Every finding on record at Oxford Health Center

Findings: A review of the facility's policy titled Surveillance for Infection/Infectious Disease, undated, revealed the facility will conduct daily surveillance for reportable infection or outbreak. The nursing staff must notify the Charge nurse of residents with any of the following conditions: Temperature of 100F or greater; Two episodes or more loose watery stools in a twenty-four-hour period; Inflammation or purulent (pus)drainage at the skin; and Transfer to the hospital because of an infection. The DON (Director of Nursing) of Infection Control (IC) Coordinator must enter the data onto the Weekly Surveillance Line Listing Report (A fundamental row-by-row epidemiological tool used in investigation to organize, track, and analyze key information about individual cases). The DON or the IC Coordinator must collect and tabulate the data to remain aware of trends of an increase in prevalence of infectious conditions. A review of the facility's policy Outbreak Plan, undated, revealed that when there is evidence that there may be an outbreak of an emerging infectious disease, but neither the disease nor the source has been identified, an outbreak investigation is to be completed to determine the source of the problem. A review of the facility's Outbreak Case-Patient Line List Report revealed that Resident 1 had more than one LBM (loose bowel movement) in 24 hours on January 30, 2026. The same report revealed that on February 1, 2026, Resident 2, 3, 4, 5, and 6 had more than one LBM in 24 hours. On February 2, 2026, Residents 7 and 8 had more than one LBM in 24 hours, a total of eight residents on the TCU (Transitional Care Unit) had more than one LBM in 24 hours from January 30, 2026, until February 2, 2026. A review of Resident 9's nursing progress notes dated February 5, 2026, at 1:58 p.m., revealed that residents had two episodes of loose stools. A review of Resident 9's progress notes dated February 9, 2026, at 1:34 p.m., revealed the resident was noted with two episodes of loose stools. Review of Resident 10's nursing progress notes dated February 6, 2026, at 1:40 p.m., revealed the resident had multiple episodes of vomiting and was noted to have multiple episodes of loose bowel. Residents 9 and 10 were not listed on the facility's Outbreak Case- Patient Line List. An interview with the IC nurse, licensed Employee E3, was conducted on March 2, 2026, at 1:00 p.m. Employee E3 reported that residents showing potential infectious symptoms were communicated to the DON during the daily morning meeting and/or verbal reporting. Employee E3 reported that they only work three times a week. Employee E3 added that the previous DON was the one who initiated the line list for resident showing GI symptoms and then was handed to them on February 2, 2026, to follow up on the residents. Employee E3 was unable to provide an explanation as to why Residents 9 and 10 were not listed on the facility's surveillance report. Employee E3 also confirmed that an investigation was not done to determine the source of the resident's GI symptoms. The above was conveyed to the Nursing Home Administrator on February 2, 2026, at 2:00 p.m. The facility failed to ensure appropriate surveillance, monitoring, and tracking were implemented for residents showing GI symptoms. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on facility documentation review, clinical record review and staff interviews it was determined the facility failed to prevent accidents for one of one residents reviewed. (Resident 1) Findings Include:Review of Resdient 1's diagnosis sheet revealed a diagnosis of Alzheimer's disease (a progressive brain disorder that causes memory loss and cognitive decline), osteoarthritis (a degenerative joint disease that happens when the protective cartilage in joints wears down, causing pain, stiffness, and reduced movement), and repeated falls.Review of facility incident report dated September 11, 2025, revealed resident was secure in stand-up lift when (they) moved (their) left arm and would not hold onto the bar causing a skin tear to the left forearm.Review of Resident 1's Occupational therapy notes dated September 8, 2025 revealed Resident 1 trialed in the stand up lift with standing tolerance of less than 30 sec (seconds) due to being anxious with standing. She needed assistance of 1 person to fix her feet on the platform for the lift going to bed, did not need assistance going back to wheelchair. Cues provided throughout to keep BLE (bilateral lower extremities or both feet) on the platform.Further review of Resident 1's incident report dated September 11, 2025 revealed a statement dated September 12, 2025 by licensed therapy employee E3, stating This OT discussed with the RN (Registered Nurse) on the unit that (Resident 1) is to stay a 2-person transfer for safety. In the event that she requires or may need a sit-to-stand up lift, it can only be done by CNAs familiar with her behavior and who has been educated as she tends to pull her fee back off the lift and requires readjustment and constant cues. Review of the incident report dated September 11, 2025 revealed a statement obtained from Nursing Employee E1 on September 12, 2025 stating I helped Nursing Employee 2 transfer (Resident 1) on the night in question. Typically nursing creates and updates the (assignment) sheets for CNAs . to know transfer statuses without having to log into the computer. I thought (OT) had said she was clear for a sit to stand lift about 2 weeks ago.An interview on October 28, 2025, at approximately 2:44 p.m. with Nursing Employee E1 revealed they assisted with the transfer and when they came into the resident's room, the resident was already in the lift. The resident wasn't holding arm rests during the transfer, but when the resident was unclipped from the lift, she witnessed the skin tear. She did not witness any other injury, and the resident was placed in bed.An interview with the Nursing Home Administrator on 10/28/25 at approximately 2:00 PM revealed that the facility conducts competency evaluations to all direct care staff on hire and annually.Review of Employee E1's new hire competency record dated July 3, 2025 revealed that the CNA who assisted with the transfer had been assessed as competent to transfer residents using mechanical lifts. This interview also revealed that the facility provides an orientation to all agency staff and they must be deemed competent to use the mechanical lifts.The facility failed to ensure that the assignment sheet accurately reflected the care needs of Resident 1 for staff to follow while transferring.28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for three of 24 residents reviewed. (Resident 18, Resident 31, and Resident 52). Findings include: Review of Resident 18's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 17, 2024, revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 18 physician's orders revealed that the resident was not ordered insulin. Review of the Medication Administration Record (MAR) revealed that the resident did not receive insulin. Interview with the licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the resident's MDS assessment was marked incorrectly. Review of Resident 31's quarterly MDS of December 6, 2024, section N0350-Insulin, indicated that the resident received an injection of insulin once in the last seven days. Review of physician's orders and MAR revealed no evidence that the resident received insulin. Interview with licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the MDS was marked incorrectly. Review of Resident 52's wound and skin documentation dated October 10, 2024, revealed resident had an unstageable pressure ulcer (full thickness tissue loss where the depth cannot be assessed due to the presence of necrotic tissue [dead or dying cells] to the right heel. Review of quarterly MDS of October 11, 2024, section M0210-Unhealed Pressure Ulcers indicated Resident 52 did not have any unhealed pressure ulcers. Interview with licensed staff, Employee E3, on January 16, 2025, at 11:14 a.m. confirmed that the MDS was marked incorrectly. 483.20 Resident Assessments Previously cited 2/15/24 28 Pa. Code 211.5(f) Clinical records Previously cited 2/15/24 28 Pa. Code 211.12(c) Nursing services Previously cited 2/15/24 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/15/24

Based on facility record reviews, and staff and resident interviews it was determined that the facility failed to ensure call bells were answered in a timely manner on two of two floors. (First & Second Floor) Findings include: Review of facility records revealed a Call Bell Response policy, undated, that documents call lights/alerts will be responded to in a timely fashion. The purpose being to respond promptly to resident calls for assistance and promote a secure atmosphere for residents. All nursing personnel must be aware of call lights/alerts at all times. Staff should answer bells/alerts promptly whether or not they are assigned to the resident Review of facility records revealed a call bell response time report dated December 9, 2024, documenting call bell response times, over 15 minutes, from November 1, 2024, thru November 30, 2024. Review of the report revealed a total of 283 call alarms with an average response time of 28.07 minutes. Further review of the report revealed response times as long as 111.05 minutes. Interviews with Residents R1, R3, R4, and R6, on December 9, 2024 revealed the residents had concerns with call bell response times. Interview with Resident R1 on December 9, 2024 at 9:45 a.m. revealed he/she experienced long call bell response times but R1 was unable to provide specific timeframes. Interview with Resident R3 on December 9, 2024 at 9:52 a.m. revealed he/she experienced call bell response times of more than 10 minutes or more but less than 60 minutes. Interview with Resident R4 on December 9, 2024 at 10:00 a.m. revealed he/she experienced call bell response times of 20 minutes or more. Interview with Resident R6 on December 9, 2024 at 10:06 a.m. revealed he/she experienced call bell response times of 45 minutes to over 60 minutes. Interview with visiting family member on December 9, 02204 at 10:20 a.m. revealed R6 called the previous night complaining that he/she had been waiting 45 minutes for staff to answer his/her call bell. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 9, 2024, at 3:15 p.m. when the above information was presented, the NHA confirmed call bell response times up to 111.05 minutes. The NHA stated call bell response times are an ongoing objective of their Quality Assurance Performance Improvement (QAPI) strategy planning. The NHA stated all response times over 40 minutes are investigated. Per the NHA the findings of the investigations usually result in staff assisting other residents at the time call bells are rung. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the four units observed (Dementia Unit). Findings include: Observation conducted during the environmental tour of the rooms in the Dementia Unit on February 11, 2024, at 10:22 a.m. The observation revealed room [room number] was occupied by two residents. A white paper with a typewritten note indicating Please use XL (extra-large) pull up with underwear over top and remind resident it's ok to urinate in underwear if can't make it to the bathroom was posted above Resident 43's bed (A) which was visible to the people walking in the hallway. Observation conducted on February 15, 2024, at 10:00 a.m., revealed the same message noted above continued to be posted on Resident 43's wall above the bed. Interview conducted with unlicensed staff, Employee E5, on February 15, 2024, at 10:15 a.m., revealed that the note had been posted on the resident's wall for a couple of weeks now but was not sure who did it. Interview conducted with the Nursing Home Administrator (NHA) on February 15, 2024, at 1:00 p.m., The NHA confirmed that the note was not posted by the resident's family. The NHA was unable to determine who posted the note mentioned above. The NHA confirmed that resident personal information should have not been posted visible to the public. The facility failed to ensure the dignity of Resident 43 was maintained by posting private information visible to the public. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to report to the State agency an allegation of abuse for one of 24 residents reviewed (Resident 28). Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed For Skilled Facilities covered under the Elder Justice Act an individual must report any alleged violations of abuse OR if there was serious bodily injury the facility MUST report the allegation to the DOH IMMEDIATELY BUT NO LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE. For those allegations that are neglect, exploitation, misappropriation of resident property, or mistreatment that do NOT result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was reported to the State agency. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not reported to the State Agency. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for one of 24 residents reviewed (Resident 28). Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed Events involving evidence or reports of physical, sexual, mental or verbal abuse, involuntary seclusion, neglect and misappropriation of resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 ours or within the timeframe that has been identified. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was thoroughly investigated by the facility. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not thoroughly investigated by the facility. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 24 residents reviewed (Residents 82 and 84). Findings include: Review of Resident 82's MDS Assessment (periodic assessment of resident needs) dated January 2, 2024, revealed a discharge status of home/community. Review of Resident 82's nursing progress notes dated January 2, 2024, at 12:55 p.m., revealed Nurse Practitioner ordered to transfer the resident to the ER (emergency room ) due to acute left-sided abdominal pain. Review of the nursing progress notes dated January 2, 2024, at 6:48 p.m., revealed that after the evaluation from [name of hospital] ER, Resident 82 was transferred to another hospital where she/he had previous surgery. The family will be coming to gather personal items. Interview conducted with the RNAC (Registered Nurse Assessment Coordinator) Employee E3, on February 15, 2024, at 11:00 a.m., confirmed that the Resident was sent to the hospital and was not discharged to home/community on January 2, 2024. Review of Resident 84's discharge MDS assessment dated [DATE], Section A2105 Discharge Status, indicated that the resident was discharged to an acute hospital. Review of Resident 84's clinical record including nursing progress note dated November 15, 2023, revealed that the resident was discharged home on November 14, 2023. During an interview with the RNAC , Employee E3, on February 15, 2024, at 10:08 a.m. confirmed that the resident was discharged home and that the MDS assessment was marked incorrectly. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 18 residents reviewed (Resident 141). Findings include: Review of Resident 141's admission MDS (Minimum Data Set - periodic assessment of resident needs) of February 5, 2024, revealed that the resident had an indwelling catheter (flexible tube placed in the bladder to drain urine). Review of the current physician's orders also indicated that the resident had a catheter. Further review of the clinical record failed to reveal a care plan related to the indwelling catheter. Interview with Employee E4, corporate representative, on February 15, 2024, at 9:13 a.m. confirmed that a care plan for the catheter was not developed until February 14, 2024. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23

Based on review of clinical records and staff interviews, it was determined that the facility failed to follow a physician's order regarding diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) treatment for two of 18 residents reviewed (Residents 2 and 85). Findings include: Review of Resident 2's Physician's Order Sheet (POS) dated January 12, 2023, revealed the following orders: Check blood sugar three times a day with a scheduled time at 7:30 a.m., 11:30 a.m., and 4:30 p.m. An order on the same day was also made to inform the physician if the blood glucose level results are greater than 450 mg/dl (blood glucose level). Review of Resident 2's March 2023 Medication Administration Records (MAR) revealed a blood sugar of 475 mg/dl on March 2, 2023, at 4:30 p.m. Further review of Resident 2's clinical record failed to reveal the physician was notified of the blood sugar result of 475 mg/dl on March 2, 2023. Review of Resident 2's April 2023 MAR revealed an order initiated on December 30, 2020, to administer Novolog (fast-acting insulin) 10 units subcutaneously (Insertion of medications beneath the skin either by injection or infusion) at 11:30 a.m. The MAR further revealed on April 11, 2023, the ordered blood sugar check and Novolog 10 units ordered at 11:30 a.m., were not done, with documentation that the resident was out of the facility. At 4:30 p.m., on the same day, Resident 2's blood sugar was 469 mg/dl. Review of the progress notes dated April 11, 2023, at 3:02, revealed resident attended a Walmart outing. The clinical records review failed to reveal that the physician was notified of the missed blood sugar check and ordered Novolog 10 units at 11:30 a.m. There was no evidence that the physician was also notified of the blood sugar of 469mg/dl at 4:30 p.m. Review of Resident 85's POS dated March 8, 2023, revealed an order for Insulin Aspart (A fast-acting insulin) sliding scale coverage before meals and at bedtime: 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; >400- 12 units and notify provider. Nursing notes dated March 8, 2023, at 1:51 p.m., revealed that the above order was made by the NP (Nurse Practitioner) after being informed of a blood sugar of 568 at 8:00 a.m., and a blood sugar of 507 at noon. Review of the March 2023 MAR revealed a blood sugar of 427 mg/dl on March 8, 2023, at 4:30 p.m., the resident was administered a sliding scale order of 12 units of insulin. The clinical records review failed to reveal that the physician was notified of Resident 85's blood sugar of 427 mg/dl at 4:30 p.m. Interview with licensed nurse Employee E3 was conducted on April 19, 2023, at 10:00 a.m. Employee E3 confirmed that the physician should be notified immediately of a blood sugar result above the ordered parameter for possible additional orders. Employee E3 reported that documentation of the blood sugar result, conversation with the physician, and possible new orders are documented in the resident's clinical record. Interview with the Director of Nursing was conducted on April 20, 2023, at 11:30 a.m. The DON confirmed that there was no documented evidence that the physician was notified of the following: Resident 2's elevated blood sugar result on March 2, 2023, and April 11, 2023, at 4:30 p.m.; Resident 2's missed blood sugar check and ordered Novolog insulin on April 11, 2023, at 11:30 a.m.; and Resident 95 's blood sugar of 427 on March 8, 2023, at 4:30 p.m. The facility failed to ensure Resident 2's and Resident 85's physician's order for their diabetic treatment was followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of personnel records, and interviews with staff, it was determined that the facility failed to ensure newly hired employees received the abuse training outlined in their policy for two of 5 personnel records reviewed (Employees E4 and E5). Findings include: Review of facility policy Abuse Neglect or Exploitation last revised October 24. 2022 revealed that all employees would be trained on abuse, neglect, mistreatment of residents, and misappropriation of resident's property prior to being assigned to resident care areas. Training would include education on facility policy, interventions on dealing with aggressive residents, reporting abuse without fear of reprisal, recognizing burnout, what constitutes abuse, what constitutes reasonable suspicion of crime, definition of serious bodily harm, responsibility for reporting abuse, consequences of not reporting abuse and resident's right to privacy. Review of Dietary Aide, Employee E4's personnel record revealed a hire date of January 28, 2023. Further review of Employee E4's personnel record failed to reveal any completed abuse training. Review of CNA, Employee E5's personnel record revealed a hire date of February 3, 2023. Further review of Employee E5's personnel record failed to reveal any completed abuse training. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 1:30 p.m. confirmed that there was no completed abuse training in the personnel file for CNA, Employee E5 and Dietary Aide E4. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b) Management

Based on a review of the facility's policy, documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident 1) was free of neglect during care which resulted in actual harm by sustaining a right clavicle (the collarbone) fracture due to a fall from a lift. This deficiency is cited as past non-compliance. Findings include: A review of the facility's policy titled, Abuse, Neglect, or Exploitation, dated May 21, 2020, revealed that, each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress to the resident despite knowledge that the care and services were required. A review of Resident 1's clinical record revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Comprehensive Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care) dated April 11, 2021, revealed that the resident was cognitively intact. The same MDS also revealed that the resident required extensive two-person physical assistance in bed mobility and transferring. A review of Resident 1's current care plan developed on April 16, 2021, revealed an intervention for impaired physical mobility that the resident was to be transferred with two assist using the Hoyer lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power and a sling). A review of Resident 1's clinical record revealed a nursing note dated May 6, 2021, stating the resident requested to get back in bed before dinner. She was hooked up to the Hoyer lift and while in the air, the nursing assistant noticed that one hook was not securely fastened. Before it could be corrected, it completely unhooked and the resident fell on to the floor onto her right side. A 3 centimeter (cm) x 3 cm hematoma (bruise) was noted to right side of her head with 1 cm x 1 cm open area in the middle. The site was cleaned. The resident complained of right shoulder pain. A STAT (immediate) X-ray was ordered as well as ice to the head. No complaints of nausea or dizziness. The resident's X-ray images were reviewed by the physician and a verbal order was given to send the resident to the hospital. A review of the hospital records dated May 6, 2021, revealed that Resident 1, presented to the emergency department after a fall where staff was trying to put the patient on a Hoyer lift and accidentally dropped on right side. The shoulder took the [NAME] of the force, but patient also hit the back side of her head. Patient complaining of right-sided seven out of ten shoulder pain. X-ray shows evidence of a collarbone fracture. Laceration of the scalp was mended. Review of the clinical record revealed a nursing note on May 7, 2021, that stated Resident 1 arrived at 3:20 a.m. via a stretcher from the hospital, after a fall from a Hoyer lift, laceration to the right side of the head with 2 staples, right clavicle fracture, with arm in sling. Resident was alert and oriented with clear speech and was able to make needs known. The physician was notified of return and new orders for [MEDICATION(S)]-acetaminophen 5-300mg per tab, take 1-2 every 4-6 hours as needed for pain. A review of the facility's documentation, incident report, revealed that an agency Nurse Aide (NA), Employee E3's, written statement completed on May 6, 2021, stated, Resident (1) was being transferred by Hoyer sling and came lose and resident fell to the floor. I attempted to lower the resident to the floor as she was falling. The resident hit her head. Further documentation states that when the Nurse Supervisor (Employee E4) asked the Nurse Aide (Employee E3) if he knew that the Hoyer lift was a two person assist and he stated,yes, but he was unable to find anyone to help him. Review of Employee E3's facility education revealed that on May 5, 2021, (one day prior to the incident) the, Use of Mechanical Lifts and Gait Belts, was reviewed and the nurse aide demonstrated his knowledge of the topic. A review of documentation submitted by the facility dated May 7, 2021, revealed that the facility initiated an investigation, regarding resident neglect on May 6, 2021. The investigation was completed on May 7, , and it was determined that Employee E3 used the Hoyer lift and did not request assistance from another staff member. Employee E3 was suspended from work pending the investigation. The facility's investigation concluded that Employee E3 was aware that mechanical lifts require two staff members. Employee E3 was sent home after the incident and his agency was notified that he may not return to the facility. An interview with the Director of Nursing (DON) and the Nursing Home Administrator on May 24, 2021, at 1:00 p.m. confirmed that Employee E3 did not ask for assistance when using the Hoyer lift which required two people assist. The facility failed to ensure that Resident 1 was free from neglect resulting in actual harm by sustaining a right clavicle fracture and a laceration from a fall from a Hoyer lift. This deficiency is cited as past non-compliance. On May 6, 2021, the facility initiated education to ensure that mechanical lift transfers are performed with two person assist this plan included the following: Immediate removal of the NA from the facility and the agency was contacted and informed that the NA may not return. Immediate education regarding the use of two staff members with transfers utilizing the Hoyer lift was providd to all facility and agency nursing staff which included NA, LPN (Licensed Practical Nurse) and RN's (Registered Nurse) which occurred from May 6 - May 18, 2021. Nursing staff received education prior to the start of their shifts. All staff included in the education also completed competencies conducted by the Registered Nurse Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during the onsite investigation. Audits were conducted by the DON during four mechanical lift transfers per week since May 12, 2021, and will continue for one month and randomly thereafter. These audits will be reviewed at the Quality Assurance meetings. Facility has demonstrated compliance with the regulations since May 18, 2021. During an interview with the NHA and the DON on May 24, 2021, at 1:00 p.m. and review of the facility's immediate actions, education, competencies, audits, and review of the Quality Assurance monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding the use of mechanical lifts and had achieved substantial compliance with the regulation. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 12/14/20, 6/20/19 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/30/21

Based on review of clinical record and facility documentation, and staff interview, it was determined that the facility failed to provide adequate assistance as indicated on the resident's plan of care related to their transfer status with a mechanical lift which resulted in actual harm of a right clavicle (the collarbone) fracture due to a fall from a lift for one of three residents reviewed (Resident 1). This deficiency is cited as past non-compliance. Findings include: A review of Resident 1's clinical record revealed that the resident had diagnoses that included [CONDITION(S)] affecting the right side (paralysis on right side), history of TIA ([CONDITION(S)] - symptoms similar to a stroke but may come and go), chronic pain and muscle weakness. A review of Resident 1's Comprehensive Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care) dated April 11, 2021, revealed that the resident was cognitively intact. The same MDS also revealed that the resident required extensive two-person physical assistance in bed mobility and transferring. A review of Resident 1's current care plan developed on April 16, 2021, revealed an intervention for impaired physical mobility that the resident was to be transferred with two assist using the Hoyer lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power and a sling). A review of Resident 1's clinical record revealed a nursing note dated May 6, 2021, stating the resident requested to get back in bed before dinner. She was hooked up to the Hoyer lift and while in the air, the nursing assistant noticed that one hook was not securely fastened. Before it could be corrected, it completely unhooked and the resident fell on to the floor onto her right side. A 3 centimeter (cm) x 3 cm hematoma (bruise) was noted to right side of her head with 1 cm x 1 cm open area in the middle. The site was cleaned. The resident complained of right shoulder pain. A STAT (immediate) X-ray was ordered as well as ice to the head. No complaints of nausea or dizziness. The resident's X-ray images were reviewed by the physician and a verbal order was given to send the resident to the hospital. A review of the hospital records dated May 6, 2021, revealed that Resident 1, presented to the emergency department after a fall where staff was trying to put the patient on a Hoyer lift and accidentally dropped on right side. The shoulder took the [NAME] of the force, but patient also hit the back side of her head. Patient complaining of right-sided seven out of ten shoulder pain. X-ray shows evidence of a collarbone fracture. Laceration of the scalp was mended. Review of the clinical record revealed a nursing note on May 7, 2021, that stated Resident 1 arrived at 3:20 a.m. via a stretcher from the hospital, after a fall from a Hoyer lift, laceration to the right side of the head with 2 staples, right clavicle fracture, with arm in sling. Resident was alert and oriented with clear speech and was able to make needs known. The physician was notified of return and new orders for [MEDICATION(S)]-acetaminophen 5-300mg per tab, take 1-2 every 4-6 hours as needed for pain. A review of the facility's documentation, incident report, revealed that an agency Nurse Aide (NA), Employee E3's, written statement completed on May 6, 2021, stated, Resident (1) was being transferred by Hoyer sling and came lose and resident fell to the floor. I attempted to lower the resident to the floor as she was falling. The resident hit her head. Further documentation states that when the Nurse Supervisor (Employee E4) asked the Nurse Aide (Employee E3) if he knew that the Hoyer lift was a two person assist and he stated,yes, but he was unable to find anyone to help him. Review of Employee E3's facility education revealed that on May 5, 2021 (one day prior to the incident) the Use of Mechanical Lifts and Gait Belts was reviewed and the nurse aide demonstrated his knowledge of the topic. A review of the facility's documentation, incident report, revealed that an agency Nurse Aide (NA), Employee E3's, written statement completed on May 6, 2021, stated, Resident (1) was being transferred by Hoyer sling and came lose and resident fell to the floor. I attempted to lower the resident to the floor as she was falling. The resident hit her head. Further documentation states that when the Nurse Supervisor (Employee E4) asked the Nurse Aide (Employee E3) if he knew that the Hoyer lift was a two person assist and he stated,yes, but he was unable to find anyone to help him. A review of documentation submitted by the facility dated May 7, 2021, revealed that the facility initiated an investigation, regarding resident neglect on May 6, 2021. The investigation was completed on May 7, , and it was determined that Employee E3 used the Hoyer lift and did not request assistance from another staff member. Employee E3 was suspended from work pending the investigation. The facility's investigation concluded that Employee E3 was aware that mechanical lifts require two staff members. Employee E3 was sent home after the incident and his agency was notified that he may not return to the facility. An interview with the Director of Nursing (DON) and the Nursing Home Administrator on May 24, 2021, at 1:00 p.m. confirmed that Employee E3 did not ask for assistance when using the Hoyer lift which required two people assist. The facility failed to follow Resident 1's plan of care which identified that the resident required two people to assist with a mechanical lift transfer that resulted in harm from a fall of a right clavicle fracture and a laceration. This deficiency is cited as past non-compliance. On May 6, 2021, the facility initiated education to ensure that mechanical lift transfers are performed with two person assist this plan included the following: Immediate removal of the NA from the facility and the agency was contacted and informed that the NA may not return. Immediate education regarding the use of two staff members with transfers utilizing the Hoyer lift was providd to all facility and agency nursing staff which included NA, LPN (Licensed Practical Nurse) and RN's (Registered Nurse) which occurred from May 6 - May 18, 2021. Nursing staff received education prior to the start of their shifts. All staff included in the education also completed competencies conducted by the Registered Nurse Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during the onsite investigation. Audits were conducted by the DON during four mechanical lift transfers per week since May 12, 2021, and will continue for one month and randomly thereafter. These audits will be reviewed at the Quality Assurance meetings. Facility has demonstrated compliance with the regulations since May 18, 2021. During an interview with the NHA and the DON on May 24, 2021, at 1:00 p.m. and review of the facility's immediate actions, education, competencies, audits, and review of the Quality Assurance monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are transferred safely using two assist with a mechanical lift and had achieved substantial compliance with the regulation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 12/14/20, 6/20/19 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/30/21

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy titled Bowel Management Program dated February 18, 2019, identified if resident does not have a bowel movement per normal routine follow facility specific bowel protocol or physician order. Review of clinical documentation for Resident R66 revealed active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from December 1, 2020, through December 5, 2020 (five days). Further review of clinical documentation, including the December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from December 9, 2020 through December 14, 2020 (six days). Further review of clinical documentation, including the December 2020 MAR, lacked evidence that the physician ordered medications to address no bowel movements were administered. Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from December 16, 2020, through December 23, 2020 (eight days). Further review of clinical documentation, including the December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from December 26, 2020, through January 5, 2021 (10 days). Further review of clinical documentation, including the December 2020 and January 2021 MARs lacked evidence that the physician ordered medications to address no bowel movements were administered. Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from January 15, 2021, through January 18, (four days). Further review of clinical documentation, including the January 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from February 1, 2021, through February 5, 2021 (five days). Further review of clinical documentation, including the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from February 9, 2021, through February 13, 2021 (five days). Further review of clinical documentation, including the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R66 titled Daily Charting revealed no bowel movements from February 19, 2021, through February 25, 2021 (seven days). Further review of clinical documentation, including the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of clinical documentation for Resident R66, including the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further clinical documentation lacked evidence that the physician ordered [MEDICATION(S)] suppository or Fleets Enema were administered as ordered. During an interview on April 29, 2021, at 1:30 p.m. the Director of Nursing confirmed the above findings and the lack of following the bowel protocol/physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, staff interviews, and a review of facility policy and procedure, it was determined that the facility failed to ensure infection control and prevention practices were implemented on one out of seven units observed (Rosewood South and East). Findings include: A review of the facility policy and procedure titled Environmental Services-Laundry-Soiled Linen Collection last approved on March 31, 2014, revealed that soiled linens are picked up from the nursing units at regular intervals to prevent the accumulation of linens, and to prevent the spread of odors and infectious diseases. Guidelines include: Laundry aides will collect linen from the covered containers in the hallways and soiled utility rooms, and soiled linens should be collected at least every two hours, more often if required. An observation on one of the COVID-19 units (Rosewood East), on December 14, 2020, at 10:30 a.m., in the presence of the Director of Nursing (DON) revealed two bags of soiled linen on the floor in front of a resident room (125). Further observation of the spa/shower room on the same unit revealed seven bags of soiled linens and towels on the floor. An interview with the DON on December 14, 2020 at 10:35 a.m., confirmed that the bagged dirty linens and towels should have not been placed on the floor. The DON stated that dirty linens are placed in a designated area at the end of the hallway, behind a zipped wall. An observation on the Rosewood East unit on December 14, 2020, at 12:30 p.m., revealed that the bagged soiled linens and towels were still on the floor in the spa/shower room. Further observation of the same unit revealed four bags of soiled linens and towels on the floor, placed behind an opened zip wall at the end of the hallway. An interview with licensed Employee E3, on December 14, 2020, revealed that the soiled linens and towels should not have been on the floor. Employee E3 stated that housekeeping staff was in the unit around 7:00 a.m. The employee further stated that she/he already called someone to have all the soiled lines removed. An observation on the Rosewood South Unit on December 14, 2020, at 12:40 p.m., revealed a bin in front of the nursing station (left side) overflowing with used gowns. Further observation in front of the nursing station (middle area) revealed an opened bag of linens placed on top of a resident's lounge chair (covered with white linen) and resident clean clothes on a hanger placed on a cart uncovered (right side of the nursing station). An interview with licensed Employee E4, on December 14, 2020, at 12:43 p.m., confirmed that the opened bag of linens and the resident clothes were clean, but was unsure if the lounge chair was clean. Employee E4 stated that the linens and the resident clothes should have not been left by the nursing station and should have been covered. An observation of the television room, located in front of the Rehab staff office, on December 14, 2020, at 12:45 p.m., revealed a white N-95 mask (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) placed on the headrest of a lounge chair. An interview with licensed Employee E5, on December 14, 2020, at 12:45 p.m., revealed that she/he was unsure if the N95 was used or clean. Employee E5 confirmed that the N-95 mask should not have been placed on the lounge chair. Employee E5 immediately put on gloves and discarded the N-95 mask. The above findings were conveyed to the Nursing Home Administrator (NHA), and the DON on December 14, 2020, at 3:30 p.m. The facility failed to ensure that infection control and prevention practices were implemented on the Rosewood South and East Unit. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/20/19 28 Pa. Code 201.18(b)(3) Management. Previously cited 8/25/20, 6/20/19 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 6/20/19 28 Pa. Code 211.12(d)(3(5) Nursing services. Previously cited 6/20/19

Based on review of facility documentation, resident interviews, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of four units (Rosewood). Findings include: Review of facility policy Food Temperature Logs, undated, indicated that food temperatures will be recorded on all menu items for meal service, ensuring that foods are provided in a safe, palatable manner. Interview with Resident R1 on August 25, 2020, at 11:15 a.m., revealed that the food is frequently luke warm and the coffee is always cold. Interview with Resident R2 on August 25, 2020, at 11:05 a.m., revealed that the food is often less than warm and coffee is always cold. Interview with Resident R3 on August 25, 2020 at 11:10 a.m., revealed that the food is sometimes cold. Interview with Resident R4 on August 25, 2020, at 11:15 a.m., revealed that tomato soup was served cold and coffee is always cold. Interview with Resident R5 on August 25, 2020 at 11:20 a.m., revealed that the food is usually cold and coffee is always cold. Observation of the lunch meal on August 25, 2020, revealed that the food cart arrived on the Rosewood unit at 12:25 p.m. The last resident was assisted with their meal at 12:45 p.m., at which time a test tray was evaluated with the food service director (FSD), Employee E3. The test tray revealed the following temperatures: veal parmesan 114.0 F and spinach 120.0 F. Additionally, the lemon meringue pie was 64.0 F. Interview with the FSD at that time revealed that those temperatures were not acceptable. The Nursing Home Administrator was present at the time of the evaluation and was aware of the results. 28 Pa. Code: 201.18 (b)(3) Management.

Based on observation, it was determined that the facility failed to maintain and promote resident's dignity during meals in one of three dining rooms observed (Willowwood dining room). Findings include: Observation conducted of the dining service on (MONTH) 18, 2019 at approximately 7:11 a.m., revealed that Resident 26 was seated at the table for the breakfast meal. Two additional residents sat near at a nearby table beginning to eat their breakfast meals, and the third resident in the dining room just finished ordering breakfast meal. Resident 26 was observed at 7:18 a.m. with spillage of a liquid dietary supplent on her when a dietary aide placed a lidded cup of orange juice near the resident but unable to drink without assistance. Further observations revealed that Resident 26 was not assisted to drink the juice until 7:28 a.m. by nursing aide, which was 10 minutes from the time of service. Continued observation of breakfast meal service revealed Resident 26 was served breakfast meal at 7:43 a.m, a span of 32 minutes during which resident observed other residents in close proximity order, consume, and complete their breakfast meals. Interview on (MONTH) 20, 2019 at approximately 2:20 p.m. with the Nursing Home Administrator and Director of Nursing the above information was presented. The facility failed to promote the dignity of Resident 26 during meal time. 28 Pa. Code 201.29(j) Resident Rights Previously cited on 04/06/18 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 05/22/19, 03/25/19, 11/08/18, 04/06/18

Based on review of the Resident Assessment Instrument and clinical records, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for two of 19 residents reviewed (Resident #2 and Resident #3). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated (MONTH) (YEAR) and (MONTH) (YEAR), indicated that discharge tracking records must be completed and transmitted within 14 days of the Event Date (Section A2300 plus 14 days for discharge records). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). A discharge MDS tracking record for Resident #2 indicated that the resident expired in the facility on (MONTH) 29, 2019, (Section A2300); the discharge tracking record was not transmitted to CMS Quality Improvement and Evaluation System Assessment Submission and Processing System until (MONTH) 18, 2019 (exceeding 14 days). A Quarterly Assessment MDS for Resident #3 indicated a completion date of (MONTH) 7, 2019, (Section Z0500B); the assessment was not transmitted until (MONTH) 18, 2019 (exceeding 14 days). Interview with Registered Nurse Assessment Coordinator Employee E7 (a registered nurse who is responsible for the completion of MDS assessments) on (MONTH) 20, 2019, at 11:30 a.m. confirmed that Resident #2 and Resident #3 assessments were completed, but was not submitted. The facility failed to transmit Resident #2 and Resident #3's MDS assessments to the required electronic systems. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18 (a)(b)(3) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services

Based on observation, staff interview, clinical records and facility's policy and procedure review, it was determined that the facility failed to ensure proper care and maintenance of a peripherally inserted central catheter (PICC- a medical device that is placed into a vein to allow access to the bloodstream) dressing to one out of 19 residents reviewed (Resident #94). Finding include: Review of facility's policy and procedure titled Intravenous device care, created on (MONTH) 8, (YEAR) under PICC line care revealed, Dressing Change- Change transparent dressing and caps weekly and PRN (as needed). Observation on (MONTH) 17, 2019, at approximately 2:50 p.m., revealed Resident #94 with PICC line on his right upper arm. Further observation revealed Resident #94's PICC line dressing had no date on when it was changed, edges of the transparent dressing covering the PICC line was loose. Nursing supervisor, Employee E3 confirmed that Resident #94's PICC tubing should have been dated and proceeded to check when it was last changed. Review of Resident #94's clinical records revealed the resident was readmitted to the facility from an acute care hospital on (MONTH) 17, 2019, with a PICC line in place to administer antibiotic for urinary tract infection [MEDICAL CONDITION]. Review of Resident #94's (MONTH) 2019 medication administration review (MAR) revealed Resident #94's PICC line dressing was changed on (MONTH) 14, 2019. Review of Resident #94's physician order [REDACTED]. Observation on (MONTH) 18, 2019, at approximately 10:09 a.m., revealed Resident #94's PICC line dressing still undated, tape securing the tubing was torn, transparent dressing covering PICC line was more loose off from previous day's observation, PICC tubing dangling. Employee E3 confirmed that PICC line transparent dressing should have been changed and proceeded to change PICC line dressing of Resident #94. The above was discussed with the Director of Nursing on (MONTH) 20, 2019, at approximately 1:00 p.m. The facility failed to ensure proper care and maintenance of Resident #94's PICC line dressing. 28 Pa. Code 211.10(c) Resident care policies Previously cited 1/9/19 and 4/6/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 5/22/19, 3/25/19, 1/9/19, 11/8/18 and 4/6/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 5/22/19, 3/25/19, 1/9/19, and 4/6/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure each resident is provided with necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well being for one of one residents reviewed (Resident 19). Findings include: Review of Resident 19's clinical record revealed [DIAGNOSES REDACTED]. condition Symptoms are difficulty in falling and staying asleep at night). Review of Resident 19's clinical record revealed the resident was seen for a neuroscience consult on (MONTH) 7, (YEAR) with a follow up recommended in two months. Further review of Resident 19's clinical record revealed a pharmacist communication to the physician dated (MONTH) 28, 2019 recommending a dose reduction of a anxiolytic medication as well as notating that resident's last psych (psychological) consult was 9/2018. Review of Resident 19's clinical record revealed a neuroscience consult occurred on (MONTH) 5, 2019. Continued review of clinical record failed to reveal any neuroscience consults between (MONTH) 7, (YEAR) and (MONTH) 5, 2019 which is a six month gap without neuroscience contact. Review of Resident 19's clinical record revealed that during the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019 the resident experienced several behavioral outbursts including behaviors of aggression such as kicking, punching, slapping, and resisting care. Interview on (MONTH) 20, 2019 at approximately 11:26 am with Director of Nursing confirmed that the resident was not seen for psychological services from (MONTH) (YEAR) until (MONTH) 2019. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services Previously cited on 05/22/19, 03/25/19, 11/8/18

Based on review of facility policy and procedure, clinical record review and review of facility documentation, it was determined that the facility failed to ensure that agency staff was timely and appropriately educated to provide proper care to prevent resident injuries during resident transfers for one of three residents reviewed (Resident R1) which resulted in actual harm to Resident R1 sustaining a spiral fracture of the right femur. Findings include: Review of the facility policy and procedure entitled, Body Mechanics for Lifting & Moving Heavy objects, last approved March 31, 2014, indicated that residents weighing 100 pounds or more must be lifted mechanically. When using mechanical lifts, two persons must assist with the transfer. Review of Resident R1's [DIAGNOSES REDACTED].(temporary interference of blood flow to the brain), CVA (cerebral vascular accident - stroke; brain hemorrhage) and idiopathic gout (sudden, severe attacks of pain, redness and tenderness in joints, caused by elevated levels of uric acid in the blood). A review of Resident R1's quarterly Minimum Data set assessment (MDS - an assessment of care and needs) dated June 26, 2017, revealed that the staff interview for cognitive and decision making status identified the resident with short and long term memory problems. Review of Section G - Activities of Daily Living identified the resident as requiring extensive assistance with two person support for transferring and toilet use. The resident was assessed with [REDACTED]. Review of the Resident R1's current care plan identified the resident with a potential for falls due to poor cognitive loss, poor safety awareness and impaired balance. The interventions developed included for the resident to be transferred with a stand-up lift and two staff assistance. Review of Resident R1's nursing interdisciplinary notes dated August 9, 2017, at 2:27 p.m. revealed, resident's right thigh is swollen. Resident verbalizing that the right thigh hurts when touched. Further review of Resident R1's nursing interdisciplinary notes dated August 9, 2017, at 2:50 p.m. revealed, this morning went in to look at resident's leg and also noted that the right thigh was twice the size of the left thigh. Also noticed bruising to right inner thigh and right groin area. Resident would grimace and push hand away when touching the leg. Further review of this interdisciplinary note revealed, orders written for x-ray to right hip, femur and knee. Review of Resident R1's X-ray results dated August 9, 2017, revealed an oblique moderately displaced spiral fracture of the proximal/mid shaft of the right femur, there is soft tissue swelling. Review of facility documentation dated August 9, 2017, revealed that Resident R1's agency nursing staff, Employee E8, who was assigned to take care of the resident on August 7, 2017 and August 8, 2017, transferred Resident R1 from the wheelchair to the bed with no assistance from another caregiver and without the use of the mechanical lift as required per Resident R1's active plan of care. Review of the facility documentation dated August 17, 2017, revealed that Licensed Nursing Staff, Employee E7, asked Employee E8 how she obtained the resident's transfer status. Employee E8 indicated that she received information from other staff members and other nursing assistants regarding Resident R1's transfer status. Further review of this facility documentation revealed Employee E8 was not educated on the use of the electronic system utilized by the facility to allow caregivers to review the care needs of each resident until August 9, 2017 at 10:30 p.m. Further review of this facility documentation revealed that Employee E8 was not oriented and/or educated in the process of obtaining any resident information, including transfer status, prior to providing care to residents in the assigned area, which resulted in actual harm to Resident R1 sustaining a spiral fracture of the right femur. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 02/16/17, 04/07/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/06/17, 02/16/17, 08/18/16, 04/07/16 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 06/06/17, 02/16/17, 08/18/16, 04/07/16 28 Pa. Code 201.18(e)(3) Management Previously cited 02/16/17 28 Pa. Code 211.10(a) Resident care policies Previously cited 02/16/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/16/17, 10/20/16, 08/18/16, 06/23/16, 04/07/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 02/16/17, 08/18/16, 04/07/16 28 Pa. Code 211.11(a) Resident care plan Previously cited 02/16/17, 08/18/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 06/06/17, 02/16/17, 04/07/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/06/17, 02/16/17, 08/18/16, 06/23/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 06/06/17, 02/16/17, 10/20/16, 08/18/16, 06/23/16, 04/07/16

Based on clinical record reviews, review of facility documentation and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of two residents reviewed (Resident R1), which resulted in actual harm to Resident R1 who sustained a fall with a [MEDICAL CONDITION] femur and required hospitalization Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated May 10, 2017, revealed that Resident R1 required extensive assistance of two persons for transferring on and off the toilet, and identified the resident's balance as not steady and only able to stabilize with staff assistance for moving on and off the toilet. The resident was also assessed with [REDACTED]. Review of Resident R1's care plan dated December 17, 2016, identified the resident deficit with activities of daily living. The interventions included for Resident R1 to transfer with a minimum assistance of two persons in the bathroom using the grab bar in her own bathroom. The interventions also noted if the resident was tired, have the nurse assess for the need to use a stand-up lift (mechanical lift that provides support and assistance to residents while attempting to stand). Review of Resident R1's nursing notes dated May 12, 2017, at 5:45 p.m. (which was one day after a fall incident that occurred on May 11, 2017) revealed that it was reported to the licensed nurse that at 3:00 p.m., that Resident R1 was found on the floor by the aide in her bathroom. The nurse documented, found resident sitting on bathroom floor with her left side against the wall. There was two medium sized BM's (bowel movement) in the toilet and nothing wet on the floor. The resident's cognitive status was at baseline - alert and oriented x 3 (person, place and time) with intermittent confusion. The Resident was able to follow verbal commands. The Resident stated she had 6/10 pain (measure of pain severity from 0-10) in lower upper extremities and left lower extremities. Further review of the nursing note revealed that the resident was administered a narcotic pain medication, [MEDICATION NAME] (a pain reliever used to treat moderate to severe pain.) Resident R1 was also administered oxygen via nasal cannula at 2 liters/per minute to increase the resident's oxygen level to 94%. Review of Resident R1's nursing notes dated May 11, 2017, revealed that the resident's physician was present and assessed the resident after the fall in the bathroom and subsequently ordered X-rays to be obtained of Resident R1's pelvis, left hip, cervical spine (neck bones) and left shoulder. Further review of Resident R1's nursing notes dated May 12, 2017 (which was one day after the fall), indicated that an X-ray of Resident R1's left hip, which was ordered by the physician on May 11, 2017, revealed a left femur (large thigh bone) fracture as a result of the fall. Review of Resident R1's nursing notes dated May 12, 2017, revealed that Resident R1 was sent to the hospital emergency roiagnom on [DATE] at 8:29 p.m. for evaluation and treatment. On May 12, 2017, at 12:56 a.m. the nursing notes documented that the resident was being admitted to the hospital for a [MEDICAL CONDITION]. Review of nursing admission notes dated May 16, 2017, at 2:18 p.m. confirmed that the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. Review of information dated May 11, 2017 submitted by the facility revealed that on May 11, 2017, at approximately 2:00 p.m. Resident R1's caregiver was informed that Resident R1 was in the bathroom of the resident's room. Further review of the facility report revealed that Resident R1 was checked by the caregiver at 2:10 p. m. and the resident stated that she needed more time for toileting. The caregiver left the room and decided to go off the floor. Prior to Resident R1's caregiver exiting the nursing unit on May 11, 2017, a second caregiver was notified that Resident R1 was in the bathroom of the resident's room. Facility documentation indicated the second caregiver did not check on the resident and at 3:00 p.m. the resident was found on the bathroom floor. The facility's documentation indicated that neither of the caregivers returned to the bathroom to check on Resident R1 and the resident was found on the floor. The documentation also indicated neglect by both caregivers. During an interview on June 6, 2017, at approximately 1:00 p.m. the Director of Nursing confirmed the resident was left alone in the bathroom for approximately 50 minutes which resulted in a fall. The facility failed to ensure adequate supervision and monitoring of Resident R1 to ensure safety, which resulted in actual harm to Resident R1, who sustained a fall with a [MEDICAL CONDITION] femur and required hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/07/16, 08/18/16, 02/16/17 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 04/07/16, 08/18/16, 02/16/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 04/07/16, 08/18/16, 02/16/17 28 Pa. Code 211.12(c) Nursing services Previously cited 08/18/16, 02/16/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/07/16, 06/23/16, 08/18/16, 10/20/16, 02/16/17

Based on observations, review of clinical records, review of facility policy, review of facility documentation and staff interviews, it was determined that the facility failed to ensure that adequate supervision, monitoring and interventions were provided to prevent accidents and injuries for three of 24 residents reviewed (Resident C11, Resident C16 and Resident D14) which resulted in actual harm to Resident C16 who sustained a fractured left ankle as a result of a fall that occurred when the resident eloped. Findings include: Review of the facility policy entitled, Elopement, revised February 18, 2015, revealed that the facility will identify residents at risk for elopement and develop a plan to prevent unauthorized resident absences from the facility. Further review of this policy revealed that prevention mechanisms used included a secure unit with electronic locking mechanisms, door alarms on the doors that exit to the outside, staff observation of residents, evaluation of potential for elopement and monitor the main entrance for residents at risk for elopement. Review of Resident C16's [DIAGNOSES REDACTED]. Review of Resident C16's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated September 21, 2016, Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS - 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) revealed a score of 10 indicating moderately impaired cognition. Review of Resident C16's Elopement Risk assessment dated [DATE] revealed a score of 10 which indicated that Resident C16 was a risk for elopement. Continued review of the Elopement Risk Assessment revealed Intervention Options including Diversion-Distraction; Care Planned Visual Check; Wanderguard Bracelet Door Alarm and Secured Area. Further review of the Elopement Risk Assessment revealed that none of the above Intervention Options were chosen as an intervention for Resident C16 regarding the resident being a risk for elopement. Review of facility documentation revealed that on October 2, 2016, at approximately 3:20 p.m. Resident C16 exited the building, in a wheelchair, after attending church services in the facility chapel. Further review of this facility documentation revealed that Resident C16 exited the building via the front entrance along with other church members. Review of nursing interdisciplinary notes dated October 2, 2016, revealed that the facility's receptionist was alerted by visitors that Resident C16 was observed lying on the driveway in the drop off circle, at the end of the walkway. Review of the resident's incident report revealed that the receptionist observed Resident C16 exit the building but the receptionist did not know the identity of Resident C16. Review of the nursing interdisciplinary notes dated October 2, 2016, revealed that Resident C16 was transferred to the hospital. X-rays obtained at the hospital revealed that Resident C16 had suffered a left ankle fracture as a result of the fall. Review of the care plan for falls in effect on October 2, 2016, revealed that Resident C16 was at risk for falls related to weakness and deconditioning, periods of confusion and pain in knees. Interventions included monitor and anticipate/intervene factors causing previous or potential for falls and provide assistance with all transfers via stand up lift and two assist. Resident C16's care plan failed to reveal any interventions in place with regard to elopement. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on February 16, 2017 at approximately 2:00 p.m. The facility failed to ensure that interventions were in place for a resident assessed as a risk for elopements which contributed to the resident exiting the building, and resulting in actual harm with the resident sustaining a fractured left ankle as a result of a fall. Review of Resident C11's [DIAGNOSES REDACTED]. Review of Resident C11's current fall care plan revealed that Resident C11 had a potential for falls by history and related to cognitive loss, psychoactive drug use, seizure disorder, non-compliance with waiting for help with assistance with transfers, weakness and orthostatic hypotension. Further review of Resident C11's current fall care plan revealed interventions including a bed sensor (a device that detects or measures a physical property and records, indicates, or otherwise responds to it) for safety and a wireless chair sensor. Review of Resident C11's nursing notes dated November 19, 2016, at approximately 3:10 p.m. revealed that Resident C11 was found on the floor of the resident's room, lying face down. Further review of the nursing notes revealed that Resident C11 complained of pain and was sent to the emergency room for evaluation on November 20, 2016. Review of facility documentation dated November 19, 2016, revealed that Resident C11 was observed in bed at approximately 2:30 p.m. on November 19, 2016. Further review of the facility documentation dated November 19, 2016 revealed that Resident C11's bed sensor was unplugged and was unable to alarm at the time of the fall. Interview with the Director of Nursing on February 15, 2017, at approximately 10:00 a.m. failed to reveal why Resident C11's bed sensor was unplugged while Resident C11 was in bed. Review of Resident D14's [DIAGNOSES REDACTED]. Review of Resident D14's fall care plan initated on December 1, 2014 revealed that Resident D14 had a potential for falls related to cognitive loss, weakness, resistance to care at times and psychoactive medication use. Further review of Resident D14's fall care plan initated on February 25, 2016 revealed interventions including encourage resident to rest in recliner chair in lounge after meals, mobility with wheelchair and staff assist and transfer with two assist, and the resident was dependent on the wheelchair for all mobility, leave resident in common area until ready for bed, frequent rounds on resident during shift to observe safety of resident. Review of Resident D14's nursing notes dated November 23, 2016, revealed that Resident D14 fell in the dining room sustaining a 3 centimeter x 2 centimeter hematoma (bruise) to the right side of the forehead. Resident D14 was subsequently sent to the hospital emergency room for evaluation. Review of the resident's incident report revealed that Dietary Staff, Employee E9, witnessed Resident D14's fall in the dining room. Further review of facility documentation revealed that Employee E9 went to aide Resident D14 while another dietary employee sought nursing assistance. Review of the facility documentation revealed that the nursing staff were not present in the Dogwood Dining Room at the time of Resident D14's fall. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on February 16, 2017 at approximately 2:00 p.m. The facility failed to ensure that interventions and proper monitoring to prevent accidents were in place for Resident C11 and D14. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 09/30/15, 04/07/16 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 09/30/15, 04/07/16, 08/18/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 09/30/15, 04/07/16, 08/18/16 28 Pa. Code 201.18(e)(1) Management Previously cited 03/10/15, 09/30/15, 04/07/16, 08/18/16 28 Pa. Code 201.18(e)(3) Management Previously cited 09/30/15 28 Pa. Code 211.10(a) Resident care policies Previously cited 03/10/15, 09/30/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 03/10/15, 09/30/15, 04/07/16, 08/18/16 28 Pa. Code 211.11(a) Resident care plan Previously cited 09/30/15, 08/18/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 03/10/15, 09/30/15, 04/07/16, 08/18/16 28 Pa. Code 211.12(c) Nursing services Previously cited 03/10/15, 09/30/15, 06/23/16, 08/18/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 03/10/15, 06/03/15, 09/30/15, 04/07/16, 06/23/16, 08/18/16, 10/20/16

Based on observation, review of facility policy, clinical record reviews and staff interview, it was determined that the facility failed to accurately assess, timely identify and provide all the necessary care and services to prevent the development and promote the healing of pressure ulcers for one of 24 residents reviewed, resulting in actual harm to Resident D2. Findings include: Review of the facility policy entitled, Wound Care, last approved May 1, 2015, revealed that facility staff was to consult with the physician regarding orders for treatment, appearance of infection and debridement of treatable eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) or sloughing (separation of dead tissue from living tissue, yellow, tan, gray, green or brown) wounds. Further review of the policy revealed that the presence of new wounds would be documented on the, Skin Condition/Skin Assessment form upon discovery. The wounds would be measured and documented weekly on the, Skin Condition/Skin Assessment form and any indicators of infection would be reported to the physician. Review of Resident D2's admission documentation revealed that the resident was readmitted to the facility from the hospital on June 21, 2016. Review of Resident D2's discharge records from the hospital dated June 21, 2016 revealed discharge [DIAGNOSES REDACTED]. Review of the results of a podiatry (foot doctor) consultation completed while the resident was in the hospital and dated June 21, 2016, revealed, 3 eschar (three wound areas) to the lateral (side) posterior (back) LLE (back of left lower leg - calf). Further review of the nursing interdisciplinary note completed after the resident was readmitted to the facility dated June 21, 2016, revealed, left calf scattered abrasions (scratches) measuring 1.5 x .5 cm, 4 x 1.5 cm, 1 x 2 cm and 2 x 1 cm (centimeters). Review of Resident D2's Skin Evaluation Form dated June 21, 2016, completed at the time of readmission to the facilty revealed, scattered abrasions 1.5 x .5 cm, 4 x 1.5 cm, 1 x 2 cm and 2 x 1 cm. Review of the nursing interdisciplinary notes dated June 22, 2016, revealed, wound team was emailed r/t (related to) non-healing wounds to calf of LLE. Further review of the nursing interdisciplinary notes dated June 22, 2016, revealed, multiple wounds on left lower extremity. Review of the wound team notes dated July 5, 2016, revealed, resident seen for 3 wounds to left lower leg, posterior calf 1.0 x 1.1 eschar, distal (away) wound eschar 4.2 x 1.9 with 2 x 0.7 area of slough at proximal (next) aspect, proximal wound 2.0 x 1.2 eschar with open center, 0.8 x 1. Order obtained for wound culture and consult with wound center. Review of the, Skin Evaluation Form completed on July 5, 2016 confirmed that the resident was assessed with [REDACTED]. The first wound was described as an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and eschar) pressure ulcer, measuring 1.0 centimeter x 1.1 centimeter, brown in color with serosanguineous (blood shed fluid) drainage, with light exudate (fluid amount). The second wound was described as measuring 2.0 centimeter X 1.2 centimeters, unstageable wound, with serosanguineous fluid, pink in color with light exudate. The third wound was described as measuring 4.4 centimeters x 2.6 centimeters, unstageable wound, with slough, serosanguineous drainage and light exudate. Review of interdisciplinary notes and the physician's orders from June 21, 2016 to July 5, 2016 failed to reveal any physician's orders for treatment to Resident D2's posterior calf wounds and failed to reveal documentation that the wounds were treated and/or monitored from the time that the resident was readmitted to the facility on [DATE], until the resident was assessed by the wound team on July 5, 2016, a period of 15 days. Further review of Resident D2's clinical record failed to reveal that Resident D2's wounds were seen by the physician or the wound team from June 21, 2016, until July 5, 2016. Review of Resident D2's interdisciplinary notes dated July 12, 2016, revealed, the peri (around the edge) wounds have [DIAGNOSES REDACTED] (superficial reddening of the skin) and a foul odor and tan drainage was noted from all wounds. The wounds were tender to the touch. A wound culture was obtained on July 7, 2016, and the organisms staph aureus (a bacteria) and diptheroids (a bacteria) were identified and are sensitive to antibiotics. Further review of the Skin Evaluation Form dated August 9, 2016, revealed that there were two stage 3 pressure ulcers (full thickness tissue loss, bone tendon or muscle not exposed). The distal (further away) posterior calf pressure ulcer was described as measuring 4.1 centimeters x 2.0 centimeters x 0.1 centimeters with sarosanguineous fluid, brown in color . The proximal (closer) posterior calf pressure ulcer was described as measuring 0.9 centimeter x 0.4 centimeters, sarosanguineous fluid and brown in color. Observation of Resident D2's pressure ulcer dressing on August 16, 2016, at approximately 10:00 a.m. in the company of Licensed Staff, Employee E13 and the Assistant Director of Nurisng revealed a large pressure ulcer on the resident's left calf which was uncovered and with no treatment in place. Licensed Employee E13 proceeded to apply treatment to the resident's lower calf pressure ulcer. Further observation of the treatment application revealed Licensed Employee E13 doned a clean pair of gloves and then proceeded to open the package of wound treatment material, touch the wound treatment material with the same pair of gloves that touched the outside of the package, and apply the wound treatment material to the wound with the same pair of gloves. An interview with the Assistant Director of Nursing on August 18, 2016, at 10:00 a.m. failed to reveal why Resident D2's leg wounds were not evaluated by the wound team between June 21, 2016, and July 5, 2016, and failed to reveal that any treatments were in place between Resident D2's readmission on June 21, 2016, and the wound team evaluation on July 5, 2016. The facility failed to timely identify, assesses and provide treatment to prevent the worsening of Resident D2's pressure ulcers resulting in actual harm with the Resident D2 developing an infection of the pressure ulcer wound. 42 CFR 483.25(c) Treatment/Services To Prevent/Heal Pressure Sores Previously cited 04/07/16, 09/30/15, 03/10/15, 02/20/14 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 04/07/16, 09/30/15, 02/20/14 28 Pa. Code 201.18(e)(1) Management Previously cited 04/07/16, 09/30/15, 03/10/15, 02/20/14 28 Pa. Code 211.12(c) Nursing services Previously cited 06/23/16, 04/07/16, 09/30/15, 03/10/15, 01/14/15, 02/20/14

Based on clinical record review and staff interviews, it was determined that the facility failed to timely identify and prevent the development of pressure ulcers for one of 24 residents reviewed (Resident D5), resulting in actual harm. Findings include: Review of Resident D5's clinical record revealed that the resident was admitted to the facility on [DATE], for short term rehabilitation after having a right total knee replacement completed at a local hospital. Review of Resident D5's March 2016, physician's orders [REDACTED]. The resident was ordered to received [MEDICAL TREATMENT] [MEDICAL TREATMENT] (an artificial means of removing wastes from the blood since the kidneys do not work properly) three times a week. Review of a nursing note dated March 14, 2016, revealed that the resident's Braden score (a pressure ulcer (an injury to the skin and the underlying tissue resulting from prolonged pressure on the skin) risk assessment) was 14 which placed the resident at moderate risk for the development of pressure ulcers. The resident was admitted with amputations (removal of all or part of a limb) of the great toe and second toe of the left foot, and an amputation of the second toe of the right foot. Review of Resident D5's clinical record did not reveal any pressure ulcers, open skin areas or blisters at the time of admission on March 1, 2016. Review of Resident D5's clinical record revealed that the resident was transferred to a local hospital on March 7, 2016, after having rectal bleeding, and was admitted to the hospital for an active [MEDICAL CONDITION] (bleeding in the abdomen causing blood to come out of the rectum) and returned to the facility on [DATE]. Review of Resident D5's clinical record did not reveal any pressure ulcers, open skin areas or blisters when readmitted to the facility on [DATE]. Review of Resident D5's clinical record revealed a skin assessment completed on March 26, 2016, which revealed documentation that the resident did not have any pressure ulcers, open areas or blisters present at the time of the assessment. Review of Resident D5's nursing skin assessment form completed on March 28, 2016 at 11:43 p.m., stated the licensed nursing staff was notified by the resident's nursing assistant that the resident was requesting to speak with the licensed nursing staff. It was noted that, Resident complained of foot pain. Upon assessment left foot outer heel SDTI (suspected deep tissue injury-purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) 4 cm (centimeter) by 4 cm noted, left superior foot blister measuring 2 cm by 9 cm, left outer mid foot blister measuring 4 cm by 1 cm. Right foot center heel SDTI (suspected deep tissue injury) 5 cm x 6 cm, right foot superior blister measuring 1 cm x 1 cm and 2 cm x 5 cm also noted. The nursing skin assessment identified the cause of the development of the SDTI, to the right and left foot and two blisters on the left foot and one blister on the right foot, to have been pressure related. Review of the next nursing skin assessment form dated March 29, 2016, completed by the Wound Nurse, Employee E13, revealed that for each area stated above, that it was caused by pressure. The skin assessment form for the left outer heel confirmed that it was caused by pressure and measured 3.6 cm by 4.2 cm. The left outer heel was described as, 100% eschar (dry scab, tan, brown in wound bed) stable, dry circular wound per wound dry. Employee E13 also noted, Resident was assessed by the wound team, the left outer heel has intact stable eschar the wound is circular with calloused raised wound edges; no odor; no drainage; and resident denied pain. The left dorsal foot near the ankle has a Stage II (ulcer involving the the loss of the top layers of the skin) present , this was a previously intact blister that opened; wound bed is 100% [MEDICATION NAME] (superficial tissue). The left outer foot has a deep tissue injury present; intact and dark purple; edges are smooth and attached and the surrounding skin is dry. The right heel has an intact reabsorbing blister; Stage II; the wound bed is dry and intact. The resident is aware of the new interventions for pressure relief for his feet. Review of the nursing skin assessment form dated March 29, 2016, completed by Employee E13 for the pressure ulcer for the left foot dorsal (top) area stated, partial thickness wound, pressure ulcer, 100% [MEDICATION NAME], previous blister now open; located near the top of foot close to the ankle, caused by improper footwear, Stage II wound. Review of Resident D5's care plan did not reveal the development of a plan of care to address the resident's prior history of toe amputations and the potential for skin break down due to multiple medical [DIAGNOSES REDACTED]. An interview with Employee E13 on April 7, 2016 at 2:00 p.m., confirmed that the resident had developed multiple Stage II pressure ulcers and deep tissue injury to both his feet by wearing shoes that were too tight and that the resident also had foot [MEDICAL CONDITION] (swelling, excessive fluid trapped in the body's tissues) present causing the footwear to be too tight for the resident. Employee E13 stated that the physical therapy staff alerted the nursing staff on March 27, 2016, that the resident was complaining of both feet hurting and that the nurse taking care of the resident on that shift, found all of the areas on his feet after removing his shoes. The facility failed to timely identify and provide interventions to prevent the development of multiple pressure ulcers on Resident D5's feet which caused actual harm to Resident D5. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores Previously cited 09/30/2015, 03/10/2015, 02/20/2014 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 09/30/2015, 02/20/2014 28 Pa. Code 201.18(e)(1) Management. Previously cited 09/30/2015, 03/10/2015, 02/20/2014 28 Pa. Code 211.5(f) Clinical records. Previously cited 09/30/2015, 06/03/2015, 03/10/2015, 02/20/2014 28 Pa. Code 211.11(d) Resident care plan. Previously cited 09/30/2015, 03/10/2015, 02/20/2014 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 09/30/2015, 06/03/2015, 03/10/2015, 12/23/2014, 02/20/2014 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 09/30/2015, 06/03/2015, 03/10/2015, 01/14/2015, 12/23/2014, 02/20/2014

Based on clinical record review, facility documentation and staff interview, it was determined that the facility failed to provide adequate supervision to ensure the safety of the residents in the dementia unit resulting in harm to one resident (Resident B18) and failed to shut down and lock the BUNN coffee maker on the Dogwood Unit. Findings include: Review of a police report dated January 30, 2016, revealed that the Director of Nursing reported that an incident occurred where a male resident, Resident B18, was pushed from behind by a female resident, Resident A8, while they were in the hallway of the dementia unit. Additionally it was reported that the female resident, Resident A8 had told the nurse on duty that the male resident, Resident B18, had called her names. Review of Resident A8's nursing notes, revealed incidents in which the resident displayed aggression on May 15, 2015, August 17, 2015, September 2, 2015, October 3, 2015, October 14, 2015, November 28, 2015, December 11, 2015, December 26, 2015 and January 30, 2016. Review of the resident's plan of care revealed new care plan interventions after the incidents in November 2015 and December 2015, which included the following: escort away from fell ow residents during periods of agitation and increased anxiety, and intervene promptly when in conflict with other residents and a medication review. Review of Resident B18's quarterly MDS assessment (Minimum Data Set-periodic assessment of resident needs, current cognitive and physical functioning ability), dated December 24, 2015, revealed [DIAGNOSES REDACTED]. Further review of the assessment revealed that the resident had short term and long term memory problems and that the resident's cognitive skills for daily decision making were moderately impaired. Additionally, the assessment revealed that the resident's behaviors included verbal behaviors, rejection of care, wandering and other behavioral symptoms. Further review revealed that the resident required limited assistance of one person for bed mobility, transfer, ambulation in his room and the corridor, eating and toilet use. In addition, the assessment revealed that the resident was able to ambulate between his room and the corridor with the supervision of one person and further review indicated that the resident was steady at all times during transitions and walking. Review of the nursing notes for Resident B18 on November 7, 2015, November 15, 2015 and November 22, 2015 revealed incidents where the resident had been agitated and involved in physical altercations with other residents in the dementia unit. Review of the new care plan for behaviors for this time period revealed three new interventions: reassess current roommate assignment, a medication review and a psychological evaluation. Review of Resident B18's significant change MDS assessment dated [DATE], revealed in Section E1100 Change in Behavior or Other Symptoms, the resident was a 2 which identified that the resident's behaviors were worse as compared to the prior assessment completed on December 24, 2016. Additional review indicated that the resident required the assistance of two plus person for resident's bed mobility, transfer, ambulation, dressing and personal hygiene Further review indicated that the resident's functional status for eating had decreased to require the assistance of one person. Review of Resident B18 nursing notes dated February 5, 2016, noted as a late entry for January 30, 2016, revealed that at approximately 2:20 p.m., the nurse was called into the hallway as the resident was on the floor and he kept saying that someone pushed him from behind. Review of the investigation report into the incident, dated January 30, 2016, revealed a statement from Nursing Assistant, Employee E6, which indicated that she heard noise in the hallway and opened the door to see Resident B18 on the floor at which time Resident A8 informed her that she pushed him down for calling her names. Review of a statement from Licensed Nursing Staff, Employee E5, indicated that she found Resident B18 on the floor stating that someone pushed him from behind and Resident A8 was standing next to him. A nursing note on January 31, 2016 revealed that the resident was airlifted to the hospital and admitted to the trauma unit. Review of the hospital records dated February 18, 2016, revealed that the resident was found to have a hemorrhagic (abnormal flow of blood) contusion (bruise) of the left frontal lobe (located in the front of the brain), a C1 ring fracture (first vertebra of the cervical spine) and an intraparenchymal lobar hemorrhage (a bleed within the brain tissue) in the left frontal lobe with vasogenic edema (disruption of the blood brain barrier). Further review indicated that the resident would be managed with a hard collar (a support collar for the neck and which limits the neck movement) for 8 to 10 weeks. An interview with Nursing Assistant, Employee E9, on April 5, 2016 at approximately 2:15 p.m., revealed that during report, the outgoing licensed staff gives report to the incoming licensed staff while the nursing assistants do a brief report in the dining area. Employee E9 further stated that the two nursing assistants then monitor the residents in the lounge, dining room and hallway. Furthermore, this employee indicated that at the time of the altercation Nursing Assistant, Employee E6, was giving a shower to another resident and not assisting in the monitoring of the residents in the hallway, dining room and lounge. Additionally Employee E9 stated that there is a nursing assistant who comes on shift and gives a resident a shower instead of helping to monitor the residents and that all staff for the dementia unit received education after the incident on January 30, 2016, to agree that they would not give showers during shift change. An interview with Nursing Assistant, Employee E10, on April 5, 2016 at approximately 2:20 p.m., indicated the same information as Employee E9. An interview with Licensed Staff, Employee E11, on April 5, 2016 at approximately 2:30 p.m., revealed that Nursing Assistant, Employee E6, who was the employee who gave a shower during shift change, was educated and then transferred to another unit. An interview with Licensed Staff, Employee E8, on April 6, 2016 at 1:00 p.m., revealed that the general procedure for change of shift from the day shift (6:00 a.m. to 2:00 p.m.) to the evening shift was that the incoming licensed staff (2:00 p.m. to 10:00 p.m.) does report with the outgoing shift and while this happens the two nursing assistants assigned to the unit should be monitoring the residents in the lounge, dining room and hallway. An interview with Licensed Staff, Employee E11, on April 5, 2016, revealed that Nursing Assistant, Employee E6, who was the employee who gave a shower during shift change was educated and then transferred to another unit. The facility failed to provide adequate supervision in the dementia unit for Resident A8 and Resident B18 with a history of aggression which resulted in actual harm to Resident B18 requiring transfer to the hospital and sustaining a hemorrhagic contusion of the left frontal lobe and a C1 ring fracture. On April 6, 2016 at 10:55 a.m., an observation of the Dogwood Unit's small serving/dining area revealed a shelf to the right which contained a juice machine and a BUNN coffee maker. To the left are two dining room tables with one side pushed against the wall, with three sides of each table to seat residents during meal times and throughout the day. This area was accessible to the residents (bed capacity in this area was 60), facility staff and visitors and as a walk way to enter the larger dining room. On April 6, 2016 at 10:55 a.m., Resident C2 was observed self-propelling through the area in a wheelchair. Resident C2's cognitive status was severely impaired. Resident C4, whose cognitive status was severely impaired, was sitting at the second table facing the wall and Resident B14, whose cognitive status was moderately impaired, was sitting at the first table facing the larger dining room. The BUNN coffee maker had been left on and the staff were not present to provide adequate supervision for the three residents found in this area. Licensed Nurse, Employee E17, was called by the surveyor to the area on April 6, 2016 at 11:00 a.m., and confirmed that the coffee maker had not been turned off or locked. The BUNN coffee maker was shut down (turned to the night mode (inability to pour coffee from the urn)), immediately. During observations conducted on April 6, 2016 at approximately 11:10 a.m., with the Director of Dining Services on the Dogwood Unit, a temperature was taken of the coffee coming from the coffee urn and revealed that the temperature of the coffee was 150.2 degrees Fahrenheit. The Director of Dining Services stated that the dietary department was responsible for shutting down the coffee maker to the night mode and locking the unit. The facility failed to ensure that the Dietary Department followed the protocol of making sure the BUNN coffee maker was placed in the night mode and locked after each meal, ensuring the safety of the residents on the Dogwood Unit. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 09/30/2015, 02/20/2014 28 Pa. Code 201.18(b)(1) Management. Previously cited 09/30/2015, 02/20/2014 28 Pa. Code 201.18(e)(1) Management. Previously cited 09/30/2015, 03/10/2015, 02/20/2014 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 09/30/2015, 06/03/2015, 03/10/2015, 12/23/2014, 02/20/2014 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 09/30/2015, 06/03/2015, 03/10/2015, 01/14/2015, 12/23/2014, 02/20/2014

Based on observations, facility documentation, review of clinical record, staff interviews and review of the facility's policy, it was determined that the facility failed to ensure that the environment remained free of accident hazards and provided adequate supervision on two of four serving kitchens (Dogwood Unit and Chapelwood Unit), thereby placing the health and safety of the residents in Immediate Jeopardy. The facility further failed to provided proper supervision for one of 24 residents reviewed with falls and failed to ensure that the mechanical room and an employee room were properly secured in two of four nursing units (Dogwood Unit and Rosewood Unit). Findings include: Review of the facility policy and procedure entitled, Remote Dining Steam Tables/Dining Area revised May 2010, indicated that each steam table will be turned on 30 to 45 minutes prior to meal service. A temperature log will be maintained for each steam table to assure hot foods are arriving and being held at 140 degrees or higher. The steam table will not be left unattended at anytime when in operation or the area will be secured so that access is limited to staff members and safety for all is maintained. Review of the facility's policy titled, Dogwood Hot Box Policy/Procedure, dated April 3, 2015, revealed to ensure food delivered on trays on the Dogwood Unit maintain appropriate temperatures and that food safety guidelines are followed. It revealed internal safe food temperature must be maintained at 135 degrees Fahrenheit or greater per state regulation. The policy indicated that the device would be turned on by dietary staff and remained on during the following times: 7:30 a.m. to 10:00 a.m., 11:00 a.m. to 1:15 p.m. and 4:00 p.m. to 6:30 p.m. Observation of the Dogwood Dining Room on September 24, 2015, at 4:00 p.m., and to the left of the doorway in the small serving/dining area, revealed a Hot Box (a piece of equipment which is used to keep plated food trays hot until staff are able to distributed food trays to resident rooms). Review of manufacturer's manual for the Hot Box C175 Series user manual for the un-insulated heated cabinet revealed the following warning instructions: Allow the unit to cool before cleaning, as the interior of the cabinet may be hot enough to burn. There was a table also observed in this area, positioned against the wall, which could accommodate three residents. Adjacent to the satellite kitchen and small serving/dining area was a larger dining room which contained approximately twelve tables and could accommodate the rest of the second floor residents (bed capacity in this area was 60). The satellite kitchen contained a steam table. The preparation and serving areas within the satellite kitchen and small/serving dining room were not secured by a gate or other device and the area was accessible to the residents, facility staff and visitors. The observation further revealed that the steam table was observed turned 'ON' in the satellite kitchen. The steam table had the capability of housing four large metal pans. The lids to the four steam wells were hot to the touch. Upon opening the lids to the steam table, steam emanated out. The water temperature tested inside the steam wells at approximately 4:10 p.m., registered at 172 degrees Fahrenheit. There was no dietary or nursing staff observed in the satellite kitchen and the small serving/dining room from 4:00 p.m. to 4:15 p.m. There were five residents observed sitting in the large dining room during this time and there were no dietary or other facility staff located in the immediate area either during the above stated time period. On September 24, 2015, at 4:15 p.m., a dietary staff member arrived into the satellite kitchen area. The Hot Box was not visible from that area of the satellite kitchen which the staff stayed at and was not able to ensure safety of residents in the area of the Hot Box. Futher observation of the small serving/dining area, revealed that the Hot Box was observed turned 'ON'. The outer surface radiated heat and was hot to touch. On September 24, 2015, at 4:20 p.m., the digital internal temperature of the box read 182 degrees Fahrenheit. The external temperature of the Hot Box registered 126.9 degrees Fahrenheit. The door of the Hot Box was not secured and could be easily opened. A resident was observed sitting at the table about 4 feet from the Hot Box which had the CAUTION- HOT sign on it. Other residents were observed walking through this area to access entrance into the large dining room. Interview on September 24, 2015, at 6:00 p.m., with Licensed Nurse, Employee E10, confirmed that the large dinning room was generally used for activities and accessible to residents and visitors at all times. Interview with the Director of Nursing on September 25, 2015, at approximately 10:00 a.m., confirmed that there were two residents with [DIAGNOSES REDACTED]. Interview on September 24, 2015, at 6:30 p.m., with Dietary Employee E7, revealed that the steam table on the Dogwood Nursing Unit was always turned on at about 4:00 p.m. and the staff would meet with other dietary staff at the stand-up meeting, before going to their assigned station for the day. Employee E7 indicated that there was always a period of about 10 minutes (between 4:00 p.m. and 4:10 p.m. to 4:15 p.m.) that the steam table would be turned on and unsupervised by the dietary staff. Further review on September 24, 2015, of the facility documentation for time lines and tasks (daily duty task #3) for the Dogwood Unit PM Dietary Aide revealed that the staff were to turn on the steam table between the hours of 4:20 p.m. to 4:45 p.m., but their assignment did not include when to turn off the steam table and there was also no documentation or assignment of staff to watch the steam table. Additionally, there was no evidence that the staff was assigned to supervise the Hot Box when it was turned on between the hours of 4:20 p.m. to 4:45 p.m. Interview with Employee E10 on September 24, 2015, at approximately 6:45 p.m., confirmed that there was no documentation that a staff person was assigned to turn off the steam table. Observations conducted during the initial tour on September 24, 2015, at approximately 11:45 a.m., of of the Country Kitchen on the Chapelwood Unit (Dementia Unit), revealed that the, electric food warmer counter top had a power switch and a temperature dial located in an unlocked cabinet. An interview with the Assistant Director of Nursing was conducted on September 24, 2015, at approximately 11:55 a.m., and revealed that the residents do wander in this area and could not guarantee that the residents do not rummage through these open compartments. An observation at 4:45 p.m. on September 24, 2015, conducted during the dinner meal revealed the residents were observed sitting in the area of the kitchen and the staff was not present near the electric food warmer counter top. Immediate Jeopardy was identified to the Nursing Home Administrator on September 24, 2015, at 7:45 p.m., for failing to ensure that the Dogwood Unit satellite kitchen and the small serving dining area and the Chapelwood Country Kitchen were safely secured and that adequate supervision was provided to the residents on both units, which placed the health and safety of the residents in immediate jeopardy. The facility submitted an acceptable plan of action which included all dining rooms were immediately evaluated to ensure that any steam tables that were functioning and turned on, were attended at all times. All dining and nursing staff were immediately educated to ensure that the steam tables were monitored at all times. The dining services was provided education to turn off steam tables and ice was to be placed into the steam table to quickly cool the table and the frame. The Hot Box was removed from the satellite kitchen immediately and nursing and dietary staff were educated that if dietary needed to leave the area, nursing was to immediately monitor the area to ensure safety of all residents. The Immediate Jeopardy situation was removed on September 26, 2015, at 1:15 p.m. This was two days after the initial immediate jeopardy issue was identified on September 24, 2015. Review on September 30, 2015, of the facility's Resident Census and Condition Sheet for the Dogwood Nursing Unit also revealed that there were 28 residents with a [DIAGNOSES REDACTED]. An environmental tour occurred on September 29, 2015, at approximately 11:00 a.m., which revealed an unlocked door to the mechanical room on the Rosewood Unit. An interview was conducted with the Nursing Home Administrator and with the Director of Environmental Services, Employee E4, on September 29, 2015, at approximately 11:15 a.m., in which they stated the door should be locked due to the equipment that was located inside the room. The environmental tour also revealed the employee lounge on the Dogwood Unit was unlocked. Inside the room there were three to four large extension cords hanging on the wall and access to the employees' refrigerator. An interview was conducted with Employee E4 on September 29, 2015, at approximately 11:35 a.m., and indicated the room should be locked due to the concerns mentioned above. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 02/20/14 28 Pa. Code 201.18(b)(1) Management. Previously cited 02/20/14 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 02/20/14, 03/10/15 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 02/20/14, 01/14/15, 03/10/15

Based on the review of clinical records, staff interviews and facility policy review, it was determined that the facility failed to prevent significant weight loss for one of 24 residents reviewed. (Resident A1) Findings include: Review of the facility policy entitled, Change in Medical Condition, updated February 18, 2015, stated that, the facility shall provide notice of changes in medical condition, incidents, and other care issues in a timely manner meeting the requirements of accrediting agencies and federal and state regulations. The policy stated the following guidelines as, the facility must consult with competent resident and notify the physician, appropriate facility staff, responsible party or designated person if applicable, significant other, and/or power of attorney for accidents/incidents involving the resident, significant changes in resident's physical, mental, or psycho-social status, need to significantly alter treatment plan of resident and decision to transfer or discharge the resident from the facility. Review of Resident A1's clinical record revealed that at the admitted [DATE], the resident had the following [DIAGNOSES REDACTED]. The resident's Weight Tracking System Report, stated that the resident was weighed on April 2, 2015, and weighed 123 pounds. On May 7, 2015, the resident's weight was recorded as 114.6 pounds which was a weight loss of 8.5 pounds in one month and a total of 13 pounds since admission. This was a ten percent weight loss since admission. Review of the progress notes revealed that a registered dietician or physician was not contacted at this time and there were no new orders. Further review of the resident's Weight Tracking System Report, indicated that the resident's weight was obtained on June 4, 2015, and resulted in a weight of 108.2 pounds, and an additional weight was obtained on June 19, 2015, which resulted in a weight of 105 pounds. A total weight loss from admission was 22.6 pounds, a 17.8 percent weight loss. There was no evidence that the facility explored additional interventions specific to the resident with the health care team, registered dietician, family or physician that addressed the continued weight loss of the resident. Further review of the clinical record revealed that the physician was notified on June 23, 2015, and laboratory studies were ordered. Review of the Registered Dietician documentation revealed that the Registered Dietician completed a note on April 9, 2015, and then again on July 9, 2015. There was no documented evidence that the Registered Dietician provided interventions to address the resident's significant weight loss that occurred between April 2015 and June 2015. An interview was conducted with the Assistant Director of Nursing on September 29, 2015, at approximately 1:30 p.m., that revealed no further documentation could be found and the total amount of weight was substantial and the expectation would be to notify the physician and registered dietician. The facility failed to communicate weight loss between April 2015 and July 2015 to prevent a significant weight loss of 17.8% in a time period of 12 weeks. 42 CFR 483.25(i) Maintain Nutritional Status Unless Unavoidable Previously cited 02/20/14 28 Pa. Code 211.5(f) Clinical records Previously cited 02/20/14, 3/10/15, 06/03/15 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/20/14, 12/23/14, 03/10/15, 06/03/15 28 Pa. Code 211.12(c) Nursing services. Previously cited 02/20/14, 01/14/15, 03/10/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 02/20/14, 12/23/14, 01/14/15, 03/10/15, 06/03/15

Based on review of facility policy and procedure, observations, clinical record reviews and staff and resident interviews, it was determined that the facility failed to provide timely and appropriate care to manage pressure ulcers, failed to investigate for the possible cause of skin breakdown and failed to monitor the development of pressure ulcers until resolved and failed to accurately assess/stage the pressure ulcers for five of 24 residents reviewed resulting in actual harm to one of five residents reviewed (Resident A11). (Residents A11, G80, H95, J119, J106). Findings include: Review of facilities policy and procedure for wound care revealed that the care of wounds was provided in accordance with current research and practice guidelines in order to facilitate healing. Pressure ulcers were to be staged in accordance with the the following guidelines of staging: -Stage 1- intact skin with non-blanchable redness of a localized area usually over a bony prominence. -Stage 2- partial thickness skin loss of dermis presenting as a shallow ulcer with a red or pink wound base without slough. May be present as an intact or open raptured blister. -Stage 3- full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (separation of dead tissue from living tussue, yellow, tan, gray, brown or treen in color) may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. This wounds were to be refer to the primary care physician for examination. -Unstageable wound- eschar tissue is described as dead or devitalized tissue that is hard or soft in texture, usually black, brown or tan in color and may appear scab-like. Necrotic tissue (dead tissue that is black in color) and eschar are usually firmly adherent to the base of the wound and often on the side/edges of the wound. -Suspected deep tissue injury- purple or maroon of discolored intact skin due to damage of underlying soft tissue damage. The pressure ulcer guidelines further stated that wounds were to be assessed for ethiology and documented accordingly. Scabbing of a wound was not considered eschar (dead tissue) Review of Resident A11 January 2014 physician's orders revealed the [DIAGNOSES REDACTED]. Review of Resident A11's admission assessment dated [DATE] identified the resident with severe cognitive impairment. The resident required extensive assistant for transferring of one staff person and demonstrated no ambulation capabilities. Review of the Braden Scale (tool used to evaluate risk for skin breakdown) dated December 28, 2013 revealed a score of 12 which placed the resident at high risk of developing pressure ulcers. Review of Resident A11's nursing notes dated November 5, 2013 identified a 0.2 centimeters x 0.2 centimeters x 0.2 centimeters open area noted to the resident left buttock. There was no documentation of the stage of the open area and no evidence that the physician was notified. Review of Resident A11's November 2013 treatment administration record revealed that there was no treatment obtained and administered to the open area identified on the resident's left buttocks on November 5, 2013. Further review of nursing notes dated November 19, 2013 revealed an open area identified on the resident right buttock measuring 3.0 centimeter x 1.0 centimeter x 0.1 centimeter, 100 % pink [MEDICATION NAME] tissue and a Stage II (partial thickness of skin loss) on the left buttock measuring 7.4 centimeters x 1.2 centimeters x less than 0.1 centimeter with a wound bed 100 % pink [MEDICATION NAME] tissue The facility failed to document the stage of Resident A11's right buttock. Nurses notes dated November 19, 2013 further indicated the stage II open area on left buttock open area increased in size since November 5, 2013. Review of the November 2013 treatment administration record revealed that it was not until November 19, 2013 that a treatment was obtained to treat open areas identified on the resident's left and right buttocks (14 days after first open area discovered).. Further review of Resident A11's nursing documentation dated November 27, 2013 noted that both right and left pressure ulcer areas were resolved. Review of Resident A11 December 2013 physician's orders revealed that an order was obtained on December 2, 2013 for the skin protective ointment [MEDICATION NAME] External Cream 2% to be apply morning and night to the resident's right and left buttocks. On December 24, 2013 the skin protectant ointment was discontinued. There was no documented evidence that there was no other protective treatment used to prevent skin breakdown on Resident A11. Review of Resident A11's nursing documentation dated January 24, 2013 revealed that an Stage II pressure ulcer was identified on the resident left buttock measuring .1 centimeter x 0.3 centimeter x less 0.1 centimeter with a wound bed 100 % pink. The facility failed to stage, and obtained treatment in a timely manner for the development of Resident A11's pressure ulcer of the left buttock and failed to provide continuity in skin treatment to prevent the development of pressure ulcers resulting in actual harm to Resident A11, who had been assessed at high risk for the development of pressure ulcer. Review of Resident G80's current physician orders listed a [DIAGNOSES REDACTED]. Review of Resident G80's skin risk assessment (Braden scale), dated November 27, 2013, indicated that the resident was not at risk for the development of pressure ulcers. Review of Resident G80's nurse note, dated December 21, 2013 at 10:05 p.m., licensed nurse Employee E7, documented that resident was with two open areas to buttocks, physician was contacted and resumed order for treatment with Balmex (adult rash cream that protects skin from irritation). Review of Resident G80's wound team assessment note, documented by wound nurse/ Assistant Director of Nursing, Employee E5, on January 14, 2014 at 11:56 a.m., indicated that resident skin assessment was completed and resident skin appeared to be intact at this time and with standard preventative measures in place the resident would be discharged from wound rounds. There was no clinical evidence provided by facility to confirm that Resident G80 was previously/or currently receiving weekly wound team visits to evaluate the resident's skin and no documented evidence why the wound team would be discharging resident from wound rounds, as documented on January 14, 2014, when the wound team note indicated that Resident G80 had no skin breakdown. Review of Resident G80's nurse note, dated January 15, 2014 at 3:57 p.m., by licensed nurse Employee E4, documented that E4 was called to resident's room during care due to open areas found on buttocks. Noted area 0.1 centimeter by 0.1 centimeter to right inner buttock and 0.1 centimeter by 0.2 centimeter to left inner buttock. Review of incident report for these two open areas, dated January 15, 2014, confirmed that the injury type was due to pressure and the physician was notified and ordered, dated January 15, 2014, for cleansing of the areas to inner buttocks and place Allevyn 3x3 every three days and as needed for 21 days or until healed. Interview with Assistant Director of Nursing, on February 18, 2014 at 10:00 a.m., confirmed that there was no wound team assessment for Resident G80's newly identified pressure ulcer areas which were first documented and reported as per the incident report, on January 15, 2014. Assistant Director of Nursing reported that licensed nursing staff are to notify the wound team of new skin issues via the electronic mail (Email) and that there was no evidence this was done. Interview with Director of Nursing, on February 18, 2014 at 5:00 p.m., confirmed that any incident report would be presented to morning staff meeting,and that wound team staff were present for these meetings and that Resident G80's incident report, dated January 15, 2014, would have been presented to staff and then coordinated with the wound team for further assessment and monitoring. Interview with the Assistant Director of Nursing, Employee E5, on February 18, 2014 at 5:00 p.m., further confirmed that those licensed staff working on Resident G80's nursing unit and the wound team failed to monitor or document Resident G80's two pressure ulcers. However, wound nurse, Employee E5 reported that the resident's skin must have healed because the physician's treatment order, dated January 15, 2014, for cleansing of the areas to inner buttocks and place Allevyn 3x3 every three days and as needed for 21 days or until healed was discontinued by the wound team/Employee E5, on January 23, 2014. Request by surveyor for evidence that the physician was notified that Resident G80's pressure areas had resolved revealed that there was no documentation to confirm that the attending physician was notified that the pressure ulcer had healed and that treatment would be discontinued as ordered. Surveyor inquired of wound nurse/Employee E5 on February 18, 2014, if it was known by facility if the pressure ulcers areas, identified on January 15, 2014 to Resident G80's buttock were resolved as of date. Resident's current skin issues were unknown by the wound nurse/Employee E5. Facility provided surveyor, on February 19, 2014, in a nurse note, dated February 18, 2014 at 11:15 p.m., documented by licensed Employee E3, that observation of Resident G80's skin confirmed that resident's buttock was intact. Interview with Director of Nursing and Assistant Director of Nursing, on February 19, 2014 at 3:00 p.m., both confirmed that the facility should have completed an incident report when Resident G80 was first documented, on December 21, 2013, with two, open areas to the buttocks, to determine the possible cause. Further, there was no other evidence that licensed nurse Employee E7, followed facility policy and procedure in properly assessing the two open areas to determine the appropriate staging and treatment of [REDACTED]. Assistant Director of Nursing/wound nurse, also confirmed that Resident B80's skin breakdown and open areas for December 21, 2013 and resolved January 15, 2014 should have been monitored and assessed weekly by the wound team until the areas resolved. Review of Resident J119's nurse's notes dated October 17, 2013 revealed that the resident had an open area in the right buttock measuring 0.4 centimeters (length) x 0.8 centimeters (width) and there were no other description of the area (no description of tissue color, drainage). Resident J119's nurse's notes dated October 22, 2013 revealed that the resident had an open area in the left buttock measuring 0. 5 centimeters (length) x 0.8 centimeters (width) and less than 0.1(depth) centimeters and there were also no other description of the area. Further review revealed that there was no physician's order or further documentaion of the condition of the pressure ulcer in the resident's left buttock. Resident J119's wound team documentation dated November 5, 2013 revealed that the stage II (partial thickness skin loss) on the right medial buttock was resolved and that the resident had a suspected deep tissue injury (SDTI)- purple or maroon area of intact skin to the resident's right proximal buttock measuring 0.7 centimeters (length) X 0.8 centimeters (width), the wound was purple in color. Resident J119's wound team documentation dated November 12, 2013 revealed that the resident continued with pressure ulcer on the right buttock. It was described as a Stage II pressure ulcer, it measured 1.3 centimeters (length) X 1.8 centimeters x less than 0.1 centimeters (depth) and the wound bed was 90 % purple and 10 % pink. The documentation revealed that treatment to the area was changed to Santyl (ointment that cleans wounds to clear the way for healthy tissue). Further review of Resident J119's wound team documentation dated November 19, 2013 revealed that the resident had an unstageable pressure ulcer to the right proximal buttock measuring 1.3 centimeters (length) x 1.9 centimeters x less than 0.1 centimeters (depth) and the wound bed was 100 % slough (dead tissue). Review of wound team documentation dated December 3, 2013 revealed that the resident had a suspected deep tissue injury (SDTI) to the right proximal buttock measuring 4.0 centimeters (length) x 2.5 centimeters wound purple in color. Interview with wound nurse/Employee E5 in the afternoon on February 19, 2014 revealed that Resident J119's wound should not have been staged as a stage II pressure ulcer as indicated in the documentation of November 12, 2013 and should have been a Stage III Pressure Ulcer (full thickness tissue loss, slough-dead tissue may be present but does not obscure the depth of tissue loss). The interview also revealed that the documentaion of Resident J119's wound on December 3, 2013 should not have been a staged as SDTI but a Stage III pressure ulcer and the color purple should have been a description for the wound bed because it was an open wound. Review of Resident H95's Braden Assessment (determination of pressure ulcer risk) dated November 20, 2013 revealed a moderate risk of developing pressure ulcer. Resident H95's nursing notes dated December 20, 2013 revealed suspected deep tissue injury (SDTI) top on left toe. There was no other description of what the area looked like. Wound Team documentation dated December 24, 2013 revealed resident with SDTI to left great toe and described the area measuring 0. 4 centimeters (length) X 0.9 centimeters (width) with wound bed 100% dark brown in color. Review of Resident H95's physician's order for February 2014 included [DIAGNOSES REDACTED]. Resident H95's wound team documentation continues, documentation dated February 11, 2014 revealed SDTI to left distal great toe and described the area measuring 0. 2 centimeters (length) X 0.2 centimeters (width) with wound dry and dark brown in color. Observation with licensed nurse Employee E9 of the area on February 19, 2014 at 12: 55 p.m. revealed the area on the left great toe was scabbed and dark brown in color. Resdient H95's wound team documentation dated February 19, 2014 revealed an unstageable pressure ulcer due to slough/eschar (eschar-dark or devitalized tissue that is usually black, brown or tan in color). Interview wound nurse/Employee E5 in the afternoon on February 19, 2014 revealed that Resident H95's pressure ulcer should not have been staged as SDTI on the February 11, 2014 wound documentation, but unstageable pressure ulcer due to eschar ( eschar-dark or devitalized tissue that is usually black, brown or tan in color). Interview with the Director of Nursing on February 20, 2014 at 10:15 a.m. confirmed that Resident H95's pressure ulcer staging was unstageable due to slough (separation of dead tissue from living tissue and eschar (dry scab, dead tissue black in color in wound bed). Review of Resident J106 significant change assessment dated [DATE] revealed the [DIAGNOSES REDACTED]. Resdient J106 required extensive assistance for transferring of two staff and demonstrated no ambulation capabilities. Review of the Braden Scale (tool used to evaluate risk for skin breakdown) dated November 25, 2013 identified the resident with arterial insufficiency and [MEDICAL CONDITION]. The resident received a score of 17 on the assessment which placed the resident at mild risk for developing pressure ulcers. Review of Resdient J106's nursing documentation dated August 29, 2013 revealed that a 1 centimeter x 1 centimeter pressure ulcer was identified on the resident bunion; the physician was notified and an order was obtained for Santyl ointment to be applied to the right foot bunion pressure ulcer area. There was no further description noted of the area identified on Resident J106's right bunion. It was not until September 18, 2013 that the right bunion was documented on as Stage II pressure ulcer to the right bunion measuring 0 .8 centimeter x 0.3 centimeter x 0.1 centimeter with wound bed 35% white and 65% pale pink. Further review of nursing documentation revealed that on October 1, 2013 the pressure ulcer had advance to a Stage III (full thickness skin loss) measuring 0.9 centimeters x 1.0 centimeters x less than 0.1 centimeters with the wound bed 100 % yellow. On November 12, 2013, Resident J106's pressure ulcer to the right bunion is described as a Stage II measuring 1.4 centimeters x 0.8 centimeters x 0 depth 50 % maroon and 50 % purple in color. Review of the facility's wound care policy revealed that a suspected deep tissue injury was described a purple or maroon of discolored intact skin. The facility failed to accurately stage the resident's right bunion pressure ulcer in accordance with the facility's policy. Resdient J106's January 7, 2014 wound assessment documentation continued to described the right bunion pressure ulcer as a Stage II, dark brown in color and scabbed which did not correspond with the staging description of a Stage II as indicated in the facility's policy. Interview conducted with wound nurse/Employee E5 on February 18, 2014 at 3:20 p.m. confirmed that a Stage II pressure ulcer was typically described as pink not maroon or dark purple. On The February 4, 2014 Resdient J106's pressure ulcer was described as an unstageable area measuring 0.4 x 0.3 x 0 depth, black and scabbed with surrounding pink tissue. Observation of Resident J106's right foot conducted February 19, 2014 at 1:30 p.m. confirmed an unstageable scabbed area on the right bunion. Interview with the Director of Nursing on February 20, 2014 at 10:15 a.m. confirmed that Resdient J106's right foot pressure ulcer was unstageable due to the scab area. The facility failed to properly stage Resident J106 pressure ulcer in accordance with the facility policy and procedure for wound care. 28 Pa. Code: 201.14(c) Responsibility of licensee Previously cited 12/4/13 28 Pa Code: 201.18(b)(1)(e)(1) Management Previously cited 12/4/13, 3/22/13 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/22/13 28 Pa. Code: 211.5(h) Clinical records 28 Pa. Code: 211.10(c)(d) Resident care policies Previously cited 3/22/13 28 Pa Code: 211.12 (c)(d)(2)(3) Nursing services 28 Pa Code: 211.12 (d)(1)(5) Nursing services Previously cited 3/23/13, 2/24/12