the resident was observed unresponsive at 5:45 PM, until the ambulance staff tended to the resident at 6:55 PM. The resident's Accucheck was not repeated after becoming unresponsive nor were corresponding interventions provided according to the facility hypoglycemic policy despite the resident's minimal meal intake on that date and the administration of [MEDICATION NAME]at 4 PM. There was no documented evidence that the resident had been consistently assessed until the arrival of the ambulance or that the facility's policy for [DIAGNOSES REDACTED] had been implemented. There was no documented evidence that staff consistently attempted to apply oxygen, which had been ordered to be provided continuously. During an interview on November 7, 2014, at approximately 1:00 PM, with Licensed Practical Nurse (Employee 3) it was revealed that she was covering the floor for Licensed Practical Nurse (Employee 2) on the evening of October 18, 2014. She indicated that a Nurse Aide (unable to identify) alerted her that Resident CR1 was not waking up. She also indicated that when she went to the resident, she shook him, did a sternal rub, took a blood glucose reading which was 100 and obtained a pulse ox saturation level, which was in the low 80's. She indicated that Licensed Practical Nurse (Employee 2) came into the resident's room with the Registered Nurse Supervisor (Employee 1). Employee 3 stated that there was an issue with the resident's oxygen, relaying that the resident should have been on oxygen continuously, but was not receiving it because the concentrator was not in the resident's room. She further stated that the nursing staff did eventually find the oxygen concentrator and had applied oxygen to the resident. She also stated that it took at least 45 minutes for the ambulance to arrive and it was then that the resident's blood glucose level was rechecked (by the ambulance personnel) and the ambulance attendant indicated that it was 16. During an interview with Licensed Practical Nurse (Employee 2) on November 7, 2014, at approximately 9:05 AM, she relayed that she and the Registered Nurse Supervisor (Employee 1) simultaneously heard a page to come to the floor and were told that the resident was unresponsive. She stated that Licensed Practical Nurse (Employee 3) was already with the resident when they arrived. The Accucheck machine was reading Hi when his Accucheck was taken, so they washed the resident's hand because it was soiled and the Accucheck reading was 100. She also indicated that she was made aware that the resident had been fighting with staff and that staff had him in the hallway. She was also told by the 7 AM to 3 PM, shift nursing staff that the resident was diabetic, needed an Accucheck check and had a poor appetite. Employee 2 also relayed that she was not familiar with the resident and assumed that his oxygen was to be applied as needed and not continuously. When she wanted to apply oxygen to the resident at the time of his unresponsiveness, she had to look for a concentrator, which was located in the hallway. The nursing documentation at 11:12 PM, on October 18, 2014, noted that the resident was admitted to the ICU (Intensive Care Unit) with altered mental status. Upon review of the ambulance records it was revealed that the ambulance was dispatched on October 18, 2014, at 6:42 PM, was en route at 6:45 PM, at reference point at 6:50 PM, and at the resident at 6:55 PM. According to this report the resident was unresponsive, had a simple face mask on with O2 connected and delivering oxygen. Oxygen was applied via NRB (Non-rebreather, a type of mask used to deliver a high concentration of oxygen) at 15 Liters per Minute. A blood glucose analysis was performed and the result was very low at 16 mg/dl and 1 mg of glucose was administered to the resident. An intravenous access was also obtained and 25 gm D50% (glucose to increase blood sugar level) was administered via intravenous push and an IV of NS (normal saline solution used to replenish fluids and electrolytes) was initiated to keep the vein opened. The resident remained non-verbal, but became intermittently alert/responsive to verbal stimuli. Review of the Hospital emergency room report revealed that the resident was seen on October 18, 2014, at 8:00 PM. The resident had one [MEDICATION NAME] of D50 (glucose to increase blood sugar level). The resident's Accucheck was 16 prior to treatment and after treatment his Accucheck was 242 mg/dl. The diagnostic impression from the emergency room physician revealed that the resident had altered mental status, acute ischemic [MEDICAL CONDITION] (a disease characterized by reduced blood supply to the heart), [DIAGNOSES REDACTED] and Diabetes Mellitus Type II. The resident was found with a blood sugar of 16 for an unknown amount of time and was in critical condition. Observation of the medication administration pass on November 5, 2014, at 8:20 AM, revealed that Employee 4 (Licensed Practical Nurse) administered [MEDICATION NAME] 20 mg one tablet (treats depression) by mouth to Resident 12. A review of this resident's current physician's orders [REDACTED]. Interview with Employee 4 at the time of the observation confirmed she only administered one tablet, which was an error. A review of the clinical record revealed that Resident 57 had a physician ordered Bowel Protocol as of January 3, 2013, which indicated that if the resident had no bowel movement (BM) on Day 3 (without a BM), the staff were to administer 30 ml (milliliter) of Milk of Magnesia (MOM) by mouth. If MOM was ineffective, give [MEDICATION NAME] Suppository 10 mg (milligram) on Day 4 at 4:30 PM, and if the [MEDICATION NAME] Suppository was ineffective, give a Fleet Enema on Day 5 at 10:00 AM, and after 4 hours if no BM, notify the physician. Review of Resident 57's "Bowel Log" from August 3, 2014 to October 31, 2014, indicated that Resident 57 did not have a bowel movement from August 18, 2014, at 10:31 PM, to August 24, 2014, at 6:44 PM, on the 3 PM to 11 PM, shift when the resident had a BM. Review of nurses' notes dated August 22, 2014, at 6:49 PM, indicated that the resident received 30 ml of MOM. According to the nurses' notes dated August 23, 2014, at 7:06 AM, the resident refused the suppository. However, the nursing notes dated August 23, 2014, at 3:15 PM, indicated that the resident had an extra large hard formed BM, which was not consistent with the resident's "Bowel Log". Review of the resident's Medication Administration Record [REDACTED]. Further review of Resident 57's "Bowel Log" indicated that Resident 57 did not have a bowel movement from October 15, 2014, at 2:13 PM, to October 22, 2014, at 3:39 PM, on the 3 PM to 11 PM, shift. A review of the resident's Medication Administration Record [REDACTED]. Interview with the Nursing Home Administrator and the Director of Nursing on November 6, 2014, at 9:00 AM, confirmed that the facility was unable to demonstrate accurate and consistent implementation of physician's orders [REDACTED]. 28 Pa. Code 211.5(f)(g)(h) Clinical records. Previously cited: 12/12/13 28 Pa Code 211.12 9(a)(c)(d)(1)(5) Nursing services. Previously cited: 12/12/13, 2/27/24, 3/5/14, 4/21/14

Based on a review of clinical records and select facility policy, observation and staff and resident interview, it was determined that the facility failed to timely identify declines in skin integrity, conduct consistent and accurate wound assessment and provide prompt treatment and services to prevent deterioration of pressure sores for two of 24 sampled residents (Resident 39 and 62) Findings include: A review of the facility policy for "Wound Management and Prevention", reviewed/revised by the facility November 5, 2013, states that the wound management record is initiated at the time of discovery of a pressure related wound, a pressure ulcer investigation form will be completed if the area is a new pressure area (only an RN is to stage wound). One evaluation is completed for each area on identification and updated weekly (a minimum of 7 days). The evaluation may be completed more frequently than weekly, if there is a significant event such as a debridement (surgical cleansing of a wound) is completed or a significant change is noted prior to that weeks (7) day time frame. The procedure includes: 1. Open the Pressure Ulcer Evaluation in PCC(Point Click Care- computerized documentation utilized by the facility), document the origin of the wound. 2. Check the appropriate box to specify, if the wound was facility acquired or community acquired. 4. Document the current stage of the wound in the designated space. Documentation is to include measurement, date observed, stage it was first identified (how severe the wound is, a description of the wound, and if a physician's order was obtained and what it is. A review Resident 39's clinical record revealed admission to the facility on [DATE]. The resident was assessed to be cognitively intact with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment (The minimum data set (MDS) is a tool for implementing standardized assessment and for facilitating care management in nursing homes ) dated August 20, 2013, revealed that the resident required the assistance of two staff for transfers and bed mobility and was at risk for developing pressure sores. A review of an admission Braden scale (an assessment tool that identifies risk for pressure sore development) dated August 14, 2013 revealed that Resident 39 was at risk for development of pressure areas. A nursing admission assessment and nurses notes dated August 13, 2013, indicated that this resident did not have any skin issues noted at the time of admission. Admission physicians orders for preventative measures dated August 14, 2013, included an order to apply skin prep (film applied to the skin to help prevent skin breakdown) to the resident's bilateral heels twice a day and weekly skin evaluation by licensed nurse. A review of a nurses note dated August 23, 2013 at 2:30 PM revealed that an impaired area of skin was found the resident's lower coccyx measuring 1.5 cm; there was no stage or description of the wound noted. The next nurse's note regarding this area was dated August 26, 2013 at 9:10 AM and the area was noted as an open area to lower coccyx, Stage II pressure sore measuring 2 cm x 0.2 cm x < 0.1 cm. Current treatment to the pressure sore was noted as duoderm (a protective wound covering). The facility pressure ulcer investigation dated August 29, 2013 revealed no conclusion as to the possible causes of the pressure area. There was no indication that nursing had accurately assessed the area upon identification as there was no stage or description of the wound noted. There was no evidence that the pressure sore was monitored, assessed and treated for [REDACTED]. Nursing documentation dated August 28, 2013 at 3 PM revealed that therapy reported to nursing a pressure area on the resident's right heel. Nursing noted that the area on his right heel was as unstageable, black and boggy (soft and spongy) measuring 0.3 cm x 0.3 cm. The wound bed was not described despite the nurses note indicating that the area was black. The facility's investigation into this pressure sore dated August 28, 2013, also noted unstageable areas to the resident's right 1st, 3rd and 5th toes. The facility's conclusion was that the resident was wearing shoes that were to small. At the time of the survey, the pressure area on the resident's second toe remained an unstageable wound with eschar. During an interview December 11, 2013 at 9 AM Resident 39 stated that at the time of the injury to her foot, her shoes were too small and hurt her foot. She stated that she ambulated in her wheelchair using her feet and that she wore the shoes for a few weeks. There was no documented evidence at the time of the survey to indicate that during routine daily care that the facility's nursing staff had identified any impairment to the resident's heel or toes until therapy found the black areas on August 28, 2013, and reported the concern to nursing. The interventions the facility initiated following discovery of the pressure areas included that the resident not wear shoes, heel bows while in bed and to of load/raise heels off the bed and to continue skin prep to the pressure areas. A review of the treatment administration record and nurse aid flow records for August 2013 revealed that these interventions were not consistently implemented. A review of weekly wound tracking indicated that Resident 39 developed an unstageable pressure area on his right inner heel on September 13, 2013, measuring 0.2 cm x 0.3 cm with the wound bed described as "N/A" indicating non applicable. A corresponding pressure sore investigation dated September 23, 2013, revealed that the facility made no conclusion as to how the areas had occurred, but the resident continued ambulation in the wheelchair. The facility's investigation into the pressure sore development was dated 10 days after the discovery of the wound A review of a pressure area investigation dated October 14, 2013, revealed that the resident presented with a deep tissue injury to the right outer ankle and left posterior ankle. There was no indication of that the facility had evaluated the potential cause of the pressure areas and no evidence of a description of the wound was completed. On October 23, 2013, the resident developed an unstageable, scabbed area on his right great toe measuring 0.3 cm x 0.2 cm and although noted as unstageable the wound bed was described as presenting granulation tissue (granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size it heals). There was no evidence that the facility had explored the the origin of this pressure area or had conducted an accurate assessment of the wound appearance. The planned interventions remained skin prep to the areas and to off load her heals. During an observation of the resident's pressure sores on December 12, 2013 at 9 AM it was observed that the pressure area on the resident's right heel currently measured 2 cm x 2.2 cm, covered with eschar. There was an area on the right outer ankle measuring 0.5 cm x 0.6 cm, covered with eschar and the right second toe area 0.5 cm x 0.7 cm, covered with eschar. During an interview December 12, 2013 at 10:15 AM the Director of Nursing confirmed that the facility did not investigate the development of pressure areas in an attempt to ascertain causative factors and the DON was unaware of how Resident 39's skin breakdown had occurred. The DON was also unable to provide evidence that the facility had identified changes in the resident's skin integrity prior prior to finding unstageable pressure sores. A review of the clinical record revealed that Resident 62 was initially admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. On October 28, 2013, Resident 62 was readmitted to the facility. A review of the Admission/Readmission Screener dated October 28, 2013, revealed that the resident had a mushy (soft) heel and that the heel was dusky, boggy (spongy). No pressure ulcer investigation form was completed as directed by the Wound Management Policy for the area found. Upon readmission a physician's order was noted to off load the resident's heels when in bed. At the time of the survey, the facility did not provide any additional documentation to indicate that other measures were taken to manage the resident's dusky, boggy heels . A review of the resident's current care plan for [MEDICAL CONDITION] revealed interventions that included monitoring the extremities for signs/symptoms of injury, infection, or ulcers and monitor/document/report to the MD as needed any signs/symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, or other [MEDICAL CONDITION]. A review of Resident 62's Treatment Administration Record for the month of November 2013 revealed that the Weekly Skin Evaluation completed on November 4, 2013 revealed no areas were noted. On November 11, 2013, November 18, 2013, and November 25, 2013, it was noted that the resident had a pre-existing area, but there was no documentation to indicate what this pre-existing skin area was. At the time of the survey ending December 12, 2013, the Assistant Director of Nursing and the 2nd floor unit coordinator were unable to provide any documentation that the resident's right heel boggy area was being monitored on a routine basis. There were no wound management records available from October 28, 2013 to November 14, 2013. A nursing note dated November 14, 2013, indicated that the nurse was called to the resident's room by the nursing assistant and a blackened area on the resident's right heel measuring 8 cm x 2 cm was noted A new physician order was noted at that time to apply skin prep (skin protectant) and heelbows (booties to aid in decreasing the pressure on the heels) when in and out of bed. A review of a Pressure Ulcer Investigation form dated November 14, 2013 revealed that the resident was identified with an unstageable (full thickness tissue loss in which the wound bed of the ulcer is noted to have dead tissue) area to the right upper and lower heel. The facility's investigation indicated that it was not a recurrent ulcer. There was no evidence that the facility had determined how the resident had sustained the blackened area on the heel. A Pressure Ulcer Evaluation completed on November 18, 2013 indicated that an unstageable (full thickness tissue loss in which the wound bed of the ulcer is noted to have dead tissue), facility acquired, right heel pressure area was noted measuring eight centimeters in length by two centimeters in width, and unmeasurable depth. The area was non blancheable (blood flow does not return to the area) and the wound bed had eschar (black leathery tissue). A nursing note dated November 19, 2013 indicated that the pressure area on the resident's right heel was 7 centimeters x 2 centimeters in size, remained black and boggy with a scant amount of drainage noted. The wound management record dated November 19, 2013, indicated that the wound bed had granulation tissue. A nursing note dated November 20, 2013 indicated that the medical doctor was in to see the resident and a new order was noted to consult the wound care center for the right heel pressure area. A nursing note dated for November 22, 2013, indicated that the heel wound had deteriorated and there was a very large amount of straw colored bloody drainage noted with a black wound bed. The wound management record dated November 26, 2013 indicated that the wound bed had granulation tissue. A nursing note dated November 27, 2013, indicated that the resident's right heel wound had deteriorated, was now measuring 8 centimeters x 4.5 centimeters and had granulation tissue in the wound bed. A pressure ulcer evaluation dated December 3, 2013 indicated that the resident's wound was now measuring 8 cm x 7 cm, had a foul odor and the wound bed had eschar. A pressure ulcer evaluation dated December 10, 2013 indicated that the wound was 8.2 cm x 7 cm, no odor and had eschar, which was brown and loose. Observation of the wound on December 12, 2013, revealed that the wound had a mild odor, the area was black, with the edges slightly separated from flesh tone skin. The unit coordinator stated at that time that the wound currently measured 8 cm x 4 cm. An interview with the Assistant Director of Nursing, on December 12, 2013, at 11:00 a.m. confirmed that there were inconsistencies with the wound assessment documentation. She further stated that the facility had not investigated the possible cause of the pressure area. The ADON also verified that from October 28, 2013 to November 14, 2013, there was no monitoring conducted to observe the boggy, dusky heels to promptly identify and prevent further deterioration in the condition of the resident's heels. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 1/11/13, 5/13/13, 5/21/13, 6/6/13, 8/9/13,10/7/13, 11/15/13

Based on review of clinical records and resident incident/accident reports and staff interviews it was determined that the failed to sufficiently supervise residents with known histories of combative behavioral symptoms to prevent resident to resident altercations resulting in serious injury for one out of seven residents sampled (Resident B1). Findings include: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE]. Further review of the resident's clinical record revealed that on July 26, 2013, the resident became agitated after her Wanderguard was replaced to her right ankle because she had removed it from her wrist. The resident was described as "fiercely" attempting to remove the device. Staff then removed the device and the resident was "redirected." She subsequently grabbed another resident by the hair with both hands and attempted to "throw" her to the ground, stating that this resident had stolen the Wanderguard from her. A review of the resident's plan of care revealed that the facility identified the resident's behavioral problems and devised various interventions on July 26, 2013, to address these behaviors. Among these interventions was to provide 15 minute checks, offer diversional activities and ensure that the resident had moved to a positive subject before leaving the resident alone, ensure that the resident had de-escalated before leaving her alone, and make certain that the resident was at arms length from other residents at all times. Additionally during times of agitation the resident was to receive prompt redirection, activities for redirection and diversion and one to one supervision discontinuance only when assured that the resident had deescalated. A review of Resident B1's clinical record revealed that at approximately 5:30 p.m., on November 11, 2013, the resident was described as very agitated and standing at the nurses station without her pants on. According to staff witnesses, the resident was adamant that someone had stolen her pants. Redirection was provided, but staff described the resident as very difficult. Several attempts by staff were required to get the resident to go to her room to put pants on. Subsequently, the resident was taken to the dining room. There was no indication that the facility implemented the planned interventions related to her behavior in response to this incident. There was no indication that the facility monitored the resident's mood/behavior after this incident to determine if she had in fact de-escalated as stated on the resident's plan of care. On November 11, 2013, at approximately 6:30 p.m., Resident B1 wandered into Resident B3's room and either pushed or pulled the resident from her bed. According to Resident B3's roommate, Resident B1 came into their room and was agitated. In her statement made immediately after the incident, Resident B3's roommate stated that her curtain was drawn and she was not able to fully see the altercation, but was able to hear the exchange and heard Resident B1 saying that she paid full price for her bed here and Resident B3 had not. According to a review of the facility's investigative report into this incident, Resident B3 was found on the floor lying of her room on her back. Her right knee was bent and she was complaining of right leg and hip pain. Resident B3 was transferred to the hospital and admitted with a fracture of the right hip sustained as the result of the altercation with Resident B1. Further review of the facility investigation into the incident, revealed that the Employee 1, a nurse aide who had assisted the resident with changing her pants, completed a statement and described the Resident B1 as "agitated." Employee 2, a nurse aide, also completed a statement for the facility's investigative report of the event and she stated that she had last seen the resident at suppertime. When asked to describe what the resident was doing, she stated that the resident was "walking down and up." When asked if the resident was acting any differently before the incident, Employee 2 answered "yes" stating that the resident was "combative." She also stated that while giving the resident a shower and dressing her, the resident was upset and combative and this employee further stated that the nurse was aware of the resident's combativeness during care After the incident, the resident was placed on one to one monitoring which was discontinued on November 13, 2013. The facility then placed the resident on 15 minute monitoring checks, an intervention which according to the resident's plan of care had been in affect since July 26, 2013. There were no other changes made to the resident's comprehensive plan of care to protect the safety of other residents, including addressing the resident's new behavior of wandering into other residents' rooms. Nursing notes dated November 13, 2013, revealed that at 6:30 p.m., resident B1 had ambulated to the dining room. The nurse was attempting to administer a pain medication to the resident and the resident was apprehensive about taking the medication. The resident did so after staff reassurance. The resident's behavior was described as "continues to be erratic." The resident then proceeded toward another resident and poured water over him. A review of nursing progress notes revealed that the only intervention provided was redirecting the resident to another area. There was no indication that the facility had attempted any of the behavioral interventions planned for use after identification of behaviors or implementation of the preventative interventions, including keeping the resident an arms length away from other residents at all times. Observations of the resident on November 15, 2013, at 1:20 p.m. revealed that the resident was seated in the front of the large dayroom, in an area farthest from the door. She was observed seated in an arm chair among those in a row in front of the television and there were other residents observed to be seated all around her and closer than the planned arms length. 483.25(h) Quality of Care. Previously cited 5/21/13 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing Services Previously cited: 10/7/13, 6/6/13, 5/24/13, 5/13/13, 1/11/13. .

Based on review of clinical records and select facility policy, observation and staff interview, it was determined that the facility failed to demonstrate consistent monitoring and implementation of prompt measures to prevent the worsening of a pressure sore for one resident (Resident CR1) and failed to implement procedures for the accurate assessment of pressure sores for two residents (Resident 32 and Resident 119) out of 13 residents sampled. Findings include: Review of facility policy entitled "Wound Management Record" dated February 2010, revealed that the form is used to document the description of a pressure ulcer on a weekly basis. The policy also indicated that the form would be utilized prior to the week time frame if a significant change was noted by nurse. In addition, the policy also indicated that the physician would be notified with a deterioration in the healing process of the wound. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) and [DIAGNOSES REDACTED] with [MEDICAL CONDITION] (disorder in which your body's immune system attacks your nerves. Weakness and numbness in your extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body.) An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was moderately cognitively impaired, required assistance of staff for bed mobility, transfers and was admitted to the facility with two pressure sores. A review of a Braden scale, a tool for identifying a resident's risk for skin breakdown, dated May 23, 2011, revealed that Resident CR1 was at moderate risk for skin breakdown. Review of a care plan for skin integrity dated May 23, 2011, revealed that the resident was admitted with wounds (1 or more unhealed pressure ulcers). Interventions at that time called for staff to assess skin integrity every shift, turn and reposition every two hours and follow physician-ordered treatments. Review of an "Admission Skin and Body Assessment" and "Wound Management Record" both dated May 23, 2011, revealed that Resident CR1 was admitted with a Stage II (a wound described as partial thickness skin loss which presents as an abrasion, blister or shallow crater) pressure sore on the left buttock measuring 9 centimeters x 11 centimeters (cm) with serosanguinous drainage, superficial depth and a pink peri-wound area. The forms also indicated that the resident had a Stage II abscess on the right upper back measuring 3 x 2 cm with pink peri-wound area. On May 25, 2011, the physician examined the resident and ordered [MEDICATION NAME] gel (a type of dressing used to provide moisture in the healing process of a wound) once a day. The physician also ordered, at that time, a wound consult, which was scheduled for June 1, 2011, and upon admission, the resident had received a 2 inch air cushion for his wheel chair for pressure reduction. Review of a nurse's note dated May 24, 2011, revealed that resident CR1 was admitted on [DATE], at 4:30 p.m. and was placed on isolation precautions for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA - an infection) of a wound (the left buttock) and that the wounds were measured and assessed. On May 25, 2011, at 3:11 p.m., nursing documentation indicated that the physician examined the resident, assessed the wounds and ordered treatment of [REDACTED]. On May 27, 2011, at 3:58 p.m., a nurse wrote that wound care was given. On May 28, 2011, at 2:48 p.m., the nurse indicated that the treatments were done and on May 31, 2011, at 4:08 p.m., the nurse documented the that the dressing changes were done by the RN (registered nurse). On June 1, 8:21 p.m., the nurse's note revealed that the resident returned from surgical debridement (removal of dead, infected tissue from the wound) at the wound center. Review of the "Wound Consult Report" dated June 1, 2011, revealed that the wound, prior to debridement, was a Stage III (a wound described as full thickness skin loss involving damage to or necrosis of subcutaneous tissue) wound measuring 23 cm x 18 cm at a depth of .4 cm with moderate serosanguinous drainage. The area was described as a large black necrotic area. However, review of the facility's "Wound Management Record" dated June 1, 2011, the same day of the wound consult at the wound center, revealed that Resident CR1's left buttock pressure ulcer measured only 12 cm x 15 cm with superficial depth and no staging noted. Post debridement orders at the time of the consult, which were put into effect, included placing the resident on an air loss mattress, keeping the resident of his back except for meals, changing his treatment to Santyl (an enzyme used to break down collagen in damaged tissue) every day. Review of the Treatment Administration Record (TAR) from May 25 through June 1, 2011, revealed that the [MEDICATION NAME] treatments were done daily at 9:00 a.m. The Santyl treatments were done daily during the 7:00 to 3:00 shift from June 2 through June 7, 2011. On June 2, 2011, at 7:06 p.m., a nurse wrote that the treatment was done to the buttock. On June 4, 2011, at 2:52 p.m., the nurse indicated that the bloody dressing was changed and on June 5, 2011 at 11:05 p.m., the nurse documented completion of the dressing change. Nursing documentation on June 7, 2011, 10:18 a.m., revealed that the resident was observed having a difficult time breathing and oxygen was provided. The physician was notified and ordered the resident be sent to the hospital. There was no nursing documentation during this time period that the resident's pressure sore was worsening or of inadequate healing progress. Review of a "history and physical examination [REDACTED] The resident was receiving daily pressure sore treatments, but there was no documented evidence that the facility had completed daily skin checks as care planned, had timely identified decline/worsening of the pressure sore that became necrotic, and had promptly notified the resident's physician of lack of healing progress per policy. Interview on June 21, 2011 at approximately 2:37 p.m., the assistant director of nursing (ADON) and the quality assessment coordinator (QA)failed to provide documented evidence that the resident's wound was effectively monitored and that the lack of healing and deterioration of the wound was promptly identified and acted upon timely. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The skin and body assessment completed upon admission on June 1, 2011 indicated the resident had a reddened area on her buttocks measuring 6 cm by 6 cm. A review of the nursing progress note documentation for June 1, 2011, noted no pressure areas on the resident's coccyx, but a wound management record dated June 1, 2011, indicated that the resident had two "open areas" to her coccyx. The wound management record did not indicate the size of the areas, but noted they were new Stage I pressure areas (observable pressure related alteration of intact skin, the ulcer appears as a defined area of persistent redness). The physician was contacted for new orders that directed staff to cleanse the coccyx and buttock with normal saline solution, pat dry, and apply [MEDICATION NAME] (protectant) every shift and as needed and then re-evaluate x 14 days. There was no reference to these pressure areas in nursing progress note documentation until June 11, 2011 when the pressure sores had deteriorated to Stage II pressure areas (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater). The wound management records dated June 11, 2011, identified the pressure sores as Coccyx 1 and Coccyx 2. Coccyx 1 (without identification of location site of the wounds) was described as a Stage II .3 x .3 x .1 cm with granulation (red, bumpy, skin cells forming new blood vessels and connective tissue) and surrounding pink skin. The progress was noted as "deteriorated." Coccyx 2 was noted as a Stage II, .5 x .5 x .1 cm with granulation and pink surrounding skin. The pressure sore was also noted as "deteriorated." There was no further documentation in the nursing notes from June 1, 2011 to June 11, 2011 noting the decline in the pressure areas from "new" to "deteriorated" as noted on the wound management records. The resident's treatment was changed on June 11, 2011 to a [MEDICATION NAME] dressing every 3 days(a type of dressing containing gel-forming agents to form an absorbent, self adhesive, waterproof wafer) Interview with the assistant director of nursing on June 21, 2011 at approximately 11:30 AM confirmed that the facility failed to accurately document the location of the resident's pressure sores and failed to provide documented evidence of consistent monitoring and timely identification of decline and lack of healing, although staff were providing daily treatments from June 1, 2011 to June 10, 2011. Resident 119 had a physician's order [REDACTED]. Nursing documentation indicated that the resident had a Stage II pressure sore to his right hip from April 24, 2011 until May 11, 2011. A review of his skin check dated April 27, 2011, indicated the resident's skin was intact, however the resident had a Stage II pressure area to his right hip at this time. A skin integrity record dated June 6, 2011, indicated the resident's skin was intact with no open areas. On June 10, 2011 the resident was found to have a Stage III pressure area (Full thickness skin loss involving damage to, or necrosis of,subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) of his right hip measuring 4 cm x 2 cm, which remained at the time of the survey. During an observation of this resident on June 21, 2011, at 1:30 PM the resident was noted to have a right hip pressure area. The pressure area had a pink to red wound bed with yellow slough (dead tissue) surrounding the pressure sore. Review of the wound management record, which was completed on June 21, 2011, prior to surveyor observation, revealed that the record did not indicate the stage the pressure area was and failed to describe the wound bed, but indicated the periwound skin condition was reddened. This documentation was completed by an Employee 1, LPN. The Employee 2, RN stated during interview on June 21, 2011, at 2 PM that she actually did the assessment, but was unable to explain why she did not stage the area or document that slough was present to the reddened wound bed. The facility failed to accurately assess the resident's pressure area to assure accurate monitoring and evaluation of current treatment and healing progress. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services. Previously cited 3/4/11 28 Pa. Code 211.10(a)(c)(d) Resident Care Policies. 28 Pa. Code 211.5(f)(h) Clinical records. Previously cited 3/4/11