Every finding on record at Onyx Wellness Center

Based on review of facility policies, drug manufacture's information, interview with resident, and staff interviews, it was determined the facility failed to ensure a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in the resident missing a total of eight doses of the medication Tacrolimus 0.5 milligrams, which led to critical laboratory values and placed the resident in an Immediate Jeopardy situation of organ rejection for Resident 119. Findings include: Review of the facility's admission policy titled admission Assessment and Follow Up: Role of the Nurse (last revised September 2012), outlines the nurse's role in gathering information about a resident's physical, emotional, cognitive, and psychosocial status at admission. The information is used to begin care planning and complete required assessments, including the Minimum Data Set (MDS- federal mandated assessment tool for all residents). The nurse must greet and assist the resident, ensure comfort, and complete an admission assessment that includes recent medical history, prior hospitalizations, current diagnoses, medications, and treatments. A physical and supplemental assessment must also be conducted. Further review revealed the nurse must reconcile medications using the medication history, admission orders, previous medication administration record (MAR), and discharge summary. Findings are communicated to the attending physician, other departments, and outside services (laboratory or diagnostic services) are notified as needed. Review of the facility's medication reconciliation policy titled, Reconciliation of Medications on Admission (last revised July 2017) revealed it is designed to ensure medication safety when a resident is admitted or readmitted . The process requires staff to create an accurate and complete list of all medications a resident is taking in order to prevent medication errors, omissions, or unintended changes during transitions of care. Preparation includes gathering necessary information such as the approved medication reconciliation form, discharge summary from the referring facility, admission order sheet, prescription and supplement information obtained from the resident, and the most recent medication administration record (MAR) for readmissions. Medication reconciliation involves comparing the resident's medications before discharge with those ordered after admission. The list must include prescription and over-the-counter medications with the drug name, dosage, frequency, route, and indication for use. Continued review of the facility's medication reconciliation policy revealed the purpose of this process is to:Reduce medication errors and improve resident safetyEnsure medications continue without interruption at the correct dose and routeVerify medications are appropriate for the resident's condition and do not cause harmful interactionsEnsure accurate communication of all medications, routes, and dosages to the attending physician and care team The medication reconciliation procedure requires staff to first obtain a complete medication history from the resident, including prescription drugs, over-the-counter medications, herbal supplements, vitamins, patches, eye drops, creams, inhalers, injections, and other treatments. Information collected should include dose, route, frequency, last dose taken, and the reason for use. Residents should also identify all physicians and pharmacies used. Staff must then document all medications on the approved reconciliation form using information from the medication history, discharge summary, previous MAR (if applicable), and admission orders. Finally, the medication list must be reviewed carefully to identify and resolve any discrepancies or conflicts. Review of manufacturer's official prescribing information for the medication Tacrolimus revealed the medication is an immunosuppressant medication used to prevent organ rejection in patients who have received a kidney, liver, or heart transplant. It works by suppressing the immune system, reducing the risk of the body attacking the transplanted organ. In the product monograph it indicates, if a dose is missed, patients should contact their physician or pharmacist for advice and should not try to make up a missed dose on their own. The insert also emphasizes taking Tacrolimus exactly as prescribed and maintaining a consistent dosing schedule to reduce the risk of transplant rejection. Review of the National Kidney Foundation (NKF) article (Immunosuppressant anti-rejection medicines July 24, 2025) revealed, transplant patients must take immunosuppressant medications - including Tacrolimus - exactly as prescribed every day to reduce the risk of organ rejection. Missing even one dose can increase the risk of the immune system beginning to attack the transplanted organ. Continued review of the NKF revealed, missing any Tacrolimus medication doses may result in lower than needed blood levels of the drug, which is strongly associated with an increased risk of organ rejection or graft loss. Even a single missed dose can reduce drug exposure in the blood, although the exact clinical risk varies; consistent non adherence significantly raises the likelihood of rejection. Review of the Resident R119's admission Minimum Data Set (MDS- federally mandated assessment tool used to evaluate resident's clinical status and care needs), dated March 6, 2026, revealed the resident was admitted to the facility on [DATE], from an acute care hospital. The MDS documented diagnoses including Coronary Artery Disease (condition involving narrowing of the heart's arteries that reduces blood flow to the heart); heart failure (chronic condition in which the heart is unable to pump blood effectively); Hypertension (persistently elevated blood pressure that increases the risk of cardiovascular and kidney disease); Peripheral Vascular Disease (circulatory disorder causing reduced blood flow to the extremities); Renal Failure (condition in which the kidneys are unable to adequately filter waste and maintain fluid balance); Diabetes Mellitus (metabolic disorder characterized by elevated blood glucose levels), Acquired Immunodeficiency (indicating a weakened immune system that increases susceptibility to infections); acquired absence of the right leg below the knee and acquired absence of the left leg below the knee (indicating bilateral below-knee amputations); and status post kidney transplant, (resident previously received a donor kidney due to kidney failure and requires ongoing medical management and immunosuppressive therapy). Continued review of Resident R119's MDS assessment revealed the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. Review of Resident R119's hospital records dated February 27, 2026, revealed Resident R119 was a [AGE] year-old with significant past medical history, including End-Stage Renal Disease (ESRD-condition in which the kidneys permanently lose the ability to function adequately and require dialysis or transplantation). Resident R119 is status post renal transplant, meaning he/she received a donor kidney to replace the failed kidney(s). Prior to the transplant he/she required intermittent hemodialysis (treatment that filters waste and excess fluid from the blood using a machine when the kidneys cannot do so); this therapy has since been discontinued following the transplant. Continued review of the hospital records revealed that Resident R119 was a kidney transplant recipient, a condition that requires lifelong management with immunosuppressive therapy and close monitoring of transplant function and medication levels. The resident was prescribed immunosuppressive medications, including Tacrolimus and Mycophenolate, as documented in the medication administration record. These medications are used to suppress the immune response and reduce the risk of rejection of the transplanted kidney. Ongoing administration of these medications is necessary to support continued function of the transplanted organ. Further review of the hospital medication list for Resident R119 revealed the following order: Tacrolimus capsule 0.5 mg - take three capsules (1.5 mg total) by mouth every 12 hours. The discharge documentation indicated the medication was prescribed to prevent organ rejection. Review of Resident R119's hospital records revealed a laboratory study dated February 23, 2026, at 8:10 AM, which reported a Tacrolimus level of 10.9 ng/mL (nanograms per milliliter). The typical maintenance therapeutic range for Tacrolimus is 5-10 ng/mL. Review of Resident R119's Medication Administration Record (MAR) for February 2026 following Resident R119's admission to the facility failed to reveal an order for the medication Tacrolimus. Interview conducted with Resident R119 on March 2, 2026 at 10:00 am, revealed he/she has not received the (anti-rejection) medication since his/her admission of Friday February 27, 2026 (4 days prior). The resident stated that he/she is a kidney transplant recipient and emphasized that (his/her) immunosuppressant medication, Tacrolimus, is crucial for preventing transplant rejection. Resident R119 revealed, (he/she) has been requesting this medication since Friday, but staff did not seem to know anything about it. Continued interview with Resident R119 revealed (he/she) informed the Assistant Director of Nursing earlier that morning, who reportedly stated she would look into the issue; however, Resident R119 was given the same statement to medication request throughout the weekend. Resident R119 appeared anxious and unsettled, stating, although he/she has a lot on (his/her) mind, the priority is receiving his/her much-needed medications. Further interview with Resident R119 confirmed (he/she) has received all other prescribed medications except Tacrolimus and remains unclear why the medication has not been administered, whether due to availability issues or miscommunication. Resident R119 expressed significant concern about the risk associated with missing this critical component of his/her life sustaining medication regime. Interview conducted on March 2, 2026, at 2:15 p.m. with the Assistant Director of Nursing (ADON), Employee E17, revealed when a resident is admitted to the facility, it is the responsibility of the nursing supervisor or the admitting nurse to complete the admission process, which includes verifying the resident's medications against the hospital discharge record. The ADON, Employee E17 revealed she received notification prior to the resident's arrival and began processing the medication orders; however, the nurse on duty completed the admission and was responsible for finalizing the medication orders. The ADON, Employee E17 confirmed a miscommunication regarding the paperwork: revealing the facility did not receive specific discharge instructions from the hospital. Instead, the hospital sent a comprehensive packet containing all information from the hospital stay, including the resident's medications, medical history, and past diagnoses, without clearly indicating critical medications. Interview with Licensed nurse, Employee E11 on March 2, 2026, confirmed she was working on Friday, February 27, 2026, and was the admitting nurse for Resident R119. Licensed nurse, Employee E11 confirmed that she entered Resident R119 medication orders. Continued interview with Licensed Nurse, Employee E11 revealed she did not receive the official hospital discharge summary containing a verified medication list. Instead, she relied on a comprehensive packet of hospital records that included the resident's medications and medical history. During interview, Licensed nurse, Employee E11 reported the medication list provided to the physician was based on information from the hospital records and was not independently verified. As a result, Tacrolimus was not included in the admission medication orders. Further interview with Licensed nurse, Employee E11 confirmed the packet she reviewed did list the resident's medications, including Tacrolimus, stating, I must have missed that one. She also reported that she did not contact the hospital to confirm the medication list. Although she attempted to call, the hospital nurse was either leaving or had already left, and she did not receive a return call or a faxed confirmation. Phone interview conducted with Resident R119's physician, Employee E13 on March 3, 2026, at 09:30 am, revealed, he was notified the previous afternoon on March 2, 2026, that Resident R119 had missed doses of Tacrolimus. The physician revealed that he evaluated the resident on the morning of March 3, 2026, and ordered laboratory work to determine the resident's Tacrolimus level. He further instructed staff to hold the medication until the laboratory results were reported. Review of laboratory results dated [DATE], for Resident R119 revealed multiple abnormal findings indicating significant renal dysfunction and critically low immunosuppressant medication levels. Laboratory testing showed potassium 5.4 mmol/L (reference range 3.4-5.3), indicating mild hyperkalemia; chloride 110 mmol/L (reference range 98-107); and CO 20 mmol/L (reference range 22-32), suggesting metabolic imbalance. Kidney function studies revealed urea nitrogen (BUN) 70 mg/dL (reference range 8-23) and creatinine 3.24 mg/dL (reference range 0.60-1.50), both significantly elevated, indicating impaired renal function. The BUN/creatinine ratio was 21.6 (reference range 12-20). The estimated glomerular filtration rate (eGFR) was 20 (reference range >59), indicating severely decreased kidney function. Further review of laboratory results revealed Resident R119's Tacrolimus level was reported as <2.0, which is critically below the therapeutic range of 5.0-20.0. These findings are clinically significant because critically low levels of Tacrolimus, combined with abnormal kidney function laboratory values, can place a kidney transplant recipient at significant risk for acute transplant rejection and further deterioration of kidney function. Based on the above findings, Immediate Jeopardy to the health and safety of Resident R119 was identified and revealed to the Nursing Home Administrator and Director of Nursing on March 4, 2026, at 2:00 p.m. Immediate Jeopardy was identified due to the facility's failure to administer the necessary immunosuppressive medication Tacrolimus, which resulted in Resident R119 missing a total of eight doses and experiencing critically low blood medication levels; placing Resident R119 at immediate risk for acute transplant rejection and further deterioration of kidney function. The Nursing Home Administrator was provided with the immediate jeopardy template, and an immediate action plan was requested. On March 4,2026, the facility developed and submitted the following corrective action planResident was admitted on [DATE] with no med reconciliation within 24hour which created a medication omission (Tacrolimus)On 3/2/2026 MD was notified of omission of medication; Per MD resident will start on Tacrolimus 1.5mg q 12 hours on 3/3/2026 after Tacrolimus lab has been obtained.Call placed to resident's nephrologist on 3/2/2026 at 1624 to update on admission to facility and lack of after visit discharge summary received from hospital until today. Residents' medications orders were reviewed with facility physician and order for Tacrolimus was initiated along with labs orderedLab was done on 3/3/2026, and per MD (physician) administer Tacrolimus with same dosage and frequency and continue as prescribed.Results of labs were reviewed by MD on March 4, 2026, ordered to continue the same dose, re-do lab on 3/6/2026 and continue the scheduled follow up with Nephrology on 3/12/2026.The resident was monitored for adverse effects and remained clinically stable. All new admissions and re-admissions will have medication reconciliation reviewed by: Admitting nurse, and, a second licensed nurse within 24 hours of admission.Nurses will be re-educated by UM/designee on: medication reconciliation on new/readmissions and 24-hour audits are to be completedRandom medication administration audits will be conducted to ensure documentation matches administration by DNS/Designee.100% of new admissions and re-admissions will be audited within 24 hours.Random nurses and medication passes will be audited.Any errors identified will result in re-education and corrective counseling.Random Medication administration Audits will be conducted weekly for four weeks, then monthly for 4 months or until substantial compliance is met.Results will be reviewed by the DON and QA Committee.Trends will be tracked and additional education provided as needed.Staff education on admission policy and procedure ongoing will have 90% educated by 3/5/2026 and 100% by 3/6/2026 Review of employee list, facility policy, observations of medication administration pass, and interviews with licensed nurses on medication reconciliation were conducted. Interviews with Licensed nurses' Employee E18, E19, E20, E21, E22, and E22, confirmed they received education on the facility's medication reconciliation process. Interviews with staff demonstrated a thorough understanding of medication reconciliation procedures, including the requirement to reconcile medications upon admission, compare them with new physician orders, and ensure medications are verified and triple-checked for accuracy to prevent omissions. Verification of the implementation of the immediate action plan was completed through review of staff education records and staff interviews. The Immediate Jeopardy was lifted on March 5, 2026, at 4:06 p.m. The Immediate Jeopardy identified for Resident R119 occurred February 27, 2026, to March 4, 2026. 28 Pa. Code 201.14 (a)Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1)(6) Staff development 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa Code 211.9(2) Pharmacy 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on review of clinical records, facility documentation, and interview with staff, it was determined the facility failed to ensure a resident's snack bin was not in a location easily accessible to resident, which resulted in actual harm to Resident R87, while trying to obtain snacks, fell out of bed sustaining a laceration to the head, requiring two sutures and multiple steri-strips for one of two residents reviewed for falls (Resident R87). This deficiency was cited as past non compliance. Findings include: Review of facility policy Fall prevention, dated 2022, revealed the facility will implement fall prevention protocol as determined by resident's needs. Interview the resident and his/her family members to determine any factors that may predispose the resident for fall and/or activities that have helped prevent falls in the home environment. Review of Resident R87's clinical record revealed Resident R87 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (airway disease that restricts breathing), Hemiplegia affecting right dominant side (paralysis on one side of the body), and Cerebral Infarction (blood supply to part of the brain is blocked or reduced). Review of Resident R87's Minimum Data Set assessment (MDS- mandated assessment of a resident's abilities and care needs), dated December 31, 2025, revealed Resident R87 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of Resident R87's nursing note, dated July 01, 2025, revealed Approx. 4:15pm this nurse was in hallway when CNA (nurse aide) called me in resident room. Observed resident lying on (his/her) right side inside (his/her) snack box. Resident was reaching for (his/her) snacks. Review of Resident R87's care plan, (revised August 01, 2020) revealed Resident R87 is at risk for falls or fall related injury. Further review of Resident R87's care plan revealed an intervention, (initiated July 02, 2025) instructing staff to remove snack bin out of resident's sight and reach. Review of Resident R87's nursing note, dated February 07, 2026, revealed Resident R87 was found lying on floor on top of leg rests and snack bucket next to (his/her) bed by staff. Three lacerations to right side of head were noted. Review of facility investigation, dated February 07, 2026, revealed staff observed Resident R87 lying on the floor with (his/her) head on the floor and (his/her) legs in snack bin. Resident R87 was found to have three lacerations to (his/her) head. Lacerations measuring 4 long x 1/4 wide; 2 1/2 long x 1/4 wide; 1 long x 1/4 wide. At approx. 5:00 a.m. the nurse assistant provided Resident R87 with something to eat and drink at the resident's request from the snack bin. At 6:30 a.m. the resident attempted to lean over in bed and get himself another snack from the snack bin which was located next to Resident R87's bed triggering resident to roll off the bed onto the floor. Resident R87 was sent to emergency department of evaluation. The resident returned to the facility with two sutures and multiple steri- strips (thin bandages often used by surgeons as backup to dissolvable stiches). Review of witness statement, by nursing assistant, Employee E27, revealed Employee E27, observed Resident R87 on the floor inside (his/her) snack bin. Nurse aide, Employee E27, then moved the bed and nightstand to get to the resident, as well as lowered the bed. There was blood observed to the right side of Resident R87's head. Review of nurse aide witness statement, Employee E28, revealed she refilled the resident's snack bin then placed the bin back where she found it, under the bed on right side by the headboard. Interview on February 04, 2026, at 1:45 p.m. with Director of Nursing, Employee E2, confirmed Resident R87 fell out of bed while attempting to reach for snack bin under his/her bed. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R87's snack bin was not in a location easily accessible to Resident R87, who reached for more snacks, fell out of bed and sustained a laceration to the head, requiring two sutures and multiple steri- strips.The facility presented documentation indicating that the facility initiated a plan of correction February 7, 2026. The facility plan of correction included the following:-Resident R87 will have (his/her) snacks removed from (his/her) room and placed in Unit's Manager's office. Resident's daughter notified, plan of care updated.-Audit conducted to ensure that no other resident has intervention not keep snacks within reach of resident.-If resident has intervention to keep snacks out of reach of resident; staff will remove snacks; notify responsible party; place in area where snacks can be retrived for resident; update residents's plan of care.Education provided to staff to remove snacks from resident's room that can not manage snacks themselves.Results of the audits will be presented to QAPI (Quality Performance Improvement Plan) committee for review and recommendations to adjust, increase/decreasefrquency or update plan. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and interviews with staff, it was determined that the facility failed to ensure that residents were provided appropriate supervision while dining for 6 of 6 residents observed. (Resident R60, R92, R58, R94, R101, and R39) Findings include: Review of facility policy titled Dining Service (dated 12/19/2022) requires that all residents receive a nourishing, balanced diet served in accordance with their preferences. Staff are responsible for validating meal accuracy, assisting with meal service, monitoring residents during meals, and responding to resident needs. Trays must not be left unattended, and residents must have adequate time and support to safely complete their meals. Observations on March 5, 2026, at 08:35, revealed Residents R60, R92, R58, R94, R101, and R39 were observed in the first-floor dining area without assigned supervision. One resident made choking/grunting noises. Licensed nurse Employee E25 intervened after noticing the resident, stating that residents should not be left alone. Interview with Nursing Assistant Employee E26 who immediately came into the room, when asked about assignment, stated she was unaware she was scheduled to monitor the dining area. Interview with the DON Employee E2 confirmed on March 5, 2026 at 10:40 a.m. that it is facility protocol for nursing staff to monitor residents during all meals and that residents should never be left unattended while eating. 28 Pa. Code 211.12 (d)(7) Nursing Services

Based on review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure a baseline care plan was developed within 48 hours of admission related to dementia care for one of 22 residents reviewed. (Resident R9) Findings Include: Review of Resident 9's clinical records revealed Resident R9 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dementia (progressive disease characterized by impaired memory, thinking and behavior that affects ability to perform daily tasks), bipolar disorder (mood disorder marked by extremes in feelings of elation or depression), cerebral ischemia (lack of blood flow to brain causing damage or death to brain tissue), chronic obstructive pulmonary disease ( COPD, a progressive lung disease causing breathing difficulties), and difficulty in walking. Review of Resident R9's clinical record revealed Resident R9 had a care plan dated January 15, 2026, that included interventions related to focus areas of potential for discomfort/side effects related to use of psychotropic medications, alterations of respiratory status, COPD (chronic obstructive pulmonary disease), and interventions pertaining to risk for falls. Further review of Resident R9's care plan revealed no interventions in place to provide the necessary care to properly care for Resident R9's dementia care needs. Interview with Employee E2, Director of Nursing, on March 5, 2026, at approximately 1:00 PM confirmed no care plan was in place related to Resident R9's dementia care needs. 28 Pa. Code 211.10(d) Resident care policies

Based on review of clinical records, facility policies, job descriptions, medication documentation, and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure that a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in a resident missing a critical immunosuppressive medication and placing the resident an Immediate Jeopardy situation. (Resident 119) Findings include: Review of The Director of Nursing (DON)'s job description revealed that the DON is responsible for the overall planning, coordination, and supervision of nursing services, including ensuring that nursing staff perform accurate admission assessments, medication reconciliation, and timely administration of physician-ordered medications. The DON is expected to oversee staff performance, implement clinical policies, monitor compliance with federal, state, and local regulations, and facilitate interdisciplinary communication among physicians, therapists, and support personnel. This role requires the DON to make independent clinical decisions, respond to emergencies, and maintain systems that protect resident safety and quality of care. Review of the Nursing Home Administrator (NHA)'s job description revealed that the NHA is responsible for the overall operation of the facility, including ensuring compliance with all regulatory requirements, implementing operational policies, managing staffing, and overseeing coordination among departments. The NHA must ensure that systems are in place to provide safe and effective care, supervise leadership staff including the DON, address deficiencies in clinical practice, and maintain accountability for facility-wide adherence to policies and procedures. The NHA also serves as the primary liaison with regulatory agencies, residents, families, and the public, ensuring that resident safety and quality of care remain the facility's top priority. Review of the facility's policies, including admission Assessment and Follow Up: Role of the Nurse and Reconciliation of Medications on Admission, requires that nursing staff obtain a complete medication history, reconcile medications with hospital discharge summaries, previous MARs, and physician orders, and ensure critical medications are administered promptly. These policies are essential to prevent medication omissions, ensure continuity of care, and protect residents from harm. Review of Resident R119's clinical record revealed that the resident was a kidney transplant recipient. The resident was admitted to the facility on [DATE] with orders to continue Tacrolimus 1.5 milligrams (mg) by mouth every 12 hours, a critical immunosuppressant medication necessary to prevent organ rejection. Review of the Medication Administration Record (MAR) and interviews revealed that there was no order for the medication Tacrolimus entered upon admission, and the resident did not receive the medication from February 27 through March 3, 2026, missing a total of eight doses. Review of laboratory results obtained on March 3, 2026, revealed critically low Tacrolimus level of <2.0 ng/mL, significantly below the therapeutic range, placing the resident at immediate risk for transplant rejection and kidney failure. Based on the deficiencies cited in this report, the NHA and DON failed to ensure the essential functions and duties of their position, contributing to an Immediate Jeopardy situation. Refer to F760 28 Pa. Code 210.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.20 (a)(1)(6) Staff development28 Pa Code 211.12 ((c)(d)(1)(3)(5) Nursing Services

Based on record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents' advance directives and physician orders for Life-Sustaining Treatment (POLST) were followed according to the residents' expressed wishes for 2 of 2 residents reviewed with advance directives. Resident R116 and R121)Findings include: Review of the facility's Advance Directives Policy dated December 19, 2022, indicated the facility is responsible for respecting residents' rights to participate in medical decision-making and to exercise self-determination regarding their care. The policy states that residents will be informed of their right to accept or refuse medical or surgical treatment and to create an advance directive in accordance with the Patient Self-Determination Act (PSDA) and state law. The facility will provide written information about advance directives upon admission, or to the resident's representative if the resident is incapacitated. The policy further states that care will not be conditioned or withheld based on whether a resident has an advance directive. Any advance directive must be maintained in the resident's medical record, and admission staff must document whether the resident has an advance directive and that information regarding advance directives was provided during the admission process. If a resident expresses a desire to revise a prior advance directive, the change must be documented and a revised directive submitted in accordance with applicable regulations. Review of the Pennsylvania POLST (Physician Orders for Life-Sustaining Treatment) is a medical order designed to ensure that a patient's treatment preferences, including life-sustaining interventions and comfort measures, are clearly documented and followed across healthcare settings. At the time the POLST is completed, any existing advance directives must be reviewed. The form must be signed by a physician and the patient or authorized surrogate, though verbal physician orders are acceptable if followed by a physician signature per facility policy. If the patient's condition changes, the patient or surrogate must be contacted to update the POLST. Oral fluids and nutrition should be offered when medically feasible, and comfort measures must be provided in an appropriate setting. Patients or authorized surrogates may revoke or modify any part of the POLST at any time, including withholding or withdrawing life-sustaining treatment. The POLST should be reviewed periodically, and if it becomes invalid or is replaced, the previous form must be voided by marking through sections A-E and writing VOID across the form. If any section is incomplete, providers should follow other appropriate methods to determine treatment preferences. Review of Resident R 116's POLST (Physician Orders for Life-Sustaining Treatment) revealed that the resident elected DNR (Do Not Resuscitate), Do Not Attempt Resuscitation and DNH (Do Not Hospitalize) when not in cardiopulmonary arrest, with a focus on comfort measures only. Orders include the use of medications by any route, positioning, wound care, and other interventions to relieve pain and suffering. Oxygen, oral suction, and manual treatment of airway obstruction may be used as needed for comfort. Resident R 116 is not to be transferred for life-sustaining treatment but may be transferred if comfort needs cannot be met in the current location. Review of Part C (Antibiotics) indicates that antibiotics may be used only if life can be prolonged. Review of Part D (Artificially Administered Hydration/Nutrition) indicates that oral fluids and nutrition should be offered if feasible, but Resident R116 has elected no artificial hydration or nutrition by tube. The form was signed by the physician, the resident, and a registered nurse on August 9, 2021, acknowledging that the orders reflect the resident's known desires and best interests. Review of Resident R 116's Minimum Data Set (MDS- federal mandated assessment tool) dated June 30, 2025, revealed the resident had been residing in the facility since 2021. The resident scored 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Documented diagnoses included cerebrovascular accident (stroke- a condition caused by interrupted blood flow to the brain resulting in neurological impairment); diabetes mellitus (failure of the body to produce insulin); and hyperlipidemia (a condition characterized by elevated levels of fats or cholesterol in the blood, which increases the risk of cardiovascular disease). Review of the Resident R116's care plan revealed a focus area addressing advance directives. The care plan indicated the resident's code status as Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) with comfort measures only. The care plan directed staff to refer to the resident's POLST form for specific medical orders. Review of the POLST indicated it was initiated on February 16, 2022, and revised on July 22, 2025. Interventions included that the resident's physician would periodically review the POLST form and the resident's code status during routine visits with the resident. Review of Resident R 116's nursing notes dated January 3, 2026, at 2:46 PM, the resident was febrile and monitored for cold-like symptoms. On January 5, 2026, at 6:59 PM, nursing observed increased respiratory effort, diminished breath sounds, wheezing, elevated blood pressure (183/96 mmHg), temperature 103.7 Fahrenhiet, and heart rate 114 bpm (beats per minute). The physician was notified. Continued review of nursing notes dated January 6, 2026, at 11:19 AM, the physician evaluated the resident in-house, new orders were received for immediate blood work and the resident's representative was notified and updated regarding the plan of care. Laboratory results later showed sodium 157 mmol/L, and the physician on call was contacted; the resident representative was again notified. On January 7, 2026, at 10:27 AM, laboratory results and chest X-ray results were reviewed. The chest X-ray showed early changes suggestive of pneumonia, slightly worse than prior imaging. New orders for IV (intravenous) fluids and repeat BMP were implemented. The resident representative was informed of the findings and interventions, including the plan to normalize sodium levels. On January 8, 2026, at 11:44 AM, the Social Services Department notified the Director of Nursing that the resident's guardian had changed the code status to full code. The resident had a previously signed POLST indicating DNR (do not resuscitate/DNI (do no intubate)/DNH (do not hospitalize) with comfort measures only, signed prior to guardianship. The physician assistant was notified, and resident was sent to the hospital. Interview with Social Worker, Employee E6, on March 5, 2026, at 1:00 PM, she reported that she called the resident's guardian, who instructed her via phone to change the resident's code status to full code. She immediately notified the nursing department of the guardian's request. The social worker Employee E6 acknowledged that she acted on the guardian's verbal instruction without obtaining proper documentation, verifying authority, or ensuring a physician-signed POLST update. She also stated she believed there were two POLST forms in the resident's chart but was unable to provide or locate the second form. The resident's guardian stated he has another POLST but was unable to provide it. He acknowledged that the POLST in the resident's clinical record was signed by the resident prior to guardianship and that after becoming guardian, he instructed the facility to change the POLST to full code, but no signed or documented POLST exists in the chart. The guardian claimed he had authority to change the resident's code status based on verbal conversations with the resident. Review of the clinical record revealed that the resident's representative was notified throughout the resident's decline, but no code status change was documented until the physician assistant sent the resident to the ER, and there is no written record of the POLST change. Review of Resident R121's clinical record revealed Resident R121 was admitted to the facility on [DATE] with a diagnosis of heart failure (condition where the heart muscle can't pump blood as well as it should), protein calorie malnutrition (happens when you are not consuming enough protein and calories), and cerebral infarct (also known as an ischemic stroke, is the death of brain tissue due to lack of blood flow). Review of Resident R121's Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs), dated August 25, 2025 revealed Resident R121 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident R121's POLST (Portable Orders for Life Sustaining Treatment), signed August 25, 2025, revealed Resident R121 and RR (resident representative) discussed/elected DNR (Do Not Resuscitate), Do Not Attempt Resuscitation, and DNH (Do Not Hospitalize). When not in cardiopulmonary arrest, resident elected for comfort measures only, which include the use of medications by any route, positioning, wound care, and other interventions to relieve pain and suffering. Oxygen, oral suction, and manual treatment of airway obstruction may be used as needed for comfort. The resident is not to be transferred for life-sustaining treatment but may be transferred if comfort needs cannot be met in the current location. Review of facility investigation, dated August 31, 2025, revealed on August 31, 2025 Resident R121 was found in his/her room on the floor. Resident R121 was laying on right side with head at foot of bed. Resident R121 was noted to have hematoma on right side of head and nose area. The nurse then called 911 to have Resident R121 evaluated at the emergency room (ER). Further review of facility investigation revealed agency nurse did not follow resident's POLST for DNR/DNI/DNH and did not obtain an order to have resident sent to ER for further evaluation. Agency nurse called 911 and left voicemail to office . Resident was at the facility on comfort measures only and was made DNR/DNI/DNH signing a POLST form on 8/25/2025. Interview on March 05, 2026 at 11:35 p.m. with Director of Nursing, Employee E2, confirmed Resident R121's POLST was not followed on August 31, 2025. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa Code 211.2 (d)(7) Medical Director 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on observation and staff interviews, it was determined that the facility failed to ensure safe and sanitary food storage practices on four of the facility's four nursing units. Findings include:Review of facility nutrition services practice manual food policies titled Storage dry Storage revealed store perishable foods in the refrigerator and or foods kept refrigerated by the manufacturer maintain refrigerator temperatures at thirty-four thirty-eight degrees storable meat away from vegetables and cooked foods label products with delivery date including month and year the product was received store leftover foods and container which are shallow to facilitate cooling impervious and dishwasher safe label all leftovers with recipe name and date of storage discard refrigerator leftovers after seventy-two hours cover all pre-dish items with plastic wrapper foil to prevent all flavors drying and or cross-contamination A review of the facility's Nutrition Services Practice Manual, under Food Storage and Dry Storage Policies, revealed the following requirements:Perishable foods must be stored in the refrigerator or units and kept at manufacturer-recommended temperatures, with refrigerators maintained between 34-38 F.Raw meats must be stored separately from vegetables and cooked foods to prevent cross-contamination.All products must be labeled with the delivery date, including month and year of receipt.Leftover foods must be stored in shallow containers to facilitate cooling, and containers must be impervious, dishwasher safe, and labeled with the recipe name and date of storage.Refrigerator leftovers must be discarded after 72 hours.All pre-dish items must be covered with plastic wrap or foil to prevent flavor transfer, drying, and cross-contamination. During the initial tour of the facility kitchen on March 2, 2026, at 9:30 AM, several food storage concerns were observed. Sour cream and salsa containers did not have a date indicating when they were opened or received. Coleslaw dressing and relish were also observed without date labeling. A container of PAM cooking spray, received on February 25, 2026, was not labeled with an open or use date. In addition, a pan of diced chicken prepared for chicken salad intended for use that evening did not have a preparation or use date. Three trays of Jell-O were observed uncovered and without date labeling. Containers of applesauce and sliced apples were also not dated. A container of jelly was dated February 21, which exceeded the seven-day storage guideline per facility policy and should have been discarded. Observation of the dry storage area revealed that rice and flour bins contained scoops left inside the bins, which may pose a risk for contamination. An interview was conducted with the Food Service Director (Employee E9) at the time of the above observations. The Food Service Director confirmed the observations, acknowledging that several food items were not properly dated or covered in accordance with facility policy. 28 Pa Code 201.18(b)(1) Management28 Pa. Code 211.6(f) Dietary Services

Based on observations and staff interview it was determined that the facility failed to maintain essential kitchen equipment in clean and sanitary conditions related to the ice machine. Findings Include: A tour of the main kitchen was conducted on May 20, 2025, at 9:20 a.m. with Food Service Director, Employee E16. Observations inside the ice machine revealed the white, plastic, inner lining had a blackish/brown stain along the bottom half perimeter. Further observations of the area surrounding the ice machine revealed the plastic baseboard along the wall adjacent (facing) the ice machine was peeling off and has significant build-up of dirt and debris. The floor underneath and surrounding the area of the ice machine was dirty and had a significant build up of dirt and debris. Three to four fruit flies were hovering the area of the ice machine. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for two of two nursing units (First floor and Second floor nursing units). Findings Include: Observations during the initial tour on May 20, 2025 at 1:01 p.m. revealed Resident R92's room had a NPO (nothing per mouth) sign posted at the head on the resident's bed on the wall. The sign had nine residents information listed. Four residents listed as NPO Four residents listed as Necar Thick One resident listed as Honey. Two residents listed as No straws Two residents listed as Do Not Leave Liquids at Bedside Observations on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a Thickened liquids sign posted in the dining area on the left when you walk in on the wall. Interview with Resident R1 on April 1, 2025, at 11:30 a.m. stated facility always serves the food on the trays for meals. Observations during a follow up day on May 22, 2025 at 11:53 a.m. on the second floor unit in the activities/dining room during lunch revealed residents were being served their meals on plastic trays. Further observation for dining area revealed a Thickened liquids sign posted in the dining area on the left when you walk in on the wall. Interview with Regional Employee E3 on May 22, 2025 at 11:56 a.m. confirmed the Liquid Diet Posting was posted on the dining room wall area on the left when you walk in. 28 Pa. Code 201.29 (j) Resident Rights 28 Pa. Code 211.12 (d)(1) Nursing Services 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on observations, resident interviews, and staff interviews, it was determined that the facility did not ensure clean and homelike environment was maintained in resident care areas and dining experience for two of two nursing units observed (First Floor and Second Floor). Findings Include: Observations on May 20, 2025, at 10:20 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed a red paint colored on the wall next to the A-Bed. Observations on May 20, 2025, at 10:40 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed the baseboard along the perimeter of the wall behind the B-bed was peeling off. Observations on May 20, 2025, at 10:51 a.m. revealed the resident had a bathroom with a leak behind toilet, on the floor was a wet saturated towel between the sink and toilet area along the wall. On the wall in the bathroom there was also a broken piece of plastic from the plastic box that holds gloves. The box was broken so that no gloves could be held inside of it. Observations on May 20, 2025, at 11:03 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed the bottom drawer on the right side of the closet was broken and hanging off. Observations on May 20, 2025, at 11:08 a.m. revealed Resident R38's room revealed the air conditioning vents had heavy caked on dust. Observations during the initial tour on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals in this room. There was one hand sanitizer located on the wall in the dining room which was not working at the time. Observations on May 20, 2025 at 1:01 p.m. of Resident R92's room revealed the resident's bathroom had several floor tiles that were peeling. The resident was laying in her bed and at the head of the bed underneath the bed there was residue from dried up tube feeding formula and caked up dirt visible on the floor and on the baseboards. To the left of Resident R92's bed was one fall mat which also had dried up tube feeding formula. Continued observations on May 22, 2025 at 11:53 a.m. on the second floor (upper floor) unit revealed Resident R80 came out to the nurses station and said that aide is sitting down in there and she said, I am not passing out trays because I am agency staff and I don't know anybodys names. After entering the dining/activities room on the second floor nurse aide Employee E14 was seen getting up out of a chair with a cellphone in one hand a bag of chips in the other. Employee E14 was asked her name and stated it. When asked if it was her first time working at the facility Employee E14 stated, no it's not but I don't know these peoples names and diets and then walked out of the dining room area. Nurse aide Employee E15 was also in the room in the same area as Employee E15 and started to attempt to open up to food truck and read to lunch meal tickets. Employee E15 was asked if she was familiar with the residents in the room and she stated, some of them. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the POLST form accurately reflected the resident's code status for one of 32 residents reviewed (Resident R15). Findings Include: Review of Resident R15's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of Senile Degeneration of Brain ( a decline in an individual's memory, behavior, and cognitive abilities) and Chronic Obstructive Pulmonary Disease (a progressive lung disease characterized by difficulty breathing, often caused by long-term exposure to irritants). Review of Resident R15's electronic medical record revealed a physician order dated [DATE], that specified the resident's code status was Do Not Resuscitate (DNR - allow natural death if resident found with no pulse and is not breathing), Do Not Hospitalize (DNH), and Do Not Intubate (DNI). Further review of Resident R15's electronic medical record revealed a form, Physician Orders for Life Sustaining Treatment (POLST), dated and signed by the physician on February 14, 2019, that indicated the resident's code status was a CPR/Attempt Resuscitation (Cardiopulmonary Resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest). Interview with the Director of Nursing , on [DATE], at 12:50 p.m., confirmed the POLST form did not accurately reflect the physician order for code status on Resident R15's electronic medical record. 28 Pa Code 211.10(d) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services.

Based on review of clinical records and staff interview, it was determined that the facility failed to timely arrange a podiatry appointment for one of two residents reviewed for foot care (Resident R47). Findings Include: Review of Resident R47's comprehensive care plan revised December 3, 2022, revealed the resident had potential for impaired skin integrity related to congestive heart failure (heart is not able to pump enough blood to meet the body's needs causing fluid build up in the body), type 2 diabetes mellitus (body's inability to effectively process sugars (glucose) causing high blood sugar levels), and hypertension (high blood pressure). Intervention dated January 5, 2025, included to consult podiatry as ordered. Review of Resident R47's clinical record revealed a nursing note dated December 5, 2024, that indicated upon assessment with the wound team, Resident R47's right great toe was noted with ingrown toenail and touching second toe. Per the note, treatment was applied and podiatry aware and will follow-up. Review of Resident R47's clinical record revealed medication administration note dated December 9, 2024, consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinue) when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD for right foot greater and first toe. Review of Resident R47's clinical record revealed medication administration note dated December 14, 2024, consult appointment needed with podiatry ASAP (as soon as possible) d/c (discontinued) when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD (physician) for right foot greater and first toe. Review of Resident R47's clinical record revealed medication administration note dated December 15, 2024, consult appointment needed with podiatry ASAP d/c when complete. Further review of the note revealed [Resident R47] needs consult for podiatry per MD for right foot greater and first toe. Review of Resident R47's clinical record revealed medication administration note dated December 20, 2024, consult appointment needed with podiatry ASAP d/c when complete. Review of Resident 47's entire clinical record revealed no documented evidence podiatry was consulted as ordered by the physician. Further review of Resident R47's clinical record revealed a nursing note dated December 30, 2024, that the resident complained of feet pain and upon assessment by the nurse Resident R47 was noted with ruptured blisters to bilateral feet. Podiatry was in the building and consulted to assess the resident. Interview on May 22, 2025, at 1:07 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not have documented evidence that a podiatry consult was timely ordered per the physician orders. 28 Pa Code 211.10(d) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services.

Based on observations, review of facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E9, E10 and E11). Findings include: Interview on May 20, 2025, at 10:35 a.m. Resident R89 stated, agency staff don't give good care. Interview on May 20, 2025, at 11:02 a.m. Resident R27 stated, agency staff don't do anything for us. Interview on May 20, 2025, at 12:36 p.m. Resident R37 stated, agency staff just sit around and don't give us care. Interview on May 21, 2025, at 9:37 a.m. Resident R80 stated, agency staff don't give us care and never give showers at night. Interview on May 21, 2025, at 11:14 a.m. Resident R44's family member stated, agency staff don't know residents' care needs and don't reapproach Resident R44 when she's having a tough day or declines care. Review of facility staffing schedules revealed that Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; worked at the facility on May 20, 2025, as agency nursing staff. Observation on May 20, 2025, at 9:28 a.m. revealed Employee E9, agency licensed nurse, prepare and administer medications to Resident R103. Interview, at the time of the observation, Employee E9, agency licensed nurse, stated that it was her first day working at the facility and that she did not receive any trainings or skills competency evaluations by the facility. Observation on May 20, 2025, at 11:00 a.m. revealed Employee E10, agency licensed nurse, prepare and administer medications to Resident R91. Interview, at the time of the observation, Employee E10, agency licensed nurse, also stated that it was her first day working at the facility and confirmed that she did not receive any trainings or skills competency evaluations by the facility. Review of personnel files for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide; revealed that there were no trainings or skills competency evaluations that were conducted by the facility available for review at the time of the survey. Interview on May 22, 2025, at 11:46 a.m. the Director of Nursing confirmed that the facility did not conduct any skills competency evaluations for Employee E9, licensed nurse; Employee E10, licensed nurse; and Employee E11, nurse aide. 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 32 residents reviewed (Resident R 67). Findings Include: Review of the admission sheet of Resident 67, revealed that Resident R67 was admitted to the facility on [DATE], with diagnoses including Dementia (Dementia is a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). On May 21, 2025, at 1:55 p.m., review of Resident R67's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R67. During an interview on May 21, 2025, at 2:05 p.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received. The facility overlooked to develop and implement a person-centered care plan to include and support Resident R67's dementia care needs. 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.12 (d)(1)(3)(5) Nursing service

Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information, readily accessible on two of two nursing floors. (1st Floor, 2nd Nursing Units) Findings Include: Review of facility policy titled, Resident Rights with a revision date of August 31, 2022 states, Purpose: Ensures residents know that they can lodge complaints without reprecussions. During an observation of First Floor nursing units on May 20, 2025 at 11:00 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the lobby area revealed there was a standard size page for the contact information for Department of Health but the phone number was outdated in between the exterior door of the lobby and the interior glass door of the lobby. Resident Council meeting was held on May 22, 2025, at 10:30 a.m. on the first floor with nine awake, alert, and oriented residents. Several residents reported that they were not aware of where the information on how to contact the State Department of Health is in the building. (R50, R74, R78, R93). A tour was taken with the Director of Social Services, Employee E12 Observation of the First Floor Nursing unit with the Employee E12 on May 22th at 1:05 p.m. to look for required notices and postings. A tour of the first floor (bottom floor) nursing unit revealed there were no required Department of Health contact information posted. The Director of Social Services, Employee E12 showed the surveyor a clear plastic covering next to the elevator that did not have a paper in it and stated, it is usually here, but we have one resident and sometimes he takes the paper. The tour of the second floor (top floor) revealed there was another clear plastic covering next to the elevator that did not have a paper in it. Further review of floor revealed there was one posted size posting for the Department of Health but it was written in Spanish. The Director of Social Services Employee E12 confirmed 2:03 p.m. that there were no postings for the required Department of Health contact information in English on either on the nursing units (first floor or second floor). Interview with the Nursing Home Administrator Employee E1 on May 22, 2025 at 2:09 p.m. confirmed that there was no posting for the Department of Health contact information in English in the facility due to renovations of the bathrooms over the weekend and the signs had been taken down. 28 Pa. Code: 201.18(a)(e)(1) Management 28 Pa. Code: 201.18(b)(1) Management

Based on observations of care and services, interviews with residents and staff, review of clinical records and policy and procedures, it was determined that the facility failed to develop and implement a comprehensive care plan to meet the behavioral health and medical needs of one of seven residents reviewed with anxiety disorder, bipolar disorder, post traumatic stress disorder and spinal stenosis. ( Resident R1) Findings include: A review of the policy titled drug screening and drug searches for Residents dated February 24, 2025 revealed that it was the responsibility of the facility staff to maintain an environment for the residents that was free of medical marijuana on it's premises. The policy indicated that illicit drugs may include cannabis, hallucinogens opiates or amphetamines. The policy indicated that a resident found using drugs illegally would be referred to drug counseling. Clinical record review revealed a comprehensive quarterly assessment MDS(an assessment of care needs) dated February 14, 2025 that indicated that Resident R1 was cognitively intact. The assessment also indicated that this resident had diagnoses of anxiety disorder, depression, manic depression (bipolar disease) and PTSD (post traumatic stress disorder). Clinical record review revealed that Resident R1 had been identified by the PA (physician's assistant) on February 20, 2025 as being prescribed Zoloft (antidepressant) and Xanax (antianxiety agent) as needed for anxiety disorder. The PA also documented that this resident had spinal stenosis pain and was prescribed tramadol as needed for pain management. The PA indicated that this resident had bipolar disorder, major depression and post traumatic stress disorder. Clinical record review indicated that the psychologist documented on February 24, 2025 that Resident R1 had anxiety disorder from outside stressors; however the stressors were not specifically documented. The psychologist mentioned that Resident R1 was experiencing trauma from the loss of her father to cancer. The psychologist indicated that this resident was paranoid, anxious and depressed. There was no care plan developed or revised to address anxiety with outside stressors, post traumatic stress disorder, death of a family member or paranoid and anxious behavior for Resident R1. Clinical record review indicated that on March 11, 2025 the nursing staff found Resident R1 sleepy. The nursing staff member indicated that the resident had to be encouraged to wake up for meals and medication administration. Resident R1 was observed unsteady on her feet while ambulating. The nursing staff indicated that Resident R1 was encouraged to lay down and rest for safety reasons. Clinical record review indicated that on March 12, 2025 the nursing staff noted Resident R1 was not arousable. The resident was aroused and was then fell back to sleeping. The nursing staff noted that the resident's room smelled of marijuana. Resident R1 was assessed to be lethargic. Resident R1 handed nursing staff a vape pen containing marijuana oil. Resident R1 admitted to using a vape pen containing marijuana oil. Clinical record review for Resident R1 revealed a psychiatry progress note dated March 21, 2025 that indicated Resident R1 was requesting help with her anxiety symptoms. The psychologist indicated that relaxation techniques were discussed with Resident R1 on March 21, 2025. There was no indication what the relaxation techniques were, when to use or how often. There was no documentation to indicate that any relaxation techniques were added to the care plan to address Resident R1's mental health needs. Clinical record review indicated that on March 28, 2025 the physician indicated that resident was found intoxicated with marijuana vaping device in her room. The physician indicated that Resident R1 was found to be intoxicated again and her medications Xanax and tramadol would continue to be held; because of the negative, intoxicating and intensified effects of taking these drugs with marijuana. Interview with Resident R1 at 1:00 p.m., on April 16, 2025 revealed that the resident was unaware how she could cope with her continued anxiety without the use of her as needed Xanax (a benzodiazepine used to treat anxiety or panic disorders). The resident was also speaking about having pain in her right hip and back that she used tramadol (an opiod pain medication) to relieve the pain. Observations of Resident R1 at 1:00 p.m., on April 16, 2025 revealed that she was feeling nervous about her new roommate. Resident R1 said that she likes to use the fan at night and that her roommate does not like it blowing on her at night, while she was sleeping. Resident R1 was also worried about her lack of treatment of the pain in her lower back: how would this be treated. Review of Resident R1's clinical record and care plan revealed that there were no interventions developed to address the resident's chronic anxiety disorder and spinal stenosis pain of her back and right hip. Interview with the director of nursing Employee E1, and the licensed practical nurse Employee E3 who was most familiar with the care of Resident R1 at 11:30 a.m., on April 16, 2025 confirmed there was no person centered care plan interventions implemented to meet the preferences and goals of Resident R1 while addressing the medical, mental and psychosocial needs of this resident. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(d)(2)(3)(5) Nursing services 28 PA. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure adequate supervision of two staff members was provided during incontinence care to Resident R1. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip for one of seven residents reviewed. (Resident R1) Findings include: Review of facility policy titled Turning and Positioning, revised 2024, revealed assistance must be obtained in turning and repositioning residents/patients who require more than one-person assistance. Do not attempt to turn and reposition by yourself. During care, resident will be turned safely in bed, allowing for proper space to safely turn resident consistent with resident's plan of care. Clinical record review revealed Resident R1 was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (lung condition caused by damage of airways that limit airflow), lack of coordination, abnormalities of gait and mobility, and Dementia (progressive degenerative disease of the brain). Review of Resident R1's Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs) dated October 14, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Further review of Resident R1's MDS assessment under section G- Functional Status, revealed Resident R1 was assessed as requiring two plus person physical assist for bed mobility. Bed mobility in the MDS assessment is defined as how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Interview on January 21, 2024, at 3:00 p.m. with Employee E2, MDS Coordinator, revealed Resident R1 coded for a two plus person physical assist for bed mobility based on a look back period of nursing aides documentation. The doucmentation revealed Resident R1 required four out of seven days of two plus person physical assist for bed mobility. Review of Resident R1's care plan dated March 10, 2021 revealed Resident R1 had an ADL (Activities of Daily Living) self care performance deficit. Interventions related to bed mobility included assistance of two staff to turn and/or reposition. Review of Resident R1's nursing note dated December 28, 2024, at 7:38 p.m. indicated, This nurse was notified by care aide while providing care to resident, resident rolled onto the floor, this nurse notified the nursing supervisor went into the room to assess the resident. Resident had a laceration to the LLE (left lower extremity), and placed a bandage over the site/ neuro checks started. MD (physician) notified. Continued review of nursing documentation dated December 28, 2024, at 8:17 p.m. revealed, Resident was in bed with a small cut on [his/her] left shin measuring 0.3cm (centimeters) x 0.3 cm Aide then reported the resident rolled out of bed when she turned [him/her] over to change [his/her] brief. Resident c/o (complaint/of) the left arm hurting [her/him]. The nurse assessed the area but no matter where I touched [her/him], [she/he] said it hurt. The on-call physician was notified and ordered x-rays of wrist, elbow, and shoulder to be done immediately. Review of nursing note dated December 29, 2024, at 5:33 p.m. revealed, at 7:00 p.m. x-ray results were received and revealed an oblique fracture neck of the the left humerus (arm) without dislocation, left wrist possible occult fracture of the med left radius, left hip suspicious for fracture intertrochanteric region left femur (hip) without dislocation. Review of nursing note dated December 30, 2024, at 7:48 a.m. revealed that Resident R1 was transferred to the hospital via 911 (Emergency Medical Services). Continued review of nursing documentation dated December 30, 2024 at 7:18 p.m. indicated the resident was admitted into the hospital with a diagnosis of proximal end of left humerus. Review of the facility's investigation into the fall incident sustained by Resident R1 included a typed statement form Nurse aide, Employee E3, which revealed, on 12/28/2024 I was providing care for the resident and asked [her/him] to roll on [her/his] side and as [she/he] turned [herself/himself] rolled out of bed. I called for the nurse. Interview with Nursing Home Administrator, Employee E1 conducted on January 21, 2024, at 12:30 p.m. revealed that Employee E3 was no longer working at the facility. Employee E3 was not available for interview. The facility failed to ensure adequate supervision of two staff members was provided to Resident R1 while turning/repositioning resident during incontinence care. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, interviews and review of facility documentation, it was determined that the facility failed to ensure a resident safe, comfortable and home like environment for 9 out of 9 residents reviewed (Resident R1, R2, R3, R4, R5,R6, R7, R8, and R9). Finding include: Review of the facility policy, Environment of Care, with a revision date of September 2024 indicated that the purpose of the policy is to ensure that the facility's building and equipment are repaired in an effect and efficient manner and to ensure a safe and healthful workplace, and to ensure that facility work orders are completed in order of their priority. Review of the policy also indicated that work request should be placed in TELS (a computer system used by facility staff to input repair/replacement request, etc within the facility), and hat a detailed description of the request should be written as well as ensuring that staff assign the appropriate priority to that request (e.g. Low, Medium, Critical). Continued review of the policy indicated that the Environmental Services Director, Maintenance Supervisor or designee will review work order request daily and that emergency work order request will be given priority for making necessary repairs. Review of information received by the State Survey Agency on November 22, 2024, indicated that requested repairs/replacements inputted in the facility's maintenance computer system were not being addressed in a timely manner. Review of several work orders with the facility Maintenance Director (Employee E3) on December 9, 2024 at 12:15 p.m. that were submitted by facility staff indicated that the orders that impacted residents care, services and safety, were not addressed in a timely manner: Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 16, 2024, at 7:16 a.m. for room [ROOM NUMBER], where Resident R1 and Resident R2 resided reporting that the toilet in the room was not flushing properly and that it was overflowing. The work order for the toilet was documented as being Open, indicating that the repair had not been made. During a tour with the Maintenance Director on December 9, 2024 that began 12:45 p.m. following observations were made regarding the following work order request: In room [ROOM NUMBER], the Maintenance Director reported that work request that was submitted on November 16, 2024 regarding the inoperable toilet for Resident R1 was addressed last week. The Maintenance Director reported that the tank needs to be replaced. The Maintenance Director also reported that the resident had a concern about his bed was also addressed last week. During an interview with Resident R1 on December 9, 2024, at 11:29 a.m., the resident reported that his toilet was not working, and he was told that he could use the shower bathroom. Resident reported that he needed help from staff to use this bathroom. During the above referenced interview, the resident reported that his bed quit working and that it would not move up and down and explained that he told multiple people about the toilet and his bed and that it had not been addressed by maintenance staff so his room was moved sometime last week. A work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:47 p.m. reporting that the bed mattress for Resident R9 in room [ROOM NUMBER] was not staying in in place. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], Resident R9 reported that someone came in and asked him about his mattress. It was found during the investigation that a maintenance staff member addressed the work order that was submitted on December 3, 2024 regarding the resident's mattress was updated by the Maintenance Director as Completed on December 9, 2024 at 1:32 p.m., 6 days after the request was made. Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:51 p.m. reporting that the call bell for room [ROOM NUMBER] where Resident R7 and R8 resided was on outside their room, and cannot be turned off. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], the call bell light indicator outside the room was on. Resident R8 entered the room and stated that the call bell for their room had not been working and that both she and her roommate, Resident R7 just got hand-held bells today. Resident R8 entered her room with a hand-held bell for herself and a 2nd one for Resident R7. Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on August 29, 2024 at 8:01 a.m. reporting that the shower room located on the north side of the 2nd floor needed a new toilet. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In the north 2nd floor shower room, the Maintenance Director reported that the whole toilet has to be replaced and that one will be ordered, but had not been ordered yet. Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on September 16, 2024 at 8:18 a.m. indicating that the there was water leaking towards the window in front of Resident R5's bed in room [ROOM NUMBER]. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], the ceiling tile was removed from the resident's room leaving the ceiling exposed. Pointing to the ceiling, Resident R5 stated no one has done anything about this. The Maintenance Director reported that a plumber will need to come out and make repairs. Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 15, 2024 at 6:40 a.m. indicating that the call light in the room is not working in room [ROOM NUMBER] where Resident R3 and R4 resided. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. The call light outside room [ROOM NUMBER] was one. Resident R3 and Resident R4 reported that their call bells have been broken and that once she was using the bathroom and had to yell for staff to come ad help her. Resident R3 and Resident R4 reported that they just received hand held call bells, today. During an interview with the Maintenance Director on December 9, 2024 at 1:30 p.m. it was confirmed that the work orders were not addressed/resolved in a timely manner. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for 18 of 18 residents interviewed (Residents R79, R89, R65, R39, R30, R97, R64, R35, R74, R21 R62, R53, R78, R88, R28, R27, R22 and R66.) Findings include: A review of the undated Test Tray Evaluation form revealed that the standard temperature range for milk and cold beverage were 41 F. A test tray was conducted at the lunch meal on July 30, 2024, at 12:15 p.m. with the Food Service Director (FSD), which revealed that the carton of whole milk was served at 57 degrees. Upon tasting the milk tasted warm, and the baked ziti was not baked, but rather just mixed with the meat sauce and the noodles were overcooked and very soft and the meat sauce had an off sweet flavor, the mixed vegetables were very overcooked with the squash so soft the it could not be picked up with a fork, it just fell apart. The FSD confirmed that the milk should be at or below 41 degrees, and that 57 degrees was not acceptable. Resident interviews during the initial tour of the second floor North Hall on July 29, 2024, beginning at 10:05 a.m. revealed the following: Interview at 10:15 a.m. with Resident R79 revealed that he felt that the food sucks, he said that they don't send juice, but rather milk, he thinks they run out of juice all the time. Interview at 10:20 a.m. with Resident R89 revealed that she is not getting what is on the ticket, especially she is not getting the breakfast meats like ham yesterday of sausage the other day, which they are on the ticket, but she does not get it. The other day the ticket said coffee, but she did not get it. The resident indicated that she is very frustrated and feels like they don't listen to her or care. Interview at 10:27 a.m. with Resident R65 revealed that he is a diabetic and he feels that he is getting too much starch in foods like white rice, macaroni, pancake, waffles, etc. and he is concerned for his health. Interview at 10:32 a.m. with Resident R39 revealed that he is getting regular milk, and he should be getting lactose free milk every meal, and he prefers blueberry yogurt, but never gets that. Interview at 10:35 a.m. with Resident R30 revealed that she felt that the food has too much gravy on everything, and she wants whole milk with breakfast and supper, and that she does not like fish or rice and is receiving these items. Interview at 10:38 a.m. with Resident R97 revealed that he is not getting what is on the ticket, was supposed to get pancakes the other day, it is on the ticket, but he does not get it on his plate. Interview at 10:44 a.m. with Resident R64 revealed that he felt that the food sucks, he said that it is so bad that he will go days without eating, and he is tired of always spending his money, he should not have to buy his own food. Interview at 10:50 a.m. with Resident R35 revealed that she felt that the food is usually too spicy for her, that she doesn't want pork and shouldn't have dairy products, tomatoes, nuts, or eggs and yet she says she gets these items regularly. A group meeting held at 10:11 a.m., on July 31, 2024, with alert and oriented residents (R74, R21 R62, R53, R78, R88, R28, R27, R22 and R66.) revealed that these residents were unsatisfied with the taste and temperature of the food and beverages that were being served for breakfast, lunch, and dinner daily. Food is usually dry meat, a lot of gravy, overcooked vegetables, and overcooked food. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.1 Dietetic Services, Principle

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 21 residents reviewed (Resident R102). Findings include: A review of Resident R102's quarterly Minimum Data Set (MDS- assessment of resident needs) dated May 15, 2024, revealed that the resident was discharge to hospital. Review of Resident R102's physician discharge summary revealed that the resident was discharged home with family. An interview with the Registered Nurse Assessment Coordinator, Employee E8, conducted on August 1, 2024, at 11:26 a.m. confirmed that Resident 102's MDS was coded inaccurately. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Medical records

Based on review of facility policy, review of facility documentation, review of clinical records, review of video footage and interviews with staff, it was determined that the facility failed to ensure that one of six residents reviewed were free from physical abuse from nursing staff. This failure resulted in an Immediate Jeopardy situation with Resident R2 who was struck twice, and rough handled sustaining left upper arm bruising. (Resident R2). Findings Include: Review of facility policy on Abuse Prevention Program dated August 2020 states, The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Abuse-Includes Verbal, Physical, Sexual, and Mental/Emotional. Abuse- willful infliction of injury, unreasonable confinement/Involuntary seclusion. Separation of a resident from other residents, or from their room or other area, against the resident's will or the will of the resident's representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Corporal punishment and any physical or chemical restraint not required to treat the resident's symptoms. Instances of abuse of residents, irrespective of any mental or physical condition, that causes physical harm, pain, or mental anguish to include verbal, sexual, physical, & mental abuse. Abuse that includes that which is facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that he individual must have intended to inflict injury or harm. Verbal abuse includes oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families to describe the resident within hearing distance, regardless of their age &/or ability to comprehend or disability. Physical abuse includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. Review of facility policy on Catastrophic Crisis Management dated October 2021 states, The staff will strive to safely manage a behavior crisis when the resident poses immediate danger to themselves or others. If the behavior cannot be managed and the crisis continues, the resident will be transferred to an acute care facility. The procedure reads, 1. Implement immediate protective interventions for the resident (s) and staff. 2. Remain calm and speak to the resident in a calm, firm voice. A. Respond to the resident's voiced concerns. B. Reassure the resident. 3. Analyze situation for immediate actions that will promote safety of resident and/or others. 4. Summon additional staff as needed by paging (Code CAT- Catastrophic) with the location. 5. Initiate the following interventions which may include but are not limited to: a. Remove resident from the situation to a safe, supervised environment. b. Identify and reduce/remove triggers of behavior. c. Remove others from the area. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Further review of Resident R2's clinical record revealed that Resident R2 had a diagnosis of Hemiplegia (weakness on one side of the body), Urinary Tract Infection, Muscle Weakness, Major Depressive Disorder, Generalized Anxiety Disorder, Dysphagia (difficulty swallowing), Lack of Coordination, Abnormalities of Gait and Mobility, Unspecified Lack of Coordination, and Weakness. Review of Resident R2's quarterly Minimum Data Set (MDS-assessment of resident's care needs) dated November 6, 2023, revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) with no score which suggested that the resident had difficulty completing the assessment due to not being able to be understood due to her language barrier. Continued review of the assessment revealed that the resident did not demonstrate any physical or verbal behavioral symptoms. Review of nursing progress note from January 15, 2024 time stamped at 11:19 a.m. revealed Resident observed with a bruise to LUE (left upper extremely) this AM, call was placed to MD'S office message left . pain management in progress, resident indicated the arm hurts a little bit, nursing to monitor and assess for changes, resident speaks very little English and has not voiced how she got the bruise. Review of nursing progress notes from January 15, 2023, time stamped at 11:22 p.m. reads Resident on 1:1 for safety. Tolerated medication well. No complaints of pain or discomfort. Safety precautions maintained. Review of information submitted to the Department of Health from January 15, 2024 states On 1/15/24 is was reported at 10:30 by [licensed nurse, Employee E8] that Resident R2 was observed with a discolored area to left forearm. She did a hand gesture of as if she was hit, no additional information provided. Observation of the facility's video footage of Unit one was conducted on January 31, 2023, at 11:11 a.m. with the Director of Nursing, Employee E2 allowing access. The video footage revealed two camera angles camera #1 of the Resident R2's hallway to her bedroom and camera #2 was an angle of the nurse's station and right hallway. Both were reviewed through the timeframe the incident occurred on January 14, 2024. The video revealed Resident R2 in camera 2 view sitting alongside the wall next on to the right of the camera view at 2:40 p.m. At 2:41 p.m. nurse aide, Employee E6 walked past the resident, to the end of the nurse's station and Resident R2 began yelling at her and using hand gestures in her direction. At 2:42 p.m. nurse aide, Employee E6 was standing at the end of the nurse's station and began to use hand gestures and yelled back at the resident. At 2:43 p.m. Resident R2 began to wheel herself towards the nurse's station and tried to knock down a water bottle and a computer. Nurse aide, Employee E6 moved the water bottle and held the computer and then sat down at the nurse's station at the end of the right side. At 2:44 p.m. Resident R2 wheeled herself closer to the end of the nurse's station and attempted to hit nurse aide, Employee E6. Employee E6 pulled her hand out of the way, and it was not struck by the resident. Resident R2 then attempted to pull charts off of the filing cabinet and nurse aide, Employee E6 lifted her hand up and struck it down making contact with the resident's hand for the first time. Employee E4 at this point looked at Resident R2 and Employee E6 but continued typing on the computer. Resident R2 then attempted to grab file folders again and was struck in the hand by Employee E6 for the second time. At 2:45 p.m. nurse aide, Employee E4 interrupted the altercation and moved resident back to space by the wall where she was prior to the altercation. At 2:46 p.m. Resident R2 started moving away from the wall. Nurse aide, Employee E6 gestured with her hand pointing towards the wall for her to go back by the wall and then walked into the day room. At 2:47 p.m. Resident R2 wheeled herself away from the wall and went into day room. At 2:49 p.m. nurse aide, Employee E6 exited the day room. At 2:52 p.m. Resident R2 left the day room and sat back by the wall. Continued review of the video footage revealed that at 3:33 p.m. Resident R2 wheeled herself to the nurse's station and attempted to throw a phone off of the nurse's station and nurse aide, Employee E5 placed the phone out of reach of the resident. After placing the phone out of reach nurse aide, Employee E5 was seen pulling the resident away from the counter while her hand was still on the counter, she pulled at her upper left shoulder to remove her arm from the nurse's station. Nurse aide, Employee E5 then attempts to wheel her into the day room when the resident grabbed onto the grab bars in the hallway while attempting to swat at nurse aide, Employee E5. Employee E5 was seen holding the right side of her wheelchair for forty-five seconds restricting her movement. At this time, the resident was swatting at nurse aide, Employee E5. Employee E5 then went to the nurse's station and checks her phone. At 3:55 p.m. Employees E5, E7, and E9 were all seen at the nurse's station. At 4:01 p.m. Resident R2 was seen on the left camera coming out of her room. Resident R2 wheeled herself and sat alongside the wall. At 4:12 p.m. Resident R2 wheeled herself to the nurse's station and tried grabbing something of the nurse's station. Nurse aide, Employee E7 point towards her room. At 4:14 p.m. the resident wheeled herself back to the same spot along the wall. At 4:15 p.m. before Resident R2 stopped wheeling herself, nurse aide, Employee E7 walked away from the nurse's station and turned the resident around and wheeled the resident to her bedroom. At 4:15 p.m. nurse aide, Employee E7 was seen walking out of Resident R2's room dancing and putting her hands in front of her and behind her back. Review of facility documentation revealed an interview held on January 17, 2024, with Nursing Home Administrator, Employee E1 and Nurse aide, Employee E4. Employee E1 asked nurse aide, Employee E4, is she had ever seen any staff or resident hit Resident R2, nurse aide, Employee E4 said no, not that she can recall, no. Further review of facility documentation revealed, Ten minutes later [Employee E4] calls the [Nursing Home Administrator Employee E1] and states: that she doesn't want to blame anyone or get anyone fired, but [Resident R2] was coming after [nurse aide, Employee E6] on Saturday or Sunday while she was charting (could not recall the time) [Resident R2] was near the nursing station as she tried to grab on papers that were there and [nurse aide Employee E6] made a hand motion at Resident R2 to show that she should go away. Nursing Home Administrator Employee E1 asked [Employee E4] to come in the next day and reenact what happened to assist with better understanding. Review of facility investigation documentation revealed on January 18, 2024, Resident Physical Abuse reportable investigation: Bruise found on resident left arm below the shoulder. Resident informed family that someone wheeled her into her room and hit her. Dark and light skinned with long hair. Investigation initiated. Review of facility investigation documentation revealed observations made through the video cameras located on the unit. On Sunday 1/14/24 at 2:43 p.m. camera #1 at the first-floor nurse's station Resident R2 sitting near nursing desk goes to the nursing desk and tried to knock down a water bottle. Nurse aide, Employee E6 immediately grabbed the water bottle and closed it Resident R2 tries to knock down the desktop monitor. Employee E6 held it down. Resident R2 then come around the nursing station and tried to grab at Employee E6, Employee E6 moved her hand away. Resident R2 then grabbed a chart and as she is about to knock it down Employee E6 slapped her hand down. Employee E4 sitting at the nurse's station then come around and wheeled Resident R2 away from the nursing station. At 3:40 p.m. Resident R2 was seen on camera #1 at the nursing station knocking down the phone. Coming out of the activities room was nurse aide, Employee E5 who had witnessed this and come towards the nursing station, in front of Resident R2, and placed the phone back up. Resident R2 then hits Employee E5. Without any reaction. Employee E5 went behind Resident R2, placed her left hand away from the nursing desk and wheeled her back. At 4:00 p.m., Resident R2 on camera #1 was seen sitting at the nursing station then began throwing things at nurse aide, Employee E7, who was sitting behind the nursing desk. Nurse aide, Employee E7 then went around the nursing station and wheeled Resident R2 into her room, after a minute come out of her room with towels. (Resident R2 is known to store towels at the side of her wheelchair). Camera continues to show Employee E7 going back to the nursing station sitting down. In some time, Resident R2 starts to come out of her room sitting near her room facing the wall puts her head down on the railing. She then slowly makes it back to the nursing station and sits in her usual spot. Employee E7 then goes around the nursing station to Resident R2 and wheels her back to her room. Review of facility investigation documentation revealed on January 22, 2024, the Nursing Home Administrator Employee E1 called nurse aide, Employee E6 to notify her of her termination of employment related to the facility sustaining resident abuse. While letting nurse aide, Employee E6 know the specific actions that the employee performed, Employee E6 said I did do that, in relation to each action. Interview held with the Director of Nursing revealed upon completion of the investigation nurse aide, Employee E6 was terminated and nurse aide, Employee E7 was also terminated. Nurse aide, Employee E5 was educated but it still employed at the facility. the Director of Nursing revealed that nurse aide, Employee E4 was given a discharge warning for not reporting immediately but is still employed at the facility. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on January 31, 2024, at 1:17 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: On January 31, 2024 at 5:11 p.m. the facility provided the following corrective active plan: 1. [Resident R2] was immediately assessed by the Director of Nursing. Resident was immediately placed on 1:1 on 1/15/2023 for emotional support and to feel safe. The 1:1 was educated prior to the start of 1:1. Responsible Party, Physician and Risk Manager notified. Pain and skin assessment completed. Resident remains at her behavioral baseline with no signs nor symptoms of distress. The physician examined the resident on 1/16/2024. The resident displayed no signs of distress. The resident remained on 1:1 until IDT (Interdisciplinary Team) team made the decision that it was safe for the resident 1:1 to be removed on 1/19/2024. 2. The facility reported an event to the DOH on 1/15/2024. The three staff members that were identified during this investigation were suspended pending results. 3. A Licensed Nurse conducted skin assessments of all patients to determine if any other patient may have been impacted by abuse or neglect. The Unit Manager on duty provided supervision and oversight of this assessment. This assessment was completed on 1/20/24 with no findings of physical or psychosocial signs of abuse and neglect. 4. The Risk Management Consultant provided education to the Administrator and Director of Nursing on the facility abuse, neglect and misappropriation policy and procedure with an emphasis on the immediate reporting of potential or witnessed abuse, neglect, or misappropriation. This education was completed on 1/19/24. 5. The Administrator, Director of Nursing, and Social Services Director educated all staff on the facility abuse, neglect, and misappropriation policy with an emphasis on the immediate reporting of potential or witnessed abuse, neglect, or misappropriation and rough handling of patients. This education included the execution of the employee attestation of commitment. 100% of all staff received this training by 1/29/24. 6. The Administrator, Director of Nursing, Social Service Director, and Executive Director reviewed the facility policy on abuse, neglect, and misappropriation. No need for changes was identified at the time. The Administrator/DON/Designee will monitor residents for signs and symptoms of abuse and/or neglect weekly times 4 weeks, monthly times 4 months. Findings will be taken to QA weekly times 4 weeks, then monthly. Facility documentation was reviewed, and residents skin assessments were completed on January 16, 2024 on every resident. The immediate implementation of the action plan was verified on January 30, 2023. Interviews were conducted with facility staff from various departments, and all reported that they had been in-serviced by the facility on resident abuse, and the importance of immediate reporting any allegation or suspected abuse. On January 31, 2024, twenty staff members were interviewed. All staff interviewed were able to verbalize what constitute abuse, methods to de-escalate a resident who is agitated. and who and when to report resident abuse. The Immediate Jeopardy was lifted on January 31, 2024 at 5:32 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to serve hot beverages with the appropriate lid and failure to monitor the temperature of hot water beverages served to residents. This failure resulted in Immediate Jeopardy situation to Resident R1 who spilled a hot water beverage and sustained an abdominal burn injury, for one of six residents reviewed. (Resident R1) Findings include: Review of undated facility policy Hot Liquid Management revealed the intention of the policy was to minimize the risk for resident burns caused by hot liquids. Continued review of facility policy revealed hot beverages should be dispensed into an insulated container and temped to validate hot beverage is not greater than 165 degrees Fahrenheit (F). If beverage is hotter than 165 degrees F, allow to cool to 165 degrees F and record temperature on the Food Temperature log. Further review of facility policy revealed the insulated container should be covered with appropriate lid prior to delivery of hot beverage to the resident. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 12, 2023, revealed the resident was cognitively intact and had impairment in range of motion to upper and lower extremity on one side. The MDS revealed the resident had diagnoses of muscle wasting and atrophy, stiffness of left elbow and left shoulder, and pain in right shoulder. Further, the MDS section G0110 H. Eating - how resident eats and drinks, regardless of skill was coded as Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance with one person physical assist for support. Review of Resident R1's care plan revised April 3, 2018, revealed the resident had impaired visual function related to traumatic brain injury. Intervention dated June 12, 2016, included to orient resident to her surroundings. Continued review of Resident R1's care plan revised August 2, 2019, revealed the resident had an activities of daily living self-care performance deficit and need for assist with thoroughness related to weakness, hemiplegia (paralysis of one side of the body), and limited range of motion to upper and lower extremity. Further review of Resident R1's care plan dated April 28, 2023, revealed the resident had a contracture to her left upper extremity. Review of Resident R1's clinical record revealed a nursing note dated May 7, 2023, at 12:20 a.m. which indicated licensed nurse, Employee E7, was alerted by the nurse aide earlier in the evening, at 5:30 p.m. that Resident R1 spilled hot water on herself. Licensed nurse, Employee E7, along with another nurse, went to check on Resident R1 and observed splashed hot water in the abdominal area. Upon assessment Resident R1 complained of pain and had an affected area of 35 centimeters (cm) in width and 11 cm in length on her abdomen. Subsequently the on-call physician was notified and ordered treatment to the site. Review of Resident R1's physician orders revealed a physician order dated May 6, 2023, at 10:00 p.m. to apply Silvadene External Cream 1% (topical antibiotic cream used to treat burns and prevent infection) every shift for burn. Further review of Resident R1's clinical record revealed a nursing note dated May 7, 2023, at 6:24 a.m. that the topical cream was applied to the resident's upper abdomen. Upon assessment, blisters were noted to the area. Review of Resident R1's skin/wound note dated May 10, 2023, revealed the abdominal wound measured 9.5 cm in length and 27 cm in width. The area had 3 moist, scabbed areas and the general area of the wound is reddened and closed skin. Review of facility documentation reported to the Department of Health on May 11, 2023, revealed Resident R1 dropped a cup of hot water on the left side of her abdomen. Upon further investigation, it was determined that nurse aide, Employee E4, got a cup of hot water from the kitchen to provide for Resident R1. It was further identified that the temperature of the beverage may not have been temped. Review of facility documentation revealed a written statement dated May 6, 2023, by nurse aide, Employee E4, that revealed Resident R1 wanted tea but the beverage cart was out of hot water, so the employee went to the kitchen and dietary staff provided her with a cup of hot water. Nurse aide, Employee E4, brought the hot water to Resident R1 and placed it on her bedside table. As nurse aide, Employee E4, turned around walking out of the room she heard Resident R1 yell, Help! It's Burning!. Review of facility documentation revealed a written statement dated May 7, 2023, by Dietary Cook, Employee E5, which indicated the nurse aide went to the kitchen and requested hot water for tea. Dietary cook, Employee E5, revealed they gave the nurse aide a cup of hot water, put a lid over it, and told the nurse aide many times that it was hot and to be careful. Interview on May 15, 2023, at 9:30 a.m. with Nursing Home Administrator, Employee E1, confirmed the hot water was not temped before providing Resident R1 with the beverage. Continued interview on May 15, 2023, at 10:30 a.m. with Nursing Home Administrator, Employee E1, revealed the lid that was placed on the hot water did not fit the cup correctly. Interview on May 15, 2023, at 11:26 a.m. with nurse aide, Employee E4, confirmed the hot tea was not temped before leaving the kitchen and providing for Resident R1. Interview on May 15, 2023, at 10:15 a.m. with Resident R1 revealed when the nurse aide delivered the hot water, there was no tea bag in the cup. Resident R1 reported she picked up the cup to see if there was any cream or sugar in it when the cup tipped over. Resident R1 complained of pain to the affected area of 10/10 without pain meds. Observation and interview confirmed Resident R1 had a contracture to her left upper extremity and only used her right upper extremity for self-feeding. Observations on May 15, 2023, at 10:45 a.m. of the affected area on Resident R1's abdomen, with Registered Nurse, Employee E10, revealed the area was tender to touch and Resident R1 winced when Registered Nurse, Employee E10, removed the gauze that was laid on top of the affected area. Review of facility documentation Food Temperature Log revealed logs for May 2023. Review of the Food Temperature Log sheets revealed hot beverages were not temped on the following days and meals: 5/1 breakfast, lunch, dinner; 5/2 breakfast, lunch dinner, 5/3 breakfast, lunch; 5/5 breakfast, lunch, dinner; 5/6 breakfast; 5/7 breakfast, lunch; 5/8 breakfast, lunch, dinner; 5/9 dinner; 5/12 breakfast, lunch, dinner 5/13 lunch; 5/14 breakfast & lunch. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1; Director of Nursing, Employee E2; and Registered Nurse Consultant; Employee E3; on May 15, 2023, at 12:42 p.m. for the facility's failure to ensure that hot beverages were served at safe temperatures, resulting in Resident R1 sustaining an abdominal burn injury from hot water. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, Director of Nursing, and Registered Nurse Consultant, on May 15, 2023, at 12:46 p.m. The facility submitted a written plan of action on May 15, 2023, at approximately 3:27 p.m. and implemented the plan of action which included: 1. Resident sustained a burn after being served a hot beverage without an appropriate lid and failure to monitor the temperature of the hot water being served to the resident. 2. Resident was immediately assessed and noted with blisters to her abdomen. Residents Attending Practitioner was notified, and treatment orders received. Resident was evaluated by the Occupational Therapist on 5/10/2023 and recommended to have a lid placed on the residents' drinking cups. Resident was seen by the Attending Practitioner on 5/12/2023 with no new orders. 3. A facility wide education was initiated on 5/11/2023 by the Staff Development Coordinator/Designee including all departments regarding the facilities Hot Liquid Management Policy with an emphasis on placing appropriate lids on hot beverages prior to serving the residents. Staff will be educated before the start of their shift, including agency staff. Approximately 85% to be completed by 5/16/2023. 4. Dietary staff re-educated by the Staff Development Coordinator regarding the facilities Hot Liquid Management Policy to include action to be taken if the temperatures are above range prior to leaving the kitchen. The hot liquid will remain in the kitchen until the temperature is rechecked and the temperature is at or below 165 degrees. The temperatures will be checked by 2 staff members prior to leaving the kitchen. Approximately 85% to be completed by 5/16/2023. 5. The facilities Hot Liquid Management Policy was reviewed and updated 5/15/2023 to include only dietary staff will be allowed to provide hot liquids/foods to non-dietary personnel. 6. Dietary staff will properly monitor and record the temperature of hot beverages served to the residents during all meals and recreational activities. 7. RN [Registered Nurse] Supervisor will be education on how to appropriately check temperatures of hot liquids, should a resident request during off hours. Approximately 85% to be completed by 5/16/2023. 8. NHA [Nursing Home Administrator]/Designee will conduct daily audits of beverage temperature logs recorded at every meal x 7 days. 9. Audits will be reviewed in Quality Assurance Meetings. Interviews with 29 staff members from all departments were conducted on May 16, 2023. All staff members reported that they received education regarding the facilities updated Hot Liquid Management policy which included only dietary staff will be allowed to provide hot liquids to non-dietary personnel (except for off-hours when an RN supervisor is able to prepare hot beverage), making sure hot beverages have appropriate, secure fitting lids, and monitoring/recording of hot beverage temperatures to ensure safe service. Review of Food Temperature Log sheets revealed hot beverage tempeartures were monitored and documented for meals at dinner on 5/15/2023 and breakfast/lunch on 5/16/2023. While onsite on 5/16/2023, the activities department had an activity where hot chocolate was provided for the residents. Activities staff obtained hot beverages from dietary personnel as required, who monitored/documented beverage temperatures prior to service. The immediate jeopardy was lifted on May 16, 2023, at 4:10 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on observations, review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure that one of 23 residents (Resident R92) reviewed was free of unnecessary [CONDITION(S)] medications which resulted in actual harm to Resident R92 receiving an excessive dose of an antidepressant medication, experiencing a withdrawn mood and a fall incident. Finding include: Review of facility policy title, Use of Benzodiazepine and Anxiolytic Medications undated, revealed to Attempt gradual dose reduction (GDR) as ordered by the physician and according to the following: within the first year, a GDR must be attempted in two separate quarters (with at least one month between attempts, unless otherwise contraindicated, ongoing assessment and documentation of GDR, admission or within 2 weeks on new admission who do not require PASSAR screening, during quarterly care plan meeting, identification as possibly causing or contributing to an adverse consequence or change in condition and document dose reduction and resident response. Review of Resident R92's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without behavioral disturbance, violent behavior, anxiety (intense or excessive worry), and [CONDITION(S)] (have trouble falling or staying asleep). Review of Resident R92's April 2022 physician orders revealed an order for the antidepressant medication Trazadone 25 (milligrams) mg. twice a day at 9:00 a.m. and 5:00 p.m., Trazadone 75 mg. at bedtime, the antipsychotic medication [MEDICATION(S)] 2.5 mg at breakfast and [MEDICATION(S)] 5 mg with dinner and [MEDICATION(S)] (natural product to help with sleep) 3 mg at bedtime and [MEDICATION(S)] 0.25 mg every 12 hours as needed (an anti-anxiety medication). Review of nursing note dated April 12, 2022, at 1:50 p.m. noted that Resident R92 was alert, awake with periods of confusion throughout the shift. At 2:55 p.m. the resident became very anxious, pulled his sheets and blankets off bed, knocked down his bedside table. The nursing staff provided redirection, offered fluids, and assisted the resident to the common area. Review of nursing note dated April 13, 2022, at 8:03 a.m., revealed that during the 11:00 p.m. to 7 :00 a.m. shift, the resident slept until 4:30 a.m. and at that time he was awake and attempting to get out of bed. The resident was brought to nurse station, and it was noted the resident was yawning and nodding off, but he refused to get back into bed. Continued review of nursing documentation revealed that on April 14, 2022, at 9:44 p.m. the resident was playing with bed side table and tried to reach floor, actions kept repeating, attempted redirection and offer snacks without success. The resident was then administered one dose of [MEDICATION(S)] with positive effects. Review of psychiatrist (psych) Certified Registered Nurse Practitioner (CRNP) notes dated April 15, 2022, at 11:50 a.m. revealed that the resident was assessed, and it was recommended to stop Trazadone 75 mg at bedtime and start Trazadone 100 mg at bedtime, related to the resident attempting to get out of bed in the middle of the night. Review of a nursing note dated April 19, 2022, at 11:12 p.m. revealed, that the resident was placed at the nurses' station for better supervision due to being at high risk for falls. Review of nursing notes dated May 1, 2022, at 11:23 p.m. revealed that the resident was sitting at nurses' station for close observation when he was witnessed falling forward to floor from wheelchair. Neuro checks were initiated, and an order was obtained for an ice pack to be applied to Resident R92's scratch on the right side of his head. Review of psych. CRNP notes dated May 1, 2022, revealed Patient received sitting in wheelchair in hallway. Generally cooperative on approach, provides poor eye contact. Head remains down most of assessment . mood is withdrawn. Review of pharmacy consult for medication reduction dated May 2, 2022, revealed Resident had an increase to his Trazadone from 75 Milligrams to 100 milligrams HS (at night) and to continue 25 milligrams twice a day as per the Psych (Psychiatrist) eval (evaluation) dated April 11, 2022. It appears that when the 100-milligram dose was added, the 75-milligram dose was not discontinued. It appears the resident has been getting 175 milligrams at bedtime. Of note resident had a fall. Review of psych. CRNP notes dated May 2, 2022, noted Patient was seen for history of gait dysfunction and Dementia, Patient was seen slumped over in his wheelchair. The staff made a medication error and instead of getting 100 mg of Trazadone at hour of sleep they have been giving him 175 mg. Review of May 2022's physician's orders revealed that on May 2, 2022, the CRNP ordered to discontinue all Trazadone orders and [MEDICATION(S)] and ordered Trazadone 75 mg at bedtime. Review of resident's progress notes dated May 3, 2022, revealed that the interdisciplinary team reviewed the medication variance incident noted on May 2, 2022, and determined that a transcription error was made. Review of May 2022's physician orders revealed that on May 19, 2022, the CRNP ordered to discontinue [MEDICATION(S)], Trazadone and [MEDICATION(S)] as it was ordered on May 2, 2022. Review of Resident R92's May 2022 Medication Administration Record confirmed that the resident was administered [MEDICATION(S)] 2.5 mg from May 2, 2022, through May 18, 2022. The facility failed to discontinue the medication [MEDICATION(S)] on May 2, 2022 and continued to administer [MEDICATION(S)] 2.5 mg at breakfast through May 18, 2022. Review of psych. CRNP notes dated May 19, 2022, revealed Pt was seen in bed & appears lethargic. Pts (patient) [MEDICATION(S)] was DC'd (discontinued) on 5/2 but doesn't appear this was DC'd. Interview completed with the Director of Nursing on June 17, 2022, at 1:21 p.m. confirmed that the facility staff was aware of the medication error, an incident report was completed, and the resident was monitored. The facility failed to discontinue 75 mg of the medication Trazadone at night on April 15, 2022. Resident R92 was receiving an excessive dose of 175 mg of an antidepressant medication which resulted in actual harm to Resident R92 who experienced mood withdraw, was observed slumped over in his wheelchair and experienced a fall incident. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, facility policies, facility documentation and interviews with residents and staff, it was determined that the facility failed to protect residents from neglect by not providing the necessary services during showering to one resident (Resident R97) who then required emergency transport to the hospital and failed to provide the required emergency supplies and equipment for one resident with a [MEDICAL CONDITION] (Resident R74) for two of 43 residents' records reviewed. This failure placed the residents at high risk for harm from neglect and placed the facility in an Immediate Jeopardy situation. Findings include: Review of facility policy Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of Resident R97's clinical records revealed that the resident was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. properly). Continued review of the clinical record revealed a quarterly Minimum Data Set (MDS-assessment of resident needs) dated (MONTH) 17, 2019, which reflected that the resident had a BIMS (Brief Interview for Mental status) score of 15 which indicated that the resident was alert and oriented. Further review of the MDS revealed that the resident required the physical assistance of one staff person for bathing. Interview with Resident R97 on (MONTH) 17, 2019 at approximately 9:00 a.m. revealed An agency nurse left me alone in the shower room and I passed out. I told her that I needed help in the shower room. and . the next thing I knew was I woke up in the hospital. Review of Resident R97's clinical record revealed that on three separate occasions (March 3, 2019 at 9:30 a.m., (MONTH) 7, 2019, during 7-3 shift and (MONTH) 12, 2019, at 1:28 a.m.) the resident had been found unresponsive with low blood sugars. Further review of Resident R97's clinical record indicated that on all three occasions the resident required emergency transport to the hospital for further evaluation and treatment for [REDACTED]. Further review of Resident R97's clinical record revealed nursing progress notes dated (MONTH) 21, 2019 at 12:10 a.m. revealed that the resident was observed in the shower unresponsive with a blood glucose of 54 milligrams per deciliter (normal level is 80 -100). 9-1-1 (Emergency Medical Services) was called and a [MEDICATION NAME] (a carbohydrate used to increase the blood sugar) injection was administered to the resident twice. Resident R97 was subsequently transferred to the hospital at 12:30 a.m. for further evaluation and treatment. Review of Resident R97's hospital record dated 5/21/2019 revealed that the resident was brought into the hospital by EMS on 5/21/19 when she was found unresponsive. The hospital record further indicated that the resident was . found in the shower confused and nonverbal, low blood sugar of 54. She was given [MEDICATION NAME] x 2 but her blood sugar remains low at 44 when EMS arrived. Additionally, the hospital record indicated that the patient was known to them and that the Patient has had a recurrent history of presenting at the hospital with hypoglycemic episodes in the past with hypothermia (below normal body temperature) at the time of these encounters was well. The resident vital signs at the emergency department was a body temperature of 93.3 degrees Fahrenheit rectally (normal body temperature 98.6 degrees Fahrenheit) and a blood pressure of 87/53 (normal blood pressure 120/80). The resident was subsequently admitted into the hospital with a [DIAGNOSES REDACTED]. Interview with Employee E6, nursing assistant, on (MONTH) 18, 2019, at 4:35 p.m. confirmed that the employee had worked the 3-11 shift on (MONTH) 20, 2019 and recalled that Resident R97 had told Employee E7, nursing assistant, that she needed help while she was in the shower room. Employee E6 reported I was standing right there when the resident stuck her head out and asked for help. It was approximately 10:45 p.m. when I saw her because I was just about to leave at 11:00 p.m Interview with Employee E7, nursing assistant, on (MONTH) 18, 2019 at 4:40 p.m. confirmed that she was the aide that assisted Resident R97 with her shower. Employee E7 stated I took her out of the shower and she was dressing herself on the geri-chair in the shower room. One of the nursing assistants on the 11-7 shift was going to relieve me. It was after 11:00 p.m. when I left her alone in the shower room. I left around 11:15 p.m. Interview with Employee E9, Registered Nurse/RN, on (MONTH) 19, 2019 at 9:00 a.m. confirmed that she was working the night that Resident R97 was found unresponsive in the shower room. The RN stated At 10:50 p.m. on (MONTH) 20, 2019 I saw Resident R97 getting ready for a shower. I told Employee E7, nursing assistant, to go in the shower room with her. At 11:10 p.m.-11:15 p.m. Employee E7 wanted to be signed out (go home). At approximately 12:00 a.m. Employee E8, RN, told me that Resident R97 was unresponsive. Interview with Employee E8, Nursing Supervisor, on (MONTH) 18, 2019 at 5:00 p.m. confirmed she was working on the second floor that night. Employee E8 indicated I saw Employee E7, nursing assistant, leave at 11-11:15 p.m. Later on that night the aides that were working the next shift (11-7) realized they hadn't seen Resident R97 and couldn't find her. They looked all over. They went to see if she was on another floor or visiting with another resident. She was missing for an hour. Finally, Employee E10, nursing assistant, found her unconscious in the bathroom. The nursing assistant came and got me. I checked her carotid artery for a pulse. She was slumped on the shower room's toilet with her head back, unconscious. Interview with the Director of Nursing on (MONTH) 19, 2019 at approximately 2:30 p.m. revealed that the facility has no formal policy (written guidelines) developed which addresses the bathing of residents. Further interview with the director of nursing revealed that . no resident is to be left alone in the shower room, even if they are independent. They still need someone to supervise their showers. The cna (nurse's aide) can stand at the door and supervise the resident to give them privacy. The facility failed to ensure that one resident with a known history of losing consciousness was protected from neglect when left unattended in the shower room for approximately an hour. The resident was subsequently found unresponsive and emergently transferred to the hospital where she was admitted with [DIAGNOSES REDACTED] and hypothermia. Review of facility policy Airway Care, dated effective (MONTH) 2013, indicated Back-up [MEDICAL CONDITION] of actual size and the next smaller size must be readily available at all times. (An Ambu bag, used for artificial resuscitation, a [MEDICAL CONDITION], which is a catheter that is inserted into the trachea for the purpose of establishing and maintaining a patent airway for breathing and an a obturator that is part of a [MEDICAL CONDITION], used to insert a [MEDICAL CONDITION] should always be kept at the bedside for an emergency involving a [MEDICAL CONDITION], such as tube dislodgement). Review of facility Admission Notification, form dated (MONTH) (YEAR), revealed that Resident R74 was scheduled to arrive at the facility on (MONTH) 20, 2019, at 12:30 p.m. Further review of the facility form noted that [MEDICAL CONDITION]#6 Shiley (brand/type [MEDICAL CONDITION]), [MEDICATION NAME] (type [MEDICAL CONDITION] used for persons not requiring a respirator) with setup suction machine (used to remove secretions, buildup of fluids) and an oxygen concentrator (machine used to provide oxygen) was necessary for the care of this resident. Additionally, the same form noted under Equipment section:[MEDICAL CONDITION] and a suction machine would also be necessary. Review of nursing progress notes dated (MONTH) 30, 2019 at 2:51 p.m., revealed that Resident R74 was admitted to the facility at 2 :00 p.m. via wheelchair [MEDICAL CONDITION](an opening in the neck that allows air to enter the lungs) and requires frequent suctioning. Resident on 3 liters of oxygen. Review of the progress note dated (MONTH) 30, 2019 at 3:00 p.m., stated that Resident R74 had [MEDICAL CONDITION] #6 inner cannula and that the resident'[MEDICAL CONDITION] require suctioning. Review of the clinical record for Resident R74 revealed that the resident was admitted to the facility on (MONTH) 30, 2019 with [DIAGNOSES REDACTED]. that causes brief episodes of spasms, unresponsiveness). Review of the significant change Minimum Data Set (MDS- assessment of resident's care needs) for Resident R74 dated 6/10/19, indicated that there was no BIMS (brief interview for mental status) score for the resident, and also indicated that Resident R74 was moderately cognitively impaired. The MDS further indicated that the resident required extensive assistance of one staff person for bed mobility, transfers, toileting, and personal hygiene. Continued review of Resident R74's clinical record revealed no physician's order present at the time of the resident's admission into the facility on (MONTH) 30, 2019, at 2:00 p.m., for the type and/or size of [MEDICAL CONDITION] for the resident, and/or the frequency of changing [MEDICAL CONDITION] routinely. Additionally, there were no physician orders for emergency situations (such as,[MEDICAL CONDITION] becomes dislodged) and the necessity to keep emergency supplies and equipment within view in the resident's room if an emergency should occur. Review of facility documentation revealed no documentation available during the survey to verify that the [MEDICAL CONDITION] and equipment were physically present in the facility at the time of Resident R74's admission to the facility. Review of facility invoice dated (MONTH) 18, 2019, from a respiratory care services company, listed equipment of [MEDICATION NAME] #[MEDICAL CONDITION] caps for Resident R74; however, this was not the type of [MEDICAL CONDITION] ordered for the resident. Interview on (MONTH) 17, 2019, at approximately 4:00 p.m. with Employee E25, Registered Nurse (RN), revealed that the employee did not know the size of the resident's [MEDICAL CONDITION] and stated that the size was not indicated in the physician orders. The RN was asked to locate the spare [MEDICAL CONDITION] in the resident's room. Employee E25 walked to the resident's bedside and then went to a bureau that was located near the foot of the resident's bed. The RN opened the top drawer and removed numerous piles of clothes that were laying on top, then proceeded to take out numerous cleaning supplies for the [MEDICAL CONDITION] and then moved the remaining contents of the drawer with her hand until she pulled out the spare [MEDICAL CONDITION]. The RN indicated she was not sure of the size and could not be certain if this was the resident's spare [MEDICAL CONDITION]. Observation of Resident R74 on (MONTH) 19, 2019, at 12:47 p.m. revealed the resident lying in bed with his [MEDICAL CONDITION] (trach) collar unattached and hanging over [MEDICAL CONDITION] on his bedside table, out of reach of the resident. Resident R74 appeared to be in distress and moving around in the bed. The resident was noted with an ashen gray color appearance to his skin. Interview with Employee E9, Registered Nurse, on (MONTH) 19, 2019 at 12:48 p. m. revealed that the employee was unaware that Resident R74 was unattached to [MEDICAL CONDITION] and in physical distress. Further interview with Employee E9 confirmed that the resident was ashen gray in appearance and that the resident was not wearing his [MEDICATION NAME][MEDICAL CONDITION] as prescribed by his physician. Continued interview with Employee E9 revealed he pulls it off sometimes. Additionally, Employee E9 confirmed that the resident's [MEDICATION NAME][MEDICAL CONDITION] and tubing was stowed out of reach of the resident on this occasion. Further review of medical records for Resident R74 revealed physician orders [MEDICAL CONDITION] @28%= 2 LM (the fraction of inspired oxygen, or FIO2, at two liters per minute of oxygen flow rate means that approximately 28% of the air breathed in is composed of oxygen) via Compressor @ 50 PSI (pounds per square inch, or PSI) Humidity @ 50 (refers to the relative humidity of the air, meaning 50% humid) [MEDICAL CONDITION] every shift and as needed. Observation of Resident R74's respiratory equipment on (MONTH) 19, 2019, at 12:47 p.m. revealed that the FIO2 was set at 0% which meant the resident was receiving room air which is composed of approximately 21% oxygen, not the 28% of oxygen ordered by the resident's physician. The machine read 38 PSI which meant the rate at which oxygen and air would mix would be reduced. Interview with the Director of Nursing (DON) on (MONTH) 19, 2019, at approximately 1:00 p.m. confirmed that the facility failed to keep a spare [MEDICAL CONDITION] for emergencies at Resident R74's bedside and that staff had failed to clarify and/or confirm the correct size of the [MEDICAL CONDITION] with the physician when the resident's admission orders [REDACTED]. Further interview with the Director of Nursing on (MONTH) 23, 2019, at approximately 3:15 p.m., confirmed that physician's orders were not in place for Resident R74 regarding the appropriate type or size of [MEDICAL CONDITION] for the resident, frequency of changing [MEDICAL CONDITION] routinely. Additionally, it was confirmed that there were no emergency supplies and equipment within view in the resident's room if an emergency should occur. Based on the findings listed above an Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator at 1:20 p.m. on (MONTH) 23, 2019. The facility's corrective action plan included: 1. We will immedicately conduct a full house audit to ensure that the appropriate level of monitoring is provided to all residents while showering. Expected Completion 8/24/19. We will immediately conduct a full house audit to ensure that the appropriate services and equipment are provided for residents with [MEDICAL CONDITION]. Expected Completion 8/24/19. 2. We will immediately review each residents' MDS for assessing the need for assistance while showering. Care plans will be updated if appropriate. Expected completion date 8/24/19. 3. We will immediately in-service the nursing staff (licensed and CNA) regarding residents being left unattended during their shower. Expected completion date is 8/30/19. We will immediately in-service Licensed nursing staff on respiratory care for residents with [MEDICAL CONDITION] in place. Training will include orders required for care of residents including assessments of residents' respiratory status specific to the [MEDICAL CONDITION] size and type, care of [MEDICAL CONDITION] stoma, and cleaning of inner cannula, if needed. Training will also include the need for emergency supplies and equipment at bed side. Competencies will be conducted to ensure education was retained; posttest will be administered. Competencies will be completed by 8/30/19. Any nursing staff on vacation or FMLA will be notified to see the DON prior to returning to work and will receive in servicing prior to starting their shift. 4. DON or designee will be completing observations of nursing staff assisting with resident showers and completing [MEDICAL CONDITION], 5 times per week for 4 weeks, then 1 time per week for three months and results will be brought to the QAPI committee. The Nursing Home Administrator or designee is responsible for compliance. Following verification of the implementation of the immediate action plan, including onsite monitoring with interviews with staff, observation of residents receiving oxygen therapy, review of daily facility audits of residents requiring assistance during showers and residents with a [MEDICAL CONDITION] or requiring respiratory care, and review of daily Licensed Nurse and nursing assistant in-servicing on (MONTH) 24, 25, 26, and 27, 2019, the Immediate Jeopardy was lifted at 10:04 a.m. on (MONTH) 28, 2019. The facility failed to protect the rights of residents to be free from neglect by not providing the necessary services to residents while showering resulting in harm for one resident who required emergency transport to the hospital and the potential for serious injury to one resident with a [MEDICAL CONDITION] who lacked the appropriate emergency supplies and physican orders which resulted in an Immediate Jeopardy situation. CFR(s): 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation Previously cited 07/16/18, 05/15/17 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 07/16/18, 05/15/17 28 Pa Code 201.18(b)(1)(3)(e)(1) Management Previously cited 07/16/18, 05/15/17 28 Pa Code 201.29(c) Resident rights Previously cited 07/16/18, 05/15/17 28 Pa Code 201.29(j) Resident rights Previously cited 07/16/18 28 Pa Code 211.5(f) Clinical records Previously cited 07/16/18, 05/15/17 28 Pa Code 211.5(g) Clinical records 28 Pa. Code 211.5(h) Clinical records Previously cited 07/16/18 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/16/18, 05/15/17 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 07/16/18, 05/15/17

Based on observation, review of clinical records, hospital records, facility policy, facility documentation and interviews with staff, and residents, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record for Resident R71 revealed that the resident had been admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of Resident R71's Podiatrist progress note dated (MONTH) 9, (YEAR), detailed the foot care given to Resident R71 from (MONTH) 25, (YEAR), to (MONTH) 16, (YEAR). The progress note revealed that the resident was seen on (MONTH) 25, (YEAR), for nail care and a foot examination of a right heal pressure ulcer (open area and/or ulcer which develops as a result of pressure over a body area for a prolonged period of time). The note indicated that the resident was seen again on (MONTH) 15, (YEAR), and X-rays and vascular studies were ordered. Four additional visits were documented on (MONTH) 22nd, (MONTH) 13th, (MONTH) 27th, and (MONTH) 3rd, (YEAR). These notes revealed that the vascular studies, ordered on (MONTH) 15, (YEAR), had not been done. Further review of Resident R71's clinical record revealed that on (MONTH) 27, (YEAR), the Podiatrist had discussed with the staff and the scheduler the need for Resident R71's vascular studies to be done ASAP (as soon as possible). On (MONTH) 2, (YEAR), the Podiatrist identified a new blister on the resident's right hallux (big toe). During the visit, the Podiatrist ordered X-rays to rule out osteo[DIAGNOSES REDACTED] (bone infection) and indicated that the vascular studies were still not completed. Review of the radiology report dated (MONTH) 3, (YEAR), revealed no overt finding to suggest osteo[DIAGNOSES REDACTED], but recommended if osteo[DIAGNOSES REDACTED] was clinically suspected, an MRI (Magnetic Resonance Imaging) would provide a more optimal evaluation. Continued review of the clinical record revealed a progress note dated (MONTH) 9, (YEAR), which revealed that the physician ordered an MRI, and again indicated that the vascular studies (initially ordered on (MONTH) 15, (YEAR), approximately 5 months previously) were still not completed. A nursing note dated (MONTH) 12, (YEAR), from Employee E8, Unit Manager, indicated No MRI appointment this shift. On (MONTH) 16, (YEAR), the Podiatrist's progress notes reflected that the vascular studies and the MRI studies were not completed. Continued review of Resident R71's clinical record revealed a progress note dated (MONTH) 18, (YEAR), which indicated that the resident had become weak and lethargic and was sent to the hospital. Review of Resident R71's hospital record revealed that following Resident R71's admission to the hospital, a bone scan (nuclear imaging test used to diagnose bone disease) was ordered which tested positive for osteo[DIAGNOSES REDACTED] and on (MONTH) 19, (YEAR), one day after admission, Resident R71's toe was amputated. Interview with Resident R71 on (MONTH) 12, (YEAR), at 11:15 a.m. revealed that the hospital thought the resident was going to need a [MEDICAL CONDITION]. No one at the facility ever spoke to me about my toe, I had no idea it was that bad. Interview with Employee E2, Director of Nursing, on (MONTH) 12, (YEAR), at 12:00 p.m. confirmed that the Podiatrist orders were never followed by the facility. The Director of Nursing stated, there was a breakdown in my process at my facility and I cannot say why it (the orders) didn't happen. The facility failed to follow physician orders [REDACTED]. Review of Resident R28's clinical records revealed [DIAGNOSES REDACTED]. Further review of Resident R28's clinical record revealed physician orders [REDACTED]. Also, to apply compression wrap to both legs from mid-foot including heel to knee, and apply tubi grip at the end, that was to be done every evening shift for wound healing. Observation of the leg treatment on (MONTH) 12, (YEAR), at 1:30 p.m. with Employee E8, Unit Manager, revealed that both lower legs were covered with dry skin which appeared to be thick, leathery, weeping with fluid with loose sheaths of skin hanging from the legs. Continued observation revealed that Employee E8 wiped Resident R28's legs with normal saline instead of the physician instructions to use soap and water. Additionally, further observation of Resident R28's legs during all days of the survey revealed that the compression wraps were not being used. The facility failed to follow the physician orders [REDACTED]. The facility failed to follow physician orders [REDACTED]. Quality of Care CFR(s): 483.25 - Previously cited 05/15/17, 12/07/16, 10/11/16, 07/11/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 05/15/17, 01/23/17, 12/07/16, 07/11/16 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Previously cited 05/15/17, 012/23/17, 10/19/16, 12/07/16 28 Pa. Code 211.12(c) Nursing services Previously cited 07/11/16 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 05/15/17, 01/23/17, 07/11/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/15/17, 01/23/17, 10/11/16, 07/11/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 05/15/17, 01/23/17, 12/07/16, 10/19/16, 10/11/16, 07/11/16

Based on observation, review of clinical records and facility policy and procedure and interviews with staff, it was determined that the facility failed to monitor and assess skin conditions related to pressure areas in a timely manner for two of 24 residents reviewed (Resident R7 and Resident R46) that resulted in actual harm to both residents (Resident R7 and R46) when one resident sustained [REDACTED]. Findings include: Review of the facility policy and procedure on wounds, revised in October 2011, revealed that the facility implements the following interventions to prevent the development of pressure ulcers: Identify residents at risk, reduce the occurrence of pressure over the bony prominence's and increase the awareness of ulcer prevention through educational programs. Review and revise the care plans. Keep the skin clean and dry and free of body waste, perspiration and wound drainage. Inspect the skin daily for early signs and symptoms of breakdown. Further review of the facility's policy and procedures for wounds revealed that the staff shall review the skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition. After an initial identification of a new change in skin integrity, a wound tracking form will be initiated and the area will be measured weekly. The nurse will conduct weekly skin checks and/or as needed (e.g. soiled dressing) to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. Review of Resident R7's physician's orders dated April 2017 revealed that the resident had [DIAGNOSES REDACTED]. bicondylar [MEDICAL CONDITION] tibia (a bone [MEDICAL CONDITION] or shinbone affecting the knee joint, stability and motion). The quarterly Minimum Data Set assessment (MDS - a periodic assessment of needs) dated March 2, 2017, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 12, indicating the resident had moderate impairment of cognition and was dependent on staff assistance for all activities of daily living. Review of the resident's wound risk care plan dated June 10, 2015 revealed that the resident was at risk of developing a wound due to impaired mobility and due to incontinence or increased moisture. The interventions included to observe for any new areas of skin breakdown - redness, blisters, bruises, discoloration - noted during baths or daily care and to report to the nurse if noted, and the nurse was to report to the physician. Review of the physician's orders dated October 19, 2016, revealed that Resident R7 had an immobilizer (a brace to immobilize an unstable fracture) to her left lower leg, that was to be worn at all times when out of bed. The brace was to be removed at bedtime to avoid stiffness and must be removed every shift to check for skin integrity/care/treatment. The facility documentation from October 19, 2016 through December 16, 2016 failed to reveal that any skin breakdown was observed and documented by the staff. Facility documentation dated December 16, 2016, revealed that the wound nurse documented, during skin sweep rounds today, this RN observed that resident has a new open area on the posterior/lateral (back/side) of her left calf. The open area measured approx 4.0 cm (centimeters) x 2.4 cm. Wound was assessed and slight drainage was identified. Upon further inspection, wound area is in direct alignment with end of stay on knee immobilizer. Immobilizer inspected and serous drainage was noted at the metal stay area. An interview with Employee E5, the Unit Manager, on May 15, 2017, at 10:35 a.m. revealed that, the resident initially had an open area on her shin but it resolved on December 13, 2016. Employee E5 stated that, the resident had the area on her shin as a result of the fractured leg. Employee E5 stated that on December 16, 2016, a nursing assistant came to him and said that the resident had an open area on her leg. The area was identified as the posterior/lateral aspect of the left mid-calf. An interview with Employee E16, a Charge Nurse, on May 15, 2017, at 11:05 a.m. confirmed that she did not see the open area on the posterior/lateral left lower leg prior to it being identified on December 16, 2016. An interview with Employee E13, a Nursing Assistant, on May 15, 2017, at 11:15 a.m. confirmed that when she was assigned to the resident, the area had already been identified. An interview with Employee E15, a Nursing Assistant, on May 15, 2017, at 11:20 a.m. stated that, the nursing assistants are reassigned weekly to residents, so they rotate assignments. Employee E15 also stated that if she saw an open area she, would report it to the charge nurse or unit manager. The facility's wound tracking form for pressure ulcers dated December 20, 2016, for Resident R7, revealed an unstageable (covered with slough - a yellow [MEDICATION NAME] tissue or eschar - dark patches of dead skin) wound 4.0 cm x 2.1 cm x 0.1 cm with the color of the wound bed being yellow/red and moderate amounts of serosanguineous drainage (a mixture of blood and serum from the wound). An interview with the Director of Nursing on May 1, 2017, at 2:00 p.m. confirmed that the rubbing of the immobilizer appeared to be the cause of the wound. A review of Resident R46's clinical record revealed that 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 periodic review of the resident's needs) dated May 1, 2016, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores for BIMS assessment suggest the following guidelines: score of 13-15 equals cognitively intact, 8-12 equals moderately impaired cognition, 0-7 equals severe cognitive impairment) score of 13 indicating that the resident was cognitively intact. The resident needed extensive assistance for ambulation, needed two people for transfers and needed assistance of one person for all activities of daily living. Review of the wound risk care plan dated as initiated on 6/10/14 and revised on 10/17/17, revealed that the resident was at risk of developing a wound due to impaired mobility, incontinence and increased moisture. A review of the wound tracking form for Resident R46 dated August 12, 2016, revealed that an open area was found on the resident's sacral area (the area at the bottom of the spine) measuring 5.0 cm by 1.0 cm by 0 depth. The area was identified as red in color. At this time, the area was being treated by cleansing the wound with normal saline, pat dry and apply a [MEDICATION NAME] dressing (a transparent dressing for non infected wounds) on Tuesday, Thursday and Saturday and when the dressing was soiled. Further review of the wound tracking form revealed that the area was measured on August 16, 2016, and measured as 2.7 cm by 0.5 cm by 0.1 cm. The facility did not measure the sacral area for the week of August 22, 2016. The sacral area was not measured for 15 days. The sacral area increased in size from 2.7 cm by 0.5 cm by 0.1 cm to 6 cm by 4.0 cm. An interview with Employee E5, a Unit Manager on May 15, 2017, at 10:20 a.m. confirmed that, the sacral area was not measured weekly as stated in the facility policy and procedure for wound care. There was no documentation available for review that indicated that the physician had been notified of the change in the size of the sacral wound or that the treatment had been adjusted. There was also no documentation that the residents plan of care had been updated or new interventions added when the wound increased in size. On September 6, 2016, the area measured 6 cm by 4 cm by 0 cm. On September 13, 2016, the area measured 5.5 cm by 4 cm. There was no documentation available for review that indicated that the physician had been notified of the change in the size of the sacral wound or that the treatment had been adjusted. There was also no documentation that the residents plan of care had been updated or new interventions added when the wound increased in size. The measurement on September 20, 2016, revealed that the area measured 13 cm by 14 cm by ? (the depth was recorded with a question mark). An interview with the Director of Nursing on April 27, 2017, at 1:00 p.m. revealed that she was unsure what the question mark meant as this measurement was recorded before she worked at the facility. Review of the nurses' notes dated September 20, 2016, revealed that the resident was sent to the hospital due to the size of the sacral area. The resident was admitted to the hospital with [REDACTED]. The resident had a debridement (a surgical procedure to cut away dead tissue) of the sacral area while at the hospital. The resident was readmitted to the facility on [DATE], with a stage IV pressure ulcer (reaching into muscle and bone and causing extensive damage to the deeper tissues, tendons, and joints) which measured 12 centimeters by 12 centimeters by 6 centimeters. An interview with Employee E14, the Charge Nurse, on May 15, 2017, at 11:30 a.m. revealed that she did not identify any new or larger area on the resident's sacral area prior to September 20, 2016. An interview with Employee E13, a Nursing Assistant, on May 15, 2017, at 11:10 a.m. revealed that she did not observe an increase in the resident's sacral wound. She stated, if she observed a new area or change in an area she would report it to the charge nurse/unit manager. Review of the wound tracking form dated April 18, 2017, revealed that the measurement was recorded as 6.2 cm by 5.8 cm by 2.0 cm and the wound was now with tunneling (tunneling -is defined as an open area below the surface of the skin with a tunneling effect). The measurement of the tunneling was recorded as (as if you were looking at the face of a clock) at two o'clock tunneling measured at 4 cm, at 11:00 o'clock tunneling measured at 3.2 cm and between 9 o'clock and 12 o' clock tunneling measured at 2 cm. An observation of the wound on April 27, 2017, at 11:50 a.m. revealed that the sacral wound was a stage IV and measured 7.0 cm by 6.3 cm by 1.8 cm. The tunneling measured at 2 o'clock measured 4.9 cm, at 11 o'clock measured 2.8 cm, and between 9 o'clock and 12 o'clock measured 1.8 cm. The area was being treated with cleansing with normal saline and packed with calcium alginate (used in the treatment of [REDACTED]. A review of the resident's care plan for skin integrity related to actual impairment on the sacrum dated August 12, 2016, revealed that the area and care plan were resolved and discontinued on November 14, 2016, which contradicted the wound tracking sheets and the observations on April 27, 2017. Further review of the resident care plan for skin integrity/actual wound, sacral dated October 7, 2016, revealed that the resident was care planned for treatment as ordered, encourage and assist turn and reposition every two hours, diet as ordered and monitor pain. An interview with the Director of Nursing on April 28, 2017, at 12:00 p.m. revealed she was not at the facility at that time and could not speculate why the care plan was documented as resolved. An interview with Employee E5, on May 1, 2017 at 10:20 a.m. confirmed that the wound was not measured for the week of August 22, 2016 and he could not speculate on why the area was not measured. Also he could not state a reason why the resident's sacral area was not identified as becoming larger before it was measured at 13 centimeters by 14 centimeters on September 20, 2016. The facility failed to assess and measure pressure areas in a timely manner. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 01/23/17, 12/07/16, 10/19/16, 05/29/15. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/19/16, 05/29/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 01/23/17, 12/07/16, 10/19/16, 10/11/16, 07/11/16, 05/29/15. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 01/23/17, 07/11/16, 04/22/16, 05/29/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 01/23/17, 12/07/16, 10/19/16, 10/11/16, 07/11/16, 04/22/16, 05/29/15.