Every finding on record at Pavilion at St Luke Village, The

Based on observations, a review of facility policies, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement effective, individualized interventions to prevent repeated falls for one of 23 residents reviewed (Resident 104) resulting in actual harm including a subdural hematoma and sacral fracture, requiring hospitalization.Findings include: A review of the facility's Accidents and Supervision policy, last reviewed by the facility on February 12, 2026, indicated the facility would provide each resident with adequate supervision and appropriate assistive devices to prevent accidents. The policy directed staff to identify and assess accident hazards and risks, implement interventions to reduce identified risks, monitor the effectiveness of those interventions, and modify them as the resident's needs or condition changed. The policy indicated that supervision is an intervention used to reduce accident risk and must be individualized based on each resident's assessed needs while supporting the resident's highest practicable level of independence and dignity. A review of the facility's Fall Prevention Program policy, last reviewed on February 12, 2026, indicated each resident would receive a fall risk assessment and individualized interventions based on the resident's level of fall risk. The policy directed staff to implement appropriate fall prevention interventions, including maintaining a safe environment, routine rounding, monitoring changes in gait, balance, and mobility, encouraging the use of non-slip footwear, and providing assistance with ambulation or toileting as indicated. For residents identified as high risk for falls, the policy included additional interventions such as increased staff supervision, assistive devices, increased frequency of rounds, low bed placement, medication review, alternate call system access, scheduled ambulation or toileting assistance, referral to therapy services, and other individualized interventions as appropriate. A review of the clinical record revealed that Resident 104 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia with behavioral disturbances (a condition affecting memory, judgment, thinking, and decision-making that may cause confusion, poor safety awareness, agitation, wandering, and other behavioral symptoms) and cardiomyopathy (a disease of the heart muscle that reduces the heart's ability to pump blood effectively and may contribute to weakness, dizziness, or fatigue). Upon admission, Resident 104 had a physician's order for Apixaban 5 milligrams (mg) by mouth twice daily. Apixaban is an anticoagulant (blood thinner), a medication that reduces the blood's ability to clot to help prevent conditions such as stroke or blood clots. Because blood thinners increase the risk of bleeding, falls may result in more serious injuries. A review of the facility's fall risk assessment, dated May 16, 2026, revealed that Resident 104 received a fall risk score of 23, identifying the resident as high risk for falls. The assessment identified multiple fall risk factors, including a history of three or more falls within the previous three months, continuous disorientation, urinary incontinence, independent ambulation despite impaired safety awareness, impaired gait and balance, three or more medical conditions associated with an increased fall risk, recent hospitalization, and the use of multiple medications associated with an increased risk for falls. A review of the resident's comprehensive care plan, initiated on May 17, 2026, identified Resident 104 as being at risk for falls related to confusion. The care plan established a goal to minimize the risk of falls with major injury and included interventions to anticipate and meet the resident's needs, educate the resident and the resident's representative regarding fall prevention and actions to take following a fall, complete medication reviews following recent falls, and obtain physical therapy evaluation and treatment as ordered or PRN (as needed). A review of the resident's 5-day Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 22, 2026, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS), a standardized assessment used to evaluate memory and cognition, because the resident was rarely or never understood due to cognitive impairment The MDS also documented that Resident 104 required partial to moderate assistance with bathing and upper and lower body dressing, meaning a staff member completed less than half of the activity while providing lifting, holding, or supporting assistance. The MDS also documented that Resident 104 required supervision or touching assistance (the resident required verbal cueing, steadying assistance, or hands-on guidance from another person to safely complete these activities) for sit-to-stand transfers, transfers between the bed, chair, and toilet, and walking 10 feet and 50 feet. A review of facility-provided investigative documentation revealed that on May 30, 2026, at 3:30 AM staff found Resident 104 sitting on the floor near the bathroom entrance in the resident's room. The resident was wearing rubber-soled shoes; however, the call light had not been activated. The floor was free of clutter but was wet and slippery due to a urinary incontinent brief that had saturated the floor. Resident 104 was unable to explain what had occurred due to cognitive impairment. The resident was assessed and no apparent injuries were identified. Vital signs were within normal limits, and the neurological assessment (an evaluation of the brain and nervous system, including level of consciousness, movement, sensation, and pupil response) revealed no abnormal findings. The physician and the resident's responsible party were notified. After the fall, the facility revised the resident's care plan interventions to include scheduled toileting between 3:00 AM and 3:30 AM, re-education to use the call light before attempting to ambulate, and ensuring the floor remained clean and dry. A review of facility-provided documentation revealed that on June 11, 2026, at 11:00 PM staff again found Resident 104 on the floor at the foot of the bed. Documentation indicated the resident was incontinent of urine and had attempted to walk to the bathroom independently. The resident was unable to explain the fall due to confusion. The resident was assessed and no apparent injuries were identified or complaints of pain. Resident 104's spouse and roommate stated, She fell going to the bathroom. After this fall, the facility revised the resident's care plan interventions to include offering toileting assistance at 10:30 PM to reduce urinary incontinence and fall risk. A review of employee statements and nursing documentation revealed that on June 24, 2026, Resident 104 had been toileted at 12:45 AM and was last observed asleep in bed at 2:00 AM. At 2:45 AM, after returning from a scheduled meal break, Employee 1, Nurse Aide (NA), found Resident 104 sitting on the bed attempting to stand. The nurse aide observed blood coming from the resident's head, immediately requested nursing assistance, and applied pressure to the wound with a towel until nursing staff arrived. A review of the facility-provided investigative documentation, completed by Employee 2, Registered Nurse (RN), dated June 24, 2026, at 2:45 AM revealed that Employee 2 documented responding to Resident 104's room after being notified of a fall. Employee 2 documented finding Resident 104 sitting on the bed facing the doorway while a staff member applied pressure with a towel to the back (posterior) of the resident's head to control bleeding. Employee 2 documented that Resident 104 was not wearing non-skid socks or rubber-soled shoes, although staff had reportedly placed them on the resident before bedtime. The RN documented that the bed was in the lowest locked position, the call light had not been activated, and blood was present on the floor near the bed, creating a slipping hazard. According to the RN's documentation, Resident 104 stated, I was going to the bathroom and fell.Employee 2 documented completing an assessment that identified two one-inch lacerations (cuts through the skin) to the back (posterior) of the resident's scalp accompanied by a large area of localized swelling. No additional injuries were documented. Employee 2 recorded the resident's vital signs as blood pressure 150/90 millimeters of mercury (mmHg), pulse 77 beats per minute, oxygen saturation 99 percent on room air, temperature within normal limits, and neurological assessment (an evaluation of brain and nervous system function) without abnormal findings. Resident 104 remained prescribed Apixaban, an anticoagulant (blood thinner) that increased the risk of significant bleeding following a fall with head trauma, making prompt medical evaluation and effective fall prevention measures clinically necessary. Employee 2 documented treating the scalp lacerations and controlling the bleeding without additional drainage. The Employee 2 documented applying an ice pack to reduce swelling and administering Tylenol (acetaminophen, a medication used to relieve pain) as ordered after Resident 104 reported a headache rated 3 on a pain scale of 0 to 10 (0 representing the least amount of pain and 10 the worst imaginable). Employee 2 documented that staff cleaned the blood from the floor, initiated neurological monitoring, and planned to maintain the resident under close supervision. Employee 2 also documented new post-fall interventions that included offering toileting assistance each night at 2:00 AM and requesting Physical Therapy (PT) and Occupational Therapy (OT) screening due to the resident's unsteady gait. The physician and the resident's responsible party were notified. Despite Resident 104 sustaining a head injury while receiving anticoagulant therapy, the facility's post-fall interventions primarily consisted of changing the scheduled toileting time and requesting therapy screening. A review of facility-provided documentation related to the June 27, 2026, revealed that Resident 104 experienced another unwitnessed fall during the overnight hours despite sustaining a previous fall with a head injury on June 24, 2026, and despite revised post-fall interventions. Documentation completed by Employee 1, Nurse Aide (NA), dated June 27, 2026, at 1:30 AM revealed that staff offered Resident 104 toileting assistance at 11:00 PM, which the resident refused. Employee 1 documented last observing the resident asleep in bed at 12:45 AM. While attempting to provide the resident's scheduled 2:00 AM toileting assistance, at 1:30 AM, Employee 1 observed Resident 104 exiting another resident's room. As Employee 1 assisted the resident back toward the resident's room, Resident 104 stated that she had fallen. Employee 1 immediately notified nursing staff and documented that Resident 104 had a history of wandering behaviors. Documentation completed by Employee 3, Licensed Practical Nurse (LPN), also revealed that Employee 1 notified nursing staff after Resident 104 reported falling. Staff assisted the resident back to bed and administered Tylenol (acetaminophen, a medication used to relieve pain) at 1:32 AM after the resident complained of a headache. The physician and the resident's responsible party were notified. An undated signed witness statement completed by Resident 34 (assessed by the facility as cognitively intact and capable of providing a reliable witness statement), revealed Resident 104 entered Resident 34's room, walked toward the window, turned, and attempted to sit down where no chair was present, causing the resident to fall directly onto the floor. Resident 34 documented activating the call light and yelling for assistance after hearing Resident 104 moaning. According to the witness statement, after several minutes Resident 104 pulled herself up using the footboard of the bed, walked into the hallway, and told a staff member, I fell. A review of facility-provided documentation completed by Employee 2 dated June 27, 2026, at 1:30 AM revealed Employee 2 assessed Resident 104 after staff reported the fall. Employee 2 documented that Resident 104 had a history of dementia with wandering behaviors and had sustained a previous fall with a head injury on June 24, 2026. Resident 104 complained of a headache; however, the assessment identified no visible new bumps, bruises, abrasions, or other acute injuries. Employee 2 documented staff administered Tylenol, notifying the physician and the resident's responsible party, and adding a Physical Therapy (PT) screen because of the resident's unsteady gait. Employee 2 identified confusion, impaired memory, urinary incontinence, impaired gait and balance, and wandering behaviors as factors contributing to the resident's continued fall risk. Although Employee 2 documented requesting a PT/OT screen, the subsequent therapy documentation revealed Resident 104 was already receiving PT and OT services.A review of the Physical Therapy screen, dated June 27, 2026, revealed Resident 104 was already receiving Physical Therapy (PT) and Occupational Therapy (OT) services to address the resident's unsteady gait. The documentation did not identify additional therapy interventions following the June 27, 2026, fall. A review of a nursing progress note completed by Employee 2 dated June 28, 2026, at 12:43 AM revealed Resident 104 continued to complain of a headache. Employee 2 documented observing a large hematoma (a collection of blood beneath the skin caused by bleeding from damaged blood vessels) on the back (posterior) of the resident's scalp consistent with the previous fall. Documentation indicated Tylenol administered earlier that evening was ineffective, and non-pharmacological comfort measures also failed to relieve the resident's pain. After completing an assessment, Employee 2 notified the on-call physician, who ordered transfer to the Emergency Department (ED) for additional evaluation. Documentation indicated emergency medical services were contacted, the resident's responsible party consented to the transfer, and report was provided to the receiving hospital.A review of a nursing progress note completed by Employee 2 dated June 28, 2026, at 3:31 AM revealed Resident 104 was admitted to the hospital's critical care unit with a subdural hematoma (bleeding between the brain and its outer covering caused by head trauma that can become life-threatening). An additional nursing progress note dated June 28, 2026, at 1:23 PM revealed the hospital also diagnosed Resident 104 with a sacral fracture (a break in the large triangular bone at the base of the spine that connects the spine to the pelvis) and a pleural effusion (an abnormal collection of fluid surrounding the lungs). Despite this being Resident 104's fourth documented fall since admission, including two falls occurring after implementation of revised post-fall interventions, the clinical record did not identify implementation of increased supervision or additional individualized interventions to address the resident's continued attempts to ambulate independently despite impaired safety awareness, wandering behaviors, and urinary incontinence. During survey observations conducted on July 15, 2026, at 11:35 AM Resident 104 demonstrated impulsive behaviors and poor safety awareness by repeatedly attempting to bend over to clean spilled liquid from the floor. After staff removed the spill, Resident 104 immediately bent over again to adjust the Velcro fastener on Resident 38's shoe (Resident 104's spouse) despite staff attempting to redirect the resident. before walking throughout the room. Resident 104 later sat on the bed, stood without assistance several minutes later, and continued to demonstrate impulsive behaviors and poor safety awareness. Resident 38, the resident's spouse and roommate, reported Resident 104 had memory impairment, was frequently unsteady while walking, often attempted to care for others despite requiring supervision, and did not remain seated for prolonged periods. Resident 38 also reported Resident 104 had sustained a head injury during one of the previous falls. The facility failed to provide adequate supervision and implement effective, individualized interventions after Resident 104 experienced repeated falls associated with cognitive impairment, impulsive behaviors, wandering, urinary incontinence, impaired gait and balance, poor safety awareness, and anticoagulant therapy. Although each fall occurred under similar circumstances during overnight attempts to ambulate independently to the bathroom, the facility primarily responded by adjusting scheduled toileting times and requesting therapy services despite the recurrence of falls under substantially similar circumstances rather than implementing other effective interventions to address the recurring pattern of falls. Consequently, Resident 104 sustained additional falls that resulted in actual harm, including a subdural hematoma and sacral fracture requiring hospitalization. During an interview with the Nursing Home Administrator (NHA) on July 16, 2026, at 1:30 PM the above findings were reviewed. The NHA did not provide additional information or documentation demonstrating the facility implemented increased supervision or more effective, individualized interventions following Resident 104's repeated falls before the resident sustained a subdural hematoma and sacral fracture requiring hospitalization. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on pest control record review, observations, and staff interview, it was determined that the facility failed to implement and maintain an effective pest management program to prevent and control pest activity in the dietary department.Findings include:A review of the facility policy titled Pest Control Policy, last reviewed February 12, 2026, indicated the facility would maintain an effective pest control program to eradicate (eliminate) and contain common household pests and rodents. The policy indicated the facility would maintain a reporting system to address pest issues identified between scheduled visits by the contracted pest management company and would implement appropriate indoor and outdoor pest control measures in accordance with state and federal regulations. A review of the facility's contracted pest management agreement, signed May 23, 2005, indicated the contractor would provide bioremediation (the use of naturally occurring microorganisms to break down grease and organic material that can support insect breeding) to reduce drain fly breeding sites, control kitchen odors, prevent drain line clogs, and maintain grease traps. The agreement also required monthly inspection and servicing of the kitchen bioremediation injection system. A review of the contracted pest management report dated April 17, 2026, revealed the pest management technician documented observations of greater than 400 miscellaneous flies and 11 to 25 house flies in multiple areas of the kitchen. The technician performed pest treatments and recommended removing the accumulation of damaged non-food items stored beneath kitchen equipment to eliminate conditions that could attract pests. A review of the contracted pest management report dated May 18, 2026, revealed continued pest activity, including eight mosquitoes, four house flies, four moths, and greater than 35 fruit flies in multiple kitchen areas. The technician again performed pest treatments and documented that the recommendation issued on April 17, 2026, to remove the accumulated materials beneath kitchen equipment remained uncorrected. A review of the contracted pest management report dated June 17, 2026, revealed ongoing and increased pest activity, including eight mosquitoes, four house flies, four moths, and greater than 500 fruit flies in multiple kitchen areas. The technician again documented that the April 17, 2026, recommendation to remove the accumulated materials beneath kitchen equipment remained pending. During the initial tour of the dietary department on July 14, 2026, at 10:28 AM, in the presence of the Registered Dietitian, surveyors observed the juice dispensing system with sticky exterior surfaces and tubing. Greater than 10 small black flies were present on the surfaces, adhered to the tubing, and on the juice boxes. Surveyors observed the floor drain beneath the tray line steam table with corrosion, black residue, and accumulated food particles. Multiple small black flies emerged from the floor drain and flew around the base of the steam table. Surveyors also observed numerous small black flies on the wall behind the cold food preparation area. The facility failed to demonstrate that it consistently corrected environmental conditions that contributed to pest activity, implemented recommendations provided by its contracted pest management company, or maintained sanitary conditions necessary to reduce pest breeding and harborage (areas where pests live and reproduce) within the dietary department. The facility could not provide documented evidence of increased provisions for pest management visits in efforts to eradicate and deter pest activity, flies, in the dietary department. During an interview with the Nursing Home Administrator (NHA) on July 17, 2026, at 11:15 AM, the above findings were reviewed and confirmed. Cross Ref. F812 28 Pa. Code 201.18 (e) (2.1) Management

Based on observation and staff interview, it was determined the facility failed to maintain sanitary food storage and food service practices to prevent contamination and microbial growth (the growth of bacteria, mold, or other microorganisms that can make food unsafe) in the dietary department and failed to ensure that personal resident refrigerators were monitored and maintained at safe storage temperatures to reduce the risk of foodborne illness for two residents of five residents observed on the second-floor nursing unit (Residents 8 and 28).Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).A review of a facility policy entitled Environment indicated that all food preparation areas, food service areas, and dining areas would be maintained in a clean and sanitary condition. The Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Cleaning schedules will be in place for all cooking equipment, food storage areas, and surfaces. During the initial tour of the dietary department conducted with and confirmed by the Registered Dietitian (RD) on July 14, 2026, at 10:28 AM, the surveyor observed multiple unsanitary conditions with the potential to introduce contaminants into food and increase the potential for food-borne illnesses, were identified: Observation of the exterior surfaces and tubing of the juice dispensing system were sticky to the touch. More than 10 small black flies were present on the equipment, adhered to the tubing, and on juice boxes stored nearby. The nectar-thick juice dispensing nozzle was observed resting inside a green sanitizing bucket containing a cloudy, milky-colored liquid with floating gelatinous material. The honey-thick liquid dispensing nozzle rested in a stainless-steel holder containing cloudy liquid with yellow-colored particles. The floor drain beneath the tray line steam table was corroded and contained black substance and food particles. Small black flies were observed emerging from the drain and flying around the bottom of the steam table.There were numerous small black flies on the wall behind the cold food preparation area.Debris was observed on the lids of bulk food storage bins containing thickener, sugar, and flour.Inside the janitor's closet, the surveyor a mop was submerged in a mop bucket that remained inside the floor sink.Upon exiting the dietary department, there was standing water outside the dish room with insects flying around the area.At the conclusion of the initial kitchen tour, the Registered Dietitian reviewed and confirmed all of the above observations.During a follow-up observation of the dietary department on July 16, 2026, at 11:54 AM, the surveyor again observed standing water outside the dish room with insects continuing to fly around the area.During an interview on July 16, 2026, at 11:55 AM, the Dietary Services Director confirmed that small black flies had been present in the dietary department since May 2026 and stated the facility had been working to correct the problem.A review of the facility policy titled Personal Refrigerators, last reviewed February 12, 2026, revealed each personal refrigerator was to contain a working thermometer, maintain an internal temperature of 41 degrees Fahrenheit or less, and have temperatures monitored routinely by staff.During an interview on July 15, 2026, at 11:00 AM, the Director of Nursing stated staff were to document daily internal temperatures for each personal refrigerator on a temperature log posted outside the refrigerator. The Director of Nursing further stated all opened food items stored in personal refrigerators were to be dated and discarded after three days. Observation of Resident 8's personal refrigerator on July 14, 2026, at 10:30 AM revealed an internal temperature of 50 degrees Fahrenheit as measured by the thermometer inside the refrigerator. The refrigerator contained a container of chili and a hamburger. Neither food item was dated, making it impossible to determine how long the food had been stored.Observation of Resident 28's room on July 14, 2026, at 10:40 AM revealed two personal refrigerators. One refrigerator measured 50 degrees Fahrenheit. The refrigerator temperature log posted on the outside of the refrigerator lacked documented daily temperature checks for July 1, 2, 6, 7, 8, 9, 10, 11, and 12, 2026.Observation of Resident 28's second refrigerator revealed a carton of eggs stored inside; however, the refrigerator did not contain a thermometer to monitor internal temperature. No refrigerator temperature log was available to document routine temperature monitoring. Interview with the Director of Nursing on July 15, 2026, at 11:15 AM confirmed all food stored in personal refrigerators was to be dated, refrigerator temperatures were to be maintained at 41 degrees Fahrenheit or below, and the 11:00 PM to 7:00 AM shift was responsible for documenting daily refrigerator temperatures and adjusting the thermostat, as needed, to maintain safe food storage temperatures. The Director of Nursing confirmed the observations identified during the survey were not consistent with facility policy. 28 Pa. Code 201.18 (e) (2.1) Management .28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to transcribe and implement physician orders for eye care hygiene to reduce the risk of infection for one of 23 residents reviewed (Resident 71). Findings include: A clinical record review revealed Resident 71 was admitted to the facility on [DATE], with diagnoses that include blepharitis (a common, chronic inflammation of the eyelids, typically caused by bacterial overgrowth or clogged oil glands at the base of the eyelashes) and a retinal tear of the left eye (a small rip in the light-sensitive tissue lining to the back of the eye). A care plan indicating Resident 71 has a self-care performance deficit related to activity intolerance and impaired balance was indicated on October 28, 2021. Interventions implemented to improve Resident 71's current level of function with activities of daily life include providing the assistance of one staff member for personal hygiene (the ability to maintain one's own cleanliness, specifically combing hair, shaving, applying makeup, and washing and drying the face and hands). A care plan indicating Resident 71 has impaired visual function related to dry eyes, cataracts, and blepharitis initiated on August 4, 2022. Interventions implemented to ensure the resident will have no indications of acute eye problems include arranging consultation with an eye care practitioner as required and monitoring, documenting, and reporting any symptom of an acute eye problem. A review of an external ophthalmology consultation (eye care) dated June 1, 2026, revealed Resident 71 was evaluated for moderate burning of both eyes. The ophthalmologist documented that the resident had chronic blepharitis affecting the ocular surface and recommended daily eyelid hygiene using a warm washcloth, continuation of lid scrubs, and erythromycin (antibiotic medication) twice daily for two weeks. A review of the facility progress note dated June 2, 2026, at 11:31 AM, revealed staff documented that the ophthalmologist's recommendations had been reviewed, new orders were noted, and the resident representative was notified. A subsequent review of the clinical record revealed the facility failed to transcribe or implement the ophthalmologist's recommendation to provide daily eyelid hygiene with a warm washcloth. The clinical record contained no documented evidence that staff cleansed Resident 71's eyelids daily with a warm washcloth after the June 1, 2026, consultation. According to the National Eye Institute, treatment for blepharitis typically requires a consistent daily eyelid hygiene regimen that includes applying a warm compress to loosen debris and unblock oil glands, gently cleansing the eyelids, rinsing and drying the eyelids, and using artificial tears as indicated. A review of a facility progress note dated June 25, 2026, at 12:01 PM, revealed a Certified Registered Nurse Practitioner (CRNP) evaluated Resident 71 after the resident developed redness of the right eye with clear yellow drainage and complained of a picking sensation. The CRNP ordered a culture and sensitivity of the eye drainage (a laboratory test used to identify the organism causing an eye infection and determine which antibiotics are effective against). Staff documented that they notified the resident representative and reviewed hand hygiene with the resident. A review of an external ophthalmology consultation dated July 13, 2026, revealed the ophthalmologist completed a comprehensive eye examination, discussed the chronic nature of the resident's blepharitis, and again recommended daily lid scrubs preceded by application of a warm compress. A review of the facility progress note dated July 13, 2026, at 3:58 PM, revealed Resident 71 returned from the ophthalmology appointment in stable condition. Staff documented receipt of recommendations to apply a warm washcloth to the eyelids three times daily, cleanse the eyelids and eyelashes with one drop of baby shampoo while the eyelids remained closed for one to two minutes, rinse the eyelids, pat them dry, and notify the resident representative. A review of physician orders dated July 13, 2026, revealed the facility transcribed the order directing staff to cleanse the resident's eyelids and eyelashes with baby shampoo, rinse, and pat dry three times daily. However, the facility failed to transcribe or implement the ophthalmologist's recommendation to apply a warm compress before performing eyelid hygiene. The clinical record contained no documented evidence staff applied a warm compress before providing eye care as recommended by the ophthalmologist.During an interview on July 14, 2026, at 10:56 AM, Resident 71 stated that her eyes had been hurting for several weeks. She reported that her eyes itched frequently, watered often, and were painful.A review of a progress note dated July 16, 2026, at 10:41 AM, revealed Resident 71 developed redness of the left sclera (white outer covering of the eye) with clear drainage and continued to complain of a picking sensation in the eye. Staff documented that they notified the physician, who prescribed antibiotic eye drops. Staff also documented re-education regarding hand hygiene and eye care and notified the resident representative. During an interview on July 16, 2026, at 1:30 PM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). A review of the facility progress note dated July 16, 2026, at 10:41 AM, revealed Resident 71 developed redness of the left sclera with clear drainage and continued to complain of a picking sensation in the eye. Staff documented that they notified the physician, who prescribed antibiotic eye drops. Staff also documented re-education regarding hand hygiene and eye care and notified the resident representative. 28 Pa Code 211.2 (3) Medical director.28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance and providing care in a language that is understood by the resident for 6 out of 23 residents reviewed (Residents 10, 58, 69, 6, 71, and 1) and including experiences reported by 7 out of 9 residents during a resident group interview (Residents 10, 27, 28, 31, 36, 53, 59, 1, and 92). Findings include: A review of the facility policy titled Resident Rights, last reviewed by the facility on February 12, 2026, revealed it is the facility policy that residents have the right to be treated with respect and dignity and the facility will ensure all direct care and indirect care staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. During an interview on July 14, 2026, at 10:15 AM Resident 10 explained that she often waits over an hour for staff to assist her with care after she rings her call bell for assistance. She indicated that over the past weekend she waited an hour for staff to provide care. Resident 10 explained that she thinks the facility has enough employees, but they don't seem to work together to ensure residents get the care they need. She indicated that when her nurse aide is providing care for other residents, other nurse aides do not offer to help, so she often waits 45 minutes to an hour for assistance. Resident 10 explained that she has brought this up at resident council and filed grievances over the last few months, but the wait times for care have not improved. During an interview on July 14, 2026, at 10:56 AM, Resident 71 explained that she sometimes waits more than an hour for staff to respond to her call bell for assistance. She indicated that she needs help getting to the bathroom, getting cleaned up, and getting into and out of bed but sometimes has to wait for more than an hour. Resident 71 indicated that it has been this way for a while, and she experiences the longest wait times for assistance on the day shift. During an interview on July 14, 2026, at 11:25 AM, Resident 58 stated that she frequently waits so long for staff to answer her call bell that she has been unable to get to the bathroom in time and has soiled herself. She stated, I take medication for it (incontinence), but I still can't hold it in very long when I have to go. Resident 58 reported feeling embarrassed and humiliated when she is left sitting in soiled clothing while waiting for staff assistance. She stated that staff often tell residents they are short staffed because employees have called off, but she feels her dignity is not respected when she is forced to remain incontinent while waiting for help. During an interview on July 14, 2026, at 11:45 AM, Resident 69 reported that it is not uncommon to wait longer than one hour for staff to respond to her call bell. She stated, Especially around meals, like 11:30 AM to 1:30 PM, you could die, and no one will come. And if you ask why it took so long, all you receive are excuses. Resident 69 stated that the prolonged wait makes her feel ignored and that her needs are not important. She also reported that two staff members spoke to one another in a language she could not understand while providing her care. Resident 69 stated she asked them to speak English, and one staff member replied, We're not talking to you. Resident 69 stated the response made her feel disrespected and excluded while receiving personal care in her room. She reported feeling uncomfortable because staff continued talking while she was unable to understand the conversation. During an interview on July 14, 2026, at 12:25 PM, Resident 6 reported staff frequently take over an hour to respond to his call bell, leaving him waiting for assistance with his care needs. He stated the prolonged delays make him feel as though his needs do not matter. Resident 6 also reported staff speak to one another in a foreign language while providing his care, making him feel excluded and uncomfortable because he cannot understand what is being said while they are caring for him. He further reported observing staff wearing earbuds and talking on their phone during care, stating he feels they are not paying attention to him and that their behavior is disrespectful while providing personal care. During an interview on July 14, 2026, at 12:48 PM, Resident 1 stated she frequently waits more than 30 minutes for staff to answer her call bell, especially during mealtimes. She stated the repeated delays make her feel that residents are an inconvenience and that their requests are not treated with importance. She reported feeling frustrated and disrespected when left waiting for assistance. Observation on July 14, 2026, at 12:48 PM, revealed Resident 1 activated her call bell to request a nebulizer breathing treatment (method of delivering liquid medication directly into the lungs by converting it into a fine mist that the person inhales through a face mask). Staff answered the call bell at 1:00 PM, 13 minutes later. The observation confirmed a delay in responding to the resident's request for assistance, consistent with the resident's report of prolonged response times. During a resident group interview on July 15, 2026, at 10:00 AM, seven out of nine residents indicated experiencing long wait times for care (Residents 10, 27, 28, 36, 53, 59, and 1). Residents 31 and 92 indicated that they are able to care for themselves independently and do not ring their call bell for assistance. Six out of nine residents indicated that they are upset because some staff speak in a language they do not understand when they are providing care (Residents 59, 10, 27, 28, 36, and 1). During the group interview, Resident 53 indicated that after five to ten minutes of waiting for staff to help her to the bathroom, she transfers herself, despite it not being safe. She indicated that it often takes 40 minutes or longer for staff to respond and assist her off the toilet. Resident 53 explained this has been going on for a while and has not improved. During the group interview, Resident 59 indicated that she often waits 30 to 45 minutes for staff to respond to her call when she rings for assistance. She indicated that she experiences the longest wait times at night, and during meals it is hard to get anyone to provide care. Resident 59 explained that residents have raised this concern during group meetings, but the wait times for care remained long. During the group interview Resident 10 explained that she often waits over an hour for staff to assist her with care after she rings her call bell for assistance. Resident 10 explained that she has brought this up at resident council and filed grievances over the last few months, but the wait times for care have not improved. During the group interview Resident 27 explained that she often waits 30 minutes to an hour for staff to assist her to bed. She indicated that after 45 minutes she gets frustrated and sometimes yells out into the hallway for help. Resident 27 indicated that it makes her even more angry and frustrated when staff ask, Why are you yelling? She explained that she is also upset because staff sometimes speak on the phone when they are providing her care and sometimes talk on the phone in a language she does not understand when providing her care. Resident 27 indicated that residents have brought these issues up during resident council meetings, but the issue has not improved. During the group interview Resident 28 explained that he often waits 30 to 45 minutes for staff to provide him care after he rings his call bell for assistance. He indicated that these long wait times occur across all shifts. He indicated that yesterday he was upset because he overheard an aide ask another aide for assistance providing care for a resident, but the aide did not help because she was reading a novel. Resident 28 indicated that it is a problem that staff speak in a language he does not understand when providing him care. Resident 28 indicated that residents have brought up these issues during resident council meetings, but nothing has improved. During the group interview Resident 36 explained that he often waits 30 to 45 minutes for staff assistance after he rings his call bell for assistance. He indicated that he experiences these wait times across all shifts. Resident 36 indicated that it is a problem that staff speak in a language he does not understand when providing him care. Resident 36 indicated that residents have discussed these care issues during resident council meetings, but nothing has improved. During the group interview, Resident 1 explained that she is worried because it often takes staff 30 to 45 minutes to respond to her call bell rings for assistance. She indicated that it scares her because if she has an emergency, then it may be too long to get immediate help. Resident 1 explained that it bothers her when staff speak in a language she does not understand when they provide her care. She indicated that residents have raised the concern about long wait times for care and staff speaking in languages they don't understand during care, but the issues have not improved. During an interview on July 16, 2026, at 1:30 PM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. The NHA indicated that the facility has been addressing concerns regarding language and communication during care.Refer F565 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on observations, review of clinical records and facility documents, review of select facility policy, and resident and staff interviews, it was determined the facility failed to provide food and beverages consistent with residents' assessed and documented food preferences and intolerances for two residents of 23 residents reviewed (Residents 69 and 58). Findings include: Review of the facility policy titled Dining and Food Preferences, last reviewed by the facility on February 12, 2026, revealed individualized dining, food, and beverage preferences are identified for all residents. The Dining Services Director, or designee will interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose of this interview will be to identify individual preferences for dining location, mealtimes, including times outside of the routine schedule, and food and beverage preferences. The food preference interview will be entered into the medical record. Food allergies, food intolerances, food dislikes and food and fluid preferences will be entered into the resident profile in the menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. During an interview of July 14, 2026, at 11:45 AM, Resident 69 stated that she was dissatisfied with the meals because she was frequently served foods that she had repeatedly informed staff she did not like or could not tolerate. She reported disliking tomatoes, cabbage, baked beans, Brussels sprouts, asparagus, and seafood. She further stated tomatoes caused severe heartburn and stomach upset. Resident 69 stated, Every time I'm served a salad, they put tomatoes on it and every time there's hotdogs, they give me baked beans. The tomatoes and baked beans make my stomach very upset. I've told them a million times, but they don't listen or care because they keep giving them to me. Review of Resident 69's meal ticket (a menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) revealed no indication of her food dislikes or intolerances. Observation of the resident's lunch meal tray, at the time of the interview, revealed she was served a turkey burger on a bun with lettuce and tomato, broccoli salad, potato chips, fruit salad and vanilla ice cream. Review of the facility provided document titled Meal Tracker dated June 17, 2026, revealed Resident 69's documented dislikes included fish, baked beans, Brussels sprouts, cabbage, spinach, soft chicken tacos with tomatoes, beef pepper steak, beef soft tacos, corn on the cob, whole kernel corn, cornbread, corned beef, cornflake encrusted chicken dishes, beef stuffed green peppers, fried cabbage with tomatoes, oatmeal, and onion pepper chicken, and other identified food items. Despite these documented preferences, the resident's meal ticket did not reflect her food dislikes or intolerances to tomatoes.During an interview on July 14, 2026, at 12:21 PM, Resident 58 stated I hate mayo and they put it on everything. She also stated that she disliked carrots, broccoli, spinach, Brussels sprouts, asparagus, cabbage (except sauerkraut), zucchini, squash, and fish. Resident 58 stated that whenever carrots are served, she was not offered an alternate vegetable and therefore went without a vegetable for that meal. She further stated she continued to receive foods containing mayonnaise despite informing staff she could not eat them.Observation of Resident 58's lunch meal tray at the time of the interview revealed she was served a ground turkey burger on a bun with mayonnaise on the side, potato salad, broccoli salad, and sliced peaches and pears. Review of the resident's meal ticket revealed no indication of her dislike of broccoli, mayonnaise, or her other reported food preferences. Review of the facility's Meal Tracker dated April 22, 2026, revealed Resident 58's documented dislikes included broccoli, broccoli salad, spinach, fish, carrots, cauliflower, and oatmeal. There was no evidence that the resident's additional reported dislikes, including mayonnaise, cabbage, zucchini, squash, Brussels sprouts, and asparagus, had been incorporated into the meal service process or reflected on the meal ticket. The facility failed to ensure the residents' assessed and documented food preferences and intolerances were accurately reflected on meal tickets and implemented during meal service, resulting in residents being served foods they had identified as disliked or not tolerated. During an interview on July 16, 2026, at 9:35 AM, the Nursing Home Administrator confirmed the facility failed to ensure residents received meals consistent with their documented food preferences and intolerances. 28 Pa. Code 211.6(a) Dietary services.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10 (c) Resident Care Policies.

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS) accurately reflected the status of three residents out of 22 sampled (Residents 1, 4, and 96).Findings include: The Long-Term Care Facility RAI User's Manual (a standardized tool used in long-term care facilities to evaluate residents' strengths and needs),which provides instructions and guidelines for completing the Minimum data Set (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment to accurately reflect the resident's status; a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include respiratory failure with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues) with dependence on a tracheostomy (a surgical procedure that creates an opening in the neck to access the windpipe through which a tube is inserted to help with breathing or to clear the airway) and continuous oxygen. A review of Resident 1's clinical record revealed a physician's order, dated May 19, 2025, for trach suctioning as needed. A physician's order, dated May 20, 2025, to provide trach care daily and for oxygen at 6 L (liters per minute) with 28% humidification (adds moisture to oxygen) continuously. A review of Resident 1's quarterly MDS assessment dated [DATE], revealed in Section O, Special Treatments, for 0110C2 continuous oxygen therapy, that the resident was not receiving continuous oxygen therapy; for 0110D3 suctioning as needed, it indicated the resident was not receiving as-needed suctioning; and for 0110E1 tracheostomy care, it indicated that the resident was not receiving tracheostomy care. A review of Resident 1's Treatment Administration Record during September 2025 revealed the resident was receiving tracheostomy care, continuous oxygen therapy, and suction as needed, as ordered by the physician. An interview with the Nursing Home Administrator (NHA) on September 12, 2025, at 8:30 AM confirmed the resident was receiving tracheostomy care, along with continuous oxygen therapy and as-needed suctioning during the period reviewed for the quarterly MDS assessment dated [DATE]. A review of Resident 96's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses, which include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 96's annual MDS assessment dated [DATE], indicated that Section A1500 was coded as 0, indicating the resident was not considered by the State to require a Level II PASARR (process, to have serious mental illness, and/or to have intellectual disability or mental retardation or a related condition. (Preadmission Screening and Resident Review [PASARR] is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. However, a review of Resident 96's clinical record revealed a Level I PASARR was completed on February 2, 2018, which indicated the resident did meet the criteria for a Level II PASARR. A determination letter dated February 12, 2018, from the Pennsylvania Department of Health Office of Mental Health and Substance Abuse confirmed Resident 96's need for specialized services due to a mental condition. An interview with the NHA on September 12, 2025, at 8:30 AM confirmed that the Annual MDS assessment dated [DATE], for Resident 96 was inaccurate with respect to the completion of Section A 1500 related to the PASARR. A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included quadriplegia (a condition that results in the paralysis of all four limbs). A review of Resident 4's admission MDS assessment dated [DATE], Section H Bladder and Bowel, H0100 Appliances - Indwelling Catheter (including suprapubic catheter and nephrostomy) with instructions to mark all that apply, revealed the resident was assessed to have an indwelling catheter. During an observation on September 9, 2025, at 10:45 AM, an indwelling urinary catheter was not present or observed. During an interview on September 12, 2025, at 8:30 AM, the NHA confirmed that Resident 4's MDS admission assessment was not accurate with respect to Section H Bladder and Bowel- H0100 Appliances. 28 Pa. Code 211.5(f)(iii)(ix) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for one resident out of 22 sampled (Resident 8) and failed to provide person-centered care to meet the clinical needs by failing to monitor intravenous therapy (a way of giving medication or fluids through a needle or tube inserted into a vein) in accordance with professional standards of practice for one of 22 residents sampled (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person. Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include first-degree atrioventricular block (AV block-a heart rhythm disorder), hypertension (high blood pressure), and Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions).A review of Resident 8's hospital records dated September 16, 2024, indicated the resident underwent a cardiac pacemaker implantation (device implanted in the body to deliver electrical impulses to the heart to help the heart beat at a normal rate and rhythm) on August 18, 2021. A review of Resident 8's admission assessment dated [DATE], failed to document the presence of a pacemaker upon the resident's admission to the facility. Review of Resident 8's physician orders failed to identify the presence of, or care for, the resident's pacemaker. Review of Resident 8's plan of care, in effect at the time of the survey ending September 12, 2025, identified that Resident 8 had altered cardiovascular status due to hypertension and first-degree AV block. The facility failed to identify the presence of, or the care for, the resident's implantable pacemaker on the resident's current plan of care. Interview with the Director of Nursing on September 12, 2025, at 9:30 AM confirmed the facility failed to identify or include the pacemaker in the resident's admission assessment and comprehensive care plan. A review of the facility policy titled Short Peripheral Intravenous Catheter (PIVC) Insertion, last reviewed by the facility on May 28, 2025, revealed it is the policy of the facility that assessment of the PIVC site is performed during dressing changes, at least every two hours during continuous therapy, before and after administration of interim intravenous medication, at least once every shift when not in use, and routinely for signs and symptoms of IV-related complications. Further review of the policy revealed that documentation in the medical record includes date and time performed, verbal consent, catheter type, gauge, and length, site location, site assessment, and dressing type. A review of the facility policy titled Peripheral Intravenous Catheter Flushing, last reviewed by the facility on May 28, 2025, revealed it is the policy of the facility to obtain specific flush orders, and that flushing is performed to ensure and maintain catheter patency.A review of the facility policy titled Short PIVC Dressing Change, last reviewed by the facility on May 28, 2025, revealed it is the policy of the facility that transparent dressings are changed with each site rotation every seven days or sooner if the integrity of the dressing is compromised.A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include respiratory failure with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues) with dependence on a tracheostomy (a surgical procedure that creates an opening in the neck to access the windpipe through which a tube is inserted to help with breathing or to clear the airway) and continuous oxygen. A review of Resident 1's clinical record revealed a physician's order, dated September 5, 2025, for Zosyn (an antibiotic) 3.375 grams IV three times a day for five days due to sputum culture infection. A review of Resident 1's clinical record revealed a physician's order, dated September 6, 2025, for a peripheral IV to be placed due to IV antibiotics. Observation of Resident 1 on September 9, 2025, at 11:40 AM, revealed the peripheral IV catheter was present in the resident's left hand with a date on the dressing of September 7, 2025. A review of the clinical record for Resident 1 revealed no documented evidence of a physician order for care and monitoring of the peripheral IV site. Following surveyor inquiry, a review of Resident 1's physician's orders, dated September 10, 2025, revealed orders to change the IV dressing every seven days and as needed, to evaluate the IV site for leaking, bleeding, and signs of infection every shift, and to flush the IV site with 10 milliliters of normal saline every shift and as needed. An interview with the Director of Nursing on September 11, 2025, at 10:00 AM confirmed that the facility failed to provide documented evidence of required care related to Resident 1's peripheral IV as per facility policy. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.5211.5 (f)(i)(iv)(vi) Medical records.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records for one of 22 sampled residents (Resident 5). Findings include: A clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function). A physician's order for Resident 5 to receive Cefazolin (an antibiotic medication) sodium injection solution reconstituted to 2.0 g with directions to use 2.0 grams intravenously every eight hours for MRSA (methicillin-resistant Staphylococcus aureus -a type of bacterial infection that can be resistant to antibiotic medications) for 15 days was initiated on August 15, 2025. A review of Resident 5's medication administration record (MAR) dated August 2025 revealed there was missing documentation for seven scheduled administrations of Cefazolin Sodium Injection Solution Reconstituted 2.0 g. There was no documentation for the administration of cefazolin sodium injection solution reconstituted to 2.0 g on the following dates: August 18, 2025, at 2:00 PMAugust 22, 2025, at 2:00 PMAugust 25, 2025, at 2:00 PMAugust 27, 2025, at 2:00 PMAugust 28, 2025, at 6:00 AMAugust 28, 2025, at 2:00 PM During an interview on September 12, 2025, at 9:00 AM, the Nursing Home Administrator (NHA) indicated that nursing staff omitted the information from the clinical record. The NHA provided an attestation from Employee 1, Registered Nurse (RN), indicating that she administered Resident 5's cefazolin antibiotic medication but forgot to document it in the Electronic Health Record. The NHA confirmed that it is the facility's responsibility to ensure accurate and complete medical records. 28 Pa. Code 211.5(f)(ii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, resident council meeting minutes, and resident, resident representative, and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of the 22 residents sampled (Residents 5 and 17) and experiences reported by seven out of the 11 residents during a resident group interview (Residents 26, 30, 34, 37, 49, 50, and 69). Findings include: A review of Resident Council meeting minutes dated June 2025 through August 2025 revealed residents raised concerns regarding facility staff failing to respond timely to residents' requests for assistance. A review of the Resident Council meeting minutes dated June 25, 2025, revealed that six residents in attendance were continuing to experience long wait times for care. The issue was marked as unresolved, and a grievance was filed on the residents' behalf. A review of Resident Council meeting minutes dated July 16, 2025, revealed that five residents in attendance continued to express concerns regarding facility staff failing to respond timely to residents' requests for assistance. Documentation in the meeting minutes indicated that a grievance was filed on behalf of the residents in attendance that expressed these concerns. A review of grievances provided by the facility revealed no record of a grievance related to the resident's concerns for wait times for care or related concerns. A review of Resident Council meeting minutes dated August 20, 2025, revealed that six residents in attendance continued to express concerns regarding facility staff failing to respond timely to residents' requests for assistance. Documentation in the meeting minutes indicated that a grievance was filed on behalf of the residents in attendance that expressed these concerns. A review of grievances provided by the facility revealed no record of a grievance related to the resident's concerns for wait times for care or related concerns. During a resident group interview on September 10, 2025, at 10:00 AM, seven out of 11 residents in attendance expressed they continually experience long wait times for care despite continually bringing up this issue with staff and at resident council meetings (Residents 26, 30, 34, 37, 49, 50, and 69). During the meeting, Resident 26 indicated that she sometimes waits one hour to one and a half hours before staff responds to her call bell for assistance. She explained that recently she waited 3 hours for staff to assist her to bed. During the meeting, Resident 50 indicated that she waits the longest for staff assistance on the second shift. She explained that she often waits an hour for care and believes the issue is because there does not seem to be enough staff. During the meeting, Resident 69 indicated he waits about an hour for care. He explained that he has brought this issue up at Resident Council meetings in the past, but nothing has changed with the wait times. During the meeting, Resident 37 indicated he waits about an hour for care after ringing his call bell for assistance. He expressed frustration with the long wait times. During the meeting, Resident 49 indicated that the quickest response she experiences is about 20 minutes. She explained that staff will not provide any care during a meal, so if she needs assistance at that time, she is forced to wait longer. She expressed frustration that no one seems to care when the residents bring this issue up with staff. During the meeting, Resident 34 indicated he waits 30 minutes for staff to respond to his call bell rings for assistance. He also indicated that during meal times the wait is longer than 30 minutes. During the meeting, Resident 30 indicated she consistently waits 30 minutes or longer for staff to respond to her call bell rings for assistance. She explained that this issue has been ongoing for months. A clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function). A review of an admission (following an acute hospitalization) Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 17, 2025, revealed that Resident 5 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on September 9, 2025, at 11:00 AM, Resident 5 explained that she experiences 20- to 30-minute wait times for care. She expressed frustration that it takes so long for staff to respond to her call bell when she asks for assistance. Resident 5 indicated that she has brought this issue up with staff, but nothing changes. She explained that she believes that there are not enough staff available to help residents. A clinical record review revealed that Resident 17 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease and chronic kidney disease. A review of a significant change in status Minimum Data Set assessment dated [DATE], revealed that Resident 17 was severely cognitively impaired with a BIMS score of 05 (a score of 00-07 indicates cognition is severely impaired). During an interview on September 9, 2025, at 11:45 AM, Resident 17's resident representative (resident-selected individual(s) that supports and advocates for the resident in healthcare decision-making, care-planning, and expressing desires and preferences for the resident) expressed concerns about the long wait times for care and staff assistance. She explained that last week Resident 17 waited from 11:00 AM until 1:00 PM for staff to assist him out of bed. Resident 17's representative indicated that it often takes 30 to 45 minutes for staff to respond to the call bell for assistance. She expressed frustration that Resident 17 has to wait so long for care and assistance. During an interview on September 12, 2025, at 9:00 AM, the Nursing Home Administrator (NHA) indicated there were no grievances filed on behalf of residents who raised concerns regarding the long wait times for care at the July 2025 and August 2025 resident council meetings. The NHA was unable to explain why residents were expressing ongoing concerns regarding the long wait times for care. The NHA was unable to provide documented evidence regarding actions the facility has taken to implement effective change and resolution to resident concerns regarding staff responding timely to residents' requests for assistance and care. Refer F565 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by seven of 11 residents attending a resident group meeting (Residents 26, 30, 34, 37, 49, 50, and 69), and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's policy titled Complaint/Grievance, last reviewed on May 28, 2025, indicated the facility will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The facility will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The resident should have reasonable expectations of care and services, and the center should address those expectations in a timely, reasonable, and consistent manner. The Grievance Officer or designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. A review of Resident Council meeting minutes dated June 2025 through August 2025 revealed residents raised concerns regarding facility staff failing to respond timely to residents' requests for assistance and concerns that meal trays were being delivered to resident areas but not distributed to residents in a timely manner. A review of the Resident Council meeting minutes dated June 25, 2025, revealed that six residents in attendance were continuing to experience long wait times for care. The issue was marked as unresolved for six residents in attendance, and a grievance was filed on the residents' behalf. The Resident Council meeting minutes also revealed residents raising concerns that dinner has arrived late on multiple occasions. The issue continued to be a concern from a previous meeting and was indicated as unresolved for six residents in attendance. The minutes indicated a grievance was filed. A review of Resident Council meeting minutes dated July 16, 2025, revealed that five residents in attendance continued to express concerns regarding facility staff failing to respond timely to residents' requests for assistance. Also, the minutes indicated that three residents in attendance addressed concerns that dinner is late. Documentation in the meeting minutes indicated that a grievance was filed on behalf of the residents in attendance that expressed these concerns. A review of grievances provided by the facility revealed no record that a grievance was filed related to the resident's concerns for wait times for care or late meals following the July 2025 resident council meeting. A review of Resident Council meeting minutes dated August 20, 2025, revealed that six residents in attendance continued to express concerns regarding facility staff failing to respond timely to residents' requests for assistance. Also, six residents indicated that meal trays are sitting in carts at dinner (arriving timely but not being distributed to residents) and food is becoming cold. Documentation in the meeting minutes indicated that a grievance was filed on behalf of the residents in attendance that expressed these concerns. A review of grievances provided by the facility revealed no record a grievance was filed related to the resident's concerns for wait times for care or related concerns. During a resident group interview on September 10, 2025, at 10:00 AM, seven out of 11 residents in attendance expressed they continually experience long wait times for care despite continually bringing up this issues with staff and at resident council meetings (Residents 26, 30, 34, 37, 49, 50, and 69). The residents also explained that dinner is consistently served late. Resident 50 indicated the meals arrive on time, but the trays often sit for 45 minutes to an hour before they are distributed to residents by nursing staff. Residents 26, 30, 34, 37, 49, and 69 confirmed this is an ongoing problem, and they have brought it up at resident council meetings, but the issue has not been resolved. During an interview on September 12, 2025, at 9:00 AM, the Nursing Home Administrator (NHA) indicated that there were no grievances filed on behalf of residents who raised concerns regarding the long wait times for care or late meal distribution following the July 2025 and August 2025 resident council meetings. The NHA was unable to explain why residents expressed ongoing concerns regarding the long wait times for care or late distribution of meals. The NHA was unable to provide documented evidence regarding actions the facility has taken to implement effective change and resolution to resident concerns regarding staff responding timely to residents' requests for assistance and care and late distribution of meals. Refer F550 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(3)(4) Nursing services.

Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the current needs and services required by one of 22 residents sampled (Resident 96). Findings include: A review of the facility policy entitled Comprehensive Care Plans last reviewed on May 28, 2025, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), depression, and anxiety. A nurses note date June 2, 2025, indicated the resident was transferred to the hospital and admitted with a Hospital 302 (involuntary psychiatric commitment under Section 302 of Pennsylvania's Mental Health Procedures Act which allows a person to be admitted to a hospital for emergency psychiatric evaluation and treatment if they are a danger to themselves or others due to a mental illness) for verbal and physical aggression toward staff and verbal aggression toward another resident. Resident 96 was readmitted to the facility from a behavioral hospital on June 17, 2025, with diagnosis which included schizophrenia. Review of the behavioral hospital's Patient Safety Plan for the resident noted that red flags and warning signs (things that indicate a crisis may be developing, they can be big signs or little ones. Sometimes they are thoughts, images, moods, certain situations or behaviors that indicate things are not going well) include increase in paranoia (mental health condition characterized by an irrational and persistent fear or distrust of others), presence of auditory hallucinations (false perceptions of sound, such as hearing voices or noises that are not present) and visual hallucinations (perception of a vivid image, scene, or object that is not actually there, occurring without an external stimulus to cause it), and increase in agitation. Internal Coping Strategies included deep breathing and activity. The plan also noted that the resident identified his family as the most important thing that is worth living for. A review of Resident 96's comprehensive care plan, initially dated December 11, 2018, indicated a focus concern that the resident has a behavior problem related to hallucinations/delusions (no description of recent episodes or type of hallucinations/delusions), angry outbursts, mood swings, hears voices, slamming of his door, refusing care, picks at right cheek and applies toothpaste to the area with a diagnosis of schizoaffective disorder (a type of schizophrenia which is diagnosed when depression is present for the majority of time when they also experience symptoms like hallucinations, delusions, and disorganized thinking). The care plan failed to identify the resident had a diagnosis of schizophrenia. The goal last revised September 4, 2025, was for the resident to have fewer episodes of mood swings, outbursts, and hallucinations daily. A review of interventions last revised December 16, 2024, failed to reflect the resident's red fags and warnings signs, internal coping strategies, and the importance of the resident's family as identified in the behavioral hospital's Patient Safety Plan. The care plan failed to indicate that the resident's behaviors escalated to the extent that a Hospital 302 and Inpatient Behavioral Hospital stay was needed to address and evaluate the resident's mental health needs. An interview with the director of nursing on September 11, 2025, at 10:00 AM failed to provide documented evidence that the facility reviewed and revised Resident 96's care plan to accurately reflect his current mental health status, risks, and required interventions. 28 Pa. Code 211.10 (a)(b)(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations, clinical record review, select policy review, and staff interviews, it was determined the facility failed to provide care and services designed to prevent potential complications associated with enteral tube feedings for one resident receiving enteral nutrition out of 22 residents sampled (Resident 8).Findings include: Review of the facility policy titled Enteral Feeding -Enteral Nutrition Pump last reviewed by the facility April 28, 2025, indicated that nurses are responsible for administering enteral feedings (a method of providing nutrition directly into the gastrointestinal tract) when volume control is indicated and as ordered by the physician. The policy further states that closed system enteral feeding containers and tubing can hang safely for up to 48 hours. Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include dysphagia (difficulty swallowing), and Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions).Resident 8 required a PEG tube (Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate).The resident had a physician order, dated June 25, 2025, for continuous enteral feeding with Jevity 1.2 at 65 ml/hour (a liquid high calorie enteral feeding formula). Observation of the resident on September 9, 2025, at 12:08 PM revealed the resident was lying in bed. The tube feeding and pump were running and delivering enteral feedings to the resident. The tube feeding container lacked a label indicating the date and time it was opened and hung, which is necessary to ensure safe administration within the recommended 48-hour timeframe. Further observation identified a feeding pole attached to the resident's wheelchair that was coated with a dried tan residue. The same residue was observed on multiple wheelchair surfaces, including the seat cushion, seat support, back support, armrests, and wheels.Interview with the Nursing Home Administrator on September 12, 2025, at 10:30 AM, confirmed that housekeeping is responsible for scheduled cleaning of all wheelchairs and that all staff are expected to clean wheelchairs immediately when they become soiled. The facility failed to ensure proper labeling of enteral feeding containers when opened and hung, and failed to maintain resident equipment, specifically the wheelchair and feeding pole, in a sanitary condition. These deficiencies increase the risk of infection and other complications related to enteral feeding. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 22 residents reviewed (Resident 98). Findings include: A review of the facility policy titled Trauma Informed Care, last reviewed by the facility on May 28, 2025, revealed it is the policy of the facility to provide care and services that, in addition to meeting professional standards, are delivered using approaches that are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.A review of Resident 98's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event) and anxiety (a mental condition that causes a feeling of worry, nervousness, or unease).A review of an outside psychiatry consultation for Resident 98 dated August 21, 2025, revealed no mention of history for PTSD. The resident's current care plan, in effect at the time of review on September 10, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident-specific interventions to meet the resident's needs for minimizing triggers and re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address Resident 98's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. An interview with the Nursing Home Administrator and Social Services Director on September 10, 2025, at 10:00 A.M., confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences to eliminate or alleviate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a comprehensive review of clinical records, facility policies, and staff interviews, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer for one of 14 sampled residents (Resident CR 1), resulting in actual harm. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of facility policy titled Unavoidable Pressure Injury, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's risk factors demonstrate they were unavoidable. A clinical record review revealed Resident CR 1 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, dysphagia (difficulty swallowing) and urinary retention, with a foley catheter (a flexible tube inserted into the bladder to drain urine into a collection bag). A review of Resident CR 1's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 23, 2025, revealed that Resident CR 1 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact), and required substantial/maximal assistance for rolling in bed, required partial/moderate staff assistance for activities of daily living, required dependent total staff assistance for transfers, and was at-risk for the development of pressure ulcers and injuries. A review of Resident CR 1's plan of care initiated on January 17, 2025, revealed the resident was identified with skin impairments related to MASD (Moisture Associated Skin Damage). Planned interventions included providing a pressure-reducing mattress and wheelchair cushion, encouraging proper nutrition and hydration, conducting weekly skin assessments, and repositioning the resident every two hours. The goal was to maintain or achieve clean and intact skin. On February 15, 2025, the care plan was revised to address newly identified Stage II pressure ulcers on the buttocks and sacrum, with updated interventions including repositioning every hour and the use of positioning wedges. The revised goal was for the pressure injuries to show signs of healing with minimal risk of infection. A Braden Scale for Predicting Pressure Sore Risk form on admission dated January 17, 2025, identified Resident CR 1 as being at moderate risk for pressure injury development. Physician's orders dated January 17, 2025, included repositioning every two hours and the application of zinc cream each shift for MASD. A review of a facility skin assessment titled Weekly Skin Evaluation dated January 31, 2025, revealed the resident had existing skin issues that included MASD. No areas of pressure injury were noted on the weekly skin assessment. A review of an outside consultant wound report dated February 5, 2025, revealed no mention of any skin issues in the areas of the buttocks and sacrum. A review of a facility skin assessment titled Weekly Skin Evaluation dated February 7, 2025, revealed the resident had existing skin issues that included scar tissue on the buttocks and thighs. No areas of pressure injury were noted on the weekly skin assessment. A review of an outside consultant wound report dated February 12, 2025, revealed resident with IAD (Incontinence Associated Dermatitis) to the bilateral buttocks and sacrum. The right buttocks measured 1 cm in length, 1 cm in width, and 0.1 cm in depth; the left buttocks measured 3.5 cm in length, 2.5 cm in width, and 0.1 cm in depth; and the sacrum measured 2 cm in length, 2 cm in width, and 0.1 cm in depth. The wound base for the right buttocks, the left buttocks, and the sacrum all presented with granulation tissue (a type of new, temporary tissue that forms in response to an injury or wound). New treatment orders included cleansing the area with NSS (normal saline solution), apply medical-grade honey to the base of the wound, and secure with a bordered gauze twice a day and as needed. A review of a facility skin assessment titled Weekly Skin Evaluation dated February 14, 2025, revealed the resident had no mention of any skin issues in the areas of the buttocks and sacrum. No areas of pressure injury were noted on the weekly skin assessment. A review of a facility skin assessment titled Pressure Ulcer Wound Rounds dated February 15, 2025, revealed the resident had stage II pressure wounds and defined that as partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. The wounds assessed included the right buttock, which measured 1.5 cm in length, 1.5 cm in width, and 0.1 cm in depth; the left buttock, which measured 3.0 cm in length, 3.0 cm in width, and 0.1 cm in depth; and the sacrum, which measured 2.0 cm in length, 2.0 cm in width, and 0.1 cm in depth. All wounds were noted to have granulation tissue in the wound base. A review of a facility document titled Unavoidable Wound Documentation listed the resident had or was undergoing the following conditions as risk factors for developing pressure ulcers of malnutrition, weight loss, and refusal of treatments (as in hygiene, wound care, medications, and repositioning). Facility interventions noted in place prior to the development or worsening of pressure ulcers included turning and repositioning as indicated and that the resident took supplements as ordered. There was a discrepancy in the dates of this document, as one side was dated February 15, 2025, and the back side was dated January 17, 2025, before the resident had even acquired a pressure injury. An interview with the Director of Nursing (DON) on March 26, 2025, at approximately 1:45 PM revealed the document titled Unavoidable Wound Documentation should reflect February 17, 2025; however, it was not corrected on the document. The DON confirmed the facility was unable to provide evidence of weight loss or any refusal of treatments, and a review of physician's orders revealed an order for a Juven (nutritional supplement) one packet by mouth one time a day and increased to twice a day on February 21, 2025. The DON also confirmed the facility was unable to provide documented evidence of turning and repositioning every 2 hours as ordered by the physician from January 17, 2025, to February 15, 2025. A review of Resident CR 1's task summary reports (reports that capture care-related tasks completed by nurse aides) dated January 17 through February 15, 2025, failed to reveal that staff performed pressure ulcer prevention tasks of scheduled turning and repositioning to prevent the development of pressure areas. Resident CR 1's clinical record review failed to reveal that licensed nursing staff developed and implemented interventions for the prevention of the development of pressure areas related to the resident's declined mobility, to include turning and repositioning every 2 hours as ordered by the physician from January 17 through February 15, 2025. A review of a facility skin assessment titled Pressure Ulcer Wound Rounds dated February 19, 2025, revealed the resident had unstageable pressure wounds and defined that as full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow/white material consisting of dead cells) or eschar (dead tissue) in the wound bed. The wounds assessed included the right buttock that measured 2.0 cm in length, 2.0 cm in width, and 0.1 cm in depth; the left buttock measured 2.5 cm in length, 2.5 cm in width, and 0.1 cm in depth; and the sacrum measured 3.0 cm in length, 4.5 cm in width, and 0.1 cm in depth. All wounds were noted to have slough in the wound base. A review of an outside consultant wound report dated February 19, 2025, revealed resident with wound deterioration to the bilateral buttocks and sacrum and noted prior assessment of wounds were a stage II and now wounds present with slough and restaged to unstageable ulcers. The right buttocks measured at 2.0 cm in length, 2.0 cm in width, and 0.1 cm in depth; the left buttocks measured 2.5 cm in length, 2.5 cm in width, and 0.1 cm in depth; and the sacrum measured 3.0 cm in length, 4.5 cm in width, and 0.1 cm in depth. New treatment orders included cleansing the area with NSS, apply Santyl to the base of the wound, and secure with ABD (a gauze pad used to absorb drainage) daily and as needed. A review of a facility skin assessment titled Weekly Skin Evaluation dated February 21, 2025, revealed the resident had bilateral buttocks and sacrum wounds. A review of an outside consultant wound report dated February 26, 2025, revealed an assessment that the wounds of the right buttock, left buttock, and sacrum had merged into one ulceration with increased measurements and remain unstageable with 20% slough and 80% eschar in the wound base. The three wounds were then referred to as the sacrum wound and measured 9.0 cm in length, 10.0 cm in width, and 0.1 cm in depth. New treatment orders included cleansing the area with NSS, apply silver alginate to the base of the wound, and secure with ABD twice a day and as needed. A review of a facility skin assessment titled Pressure Ulcer Wound Rounds dated February 26, 2025, revealed the resident had an unstageable pressure wound. The wound assessed included the sacrum, which measured 9.0 cm in length, 10.0 cm in width, and 0.1 cm in depth. The wound was noted to have eschar in the wound base. A review of a sacrum/coccyx x-ray dated February 26, 2025, revealed findings that showed a question of subtle bone loss of the dorsal aspect of the sacrum/coccyx and soft tissues that appear swollen with ulceration dorsally, and cannot exclude osteomyelitis (bone infection). Resident CR 1 was sent out to the emergency room on February 28, 2025, for evaluation due to worsening of the sacral wound. An interview with the Director of Nursing (DON) on March 26, 2025, revealed the facility could not provide evidence of weight loss or treatment refusals by the resident. Additionally, the facility lacked documented evidence of consistent implementation of turning and repositioning every two hours as ordered from January 17 to February 15, 2025. Furthermore, records indicated the Juven nutritional supplement was not administered consistently on February 25, 26 and 27, 2025. A review of Resident CR 1's task summary reports from January 17 through February 15, 2025, failed to demonstrate that staff consistently performed scheduled turning and repositioning to prevent pressure ulcer development. Furthermore, licensed nursing staff did not develop and implement timely interventions addressing the resident's decreased mobility to prevent pressure injuries during this period. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on policy review, review of facility documentation, and staff interviews, it was determined that the facility failed to effectively implement and enforce its compliance and ethics program in a manner that uses internal controls to more effectively monitor adherence to applicable statutes, regulations, and program requirements, in order to prevent and detect criminal, civil, and administrative violations under the Act, and promote quality of care for two employees identified (Employee 1 and Employee 2) out of two employees employed by the activity department and business office. Findings include: Review of facility's current Code of Ethics manual revealed all employees are required to undergo compliance training on the Code of Ethics as a condition of employment. The principles discussed are mandatory standards and employees must follow the code to remain employed. If an employee knows or suspects a situation is unethical, illegal, or unprofessional, the employee has an obligation to report that suspicion or concern. If an employee knows of a violation and does not report it, they could face disciplinary action for not reporting. Continued review of the Code of Ethics manual revealed that the Anti-Kickback statute makes it a crime to knowingly offer or receive payment or solicit anything of value to obtain or reward a referral of business under federal health care programs. In order to follow both the letter and spirit of the Anti-Kickback stature, and to avoid even the appearance of a violation, both the company and all employees will not accept or offer to provide any items of value in exchange for the referral of a patient, or a resident, or a business opportunity; nor will the company or any employee accept any item of value in return for buying services or supplies. The prohibition on offering or accepting items of value extends to anything that may influence or even appear to influence a decision regarding a healthcare service. A kickback or item of value can include cash, as well as goods, services, or gifts of more than a nominal value. Review of the facility's Employee Corrective Action Form dated February 13, 2025, revealed that Employee 1 (Activities Director) was terminated from employment due to a violation of Level 2 #9 Solicitation or acceptance of any gratuities or gifts. Review of the facility investigation dated February 4, 2025, revealed that the Nursing Home Administrator was initially informed of a situation on February 4, 2025, at approximately 1:30 PM and started an investigation. Review of a statement from Employee 2 (Business Office Manager) on February 4, 2025, no time indicated, revealed that Employee 2 called Employee 1 regarding unconfirmed information regarding Employee 1 receiving $100.00 cash from an insurance vendor for assisting him in getting members signed up for his company's insurance plan. Employee 2 told Employee 1 what she had heard. Employee 1 stated I'm going to lie but not lie to you. Employee 1 said she was giving the money back to the vendor. Continued review of Employee 2's statement revealed that she witnessed conversations about receiving compensation for the vendor's insurance enrollments in the past. In September 2024, at a party, the insurance vendor spoke of compensating staff for helping him get residents on the plan. There were a few facility employees siting at the table when he brought it up. At that time, no one entertained his conversation. Also in September 2024, there was a situation with a family member who was upset her mother was enrolled in the insurance plan. Employee 2 contacted the vendor and asked him to reach out to the resident and daughter to get on the same page about the plan. The vendor was concerned about losing the resident as a member and asked Employee 2 to talk to the resident and family. He offered to pay Employee 2 to do so. Employee 2 told the vendor to contact the family and clear it up. Review of a statement from Employee 1 (Activities Director) on February 5, 2025, no time indicated, revealed she accepted money from an insurance vendor for introducing the vendor to residents and/or their responsible parties. She stated that around the end of the Summer 2024, the insurance vendor began encouraging her to accept payment from him in compensation for the residents she introduced him to that were signed onto his insurance plan. Employee 1 stated she declined all offers at that time. She continued to state that the verbal encouragements from the vendor continued into the Fall 2024. By the end of November 2024, Employee 1 stated that she made a comment to the vendor that her rent increased, and the vendor reiterated his offer that he would pay her $25.00 per person. She responded that she would do it for $20.00 per person and that she was going to continue the way she was making the introductions before she was accepting payment. By the end of November 2024, four (4) residents had been added to the insurance plan which the vendor paid Employee 1 $80.00. Employee 1 stated that she was not paid again until the week of January 5-10, 2025, which she was paid $100.00. She acknowledged her actions were motivated by financial need and indicated the vendor had persistently encouraged the arrangement over several months. Employee 1 stated that on February 4, 2025, the vendor arrived at the facility and came into her office with cupcakes and $100.00. She stated that she did not accept them because she was informed that it was illegal. Interview with the Nursing Home Administrator (NHA) on March 26, 2025, at approximately 4:00 PM, confirmed that Employee 1 had been terminated after an investigation was conducted which determined Employee 1 accepted money from an insurance vendor. The NHA revealed she had no knowledge that the insurance vendor had approached Employee 1 and provided monetary payments to Employee 1 for introductions/referrals. The NHA confirmed that accepting money from an outside vendor for referrals was against the facility's Code of Ethics. Continued interview with the NHA revealed that she was unaware that the insurance vendor spoke to Employee 2 and other facility employees at a party in September 2024, regarding compensation for obtaining referrals. Review of the facility's Course Completion History for employee training revealed Employee 2 completed annual training on the Code of Ethics and Corporate Compliance. There was no evidence that Employee 2, or other facility employees who attended the party and witnessed the vendor openly discuss compensating staff for facilitating enrollments, reported the unethical, illegal or unprofessional behavior of the insurance vendor. Further, there was no evidence that Employee 2 reported to the NHA or compliance hotline, of the insurance vendor's unethical, illegal, or unprofessional offer to pay Employee 2 to call a family member, despite undergoing training on the mandatory obligation of employees to report an unethical, illegal or an unprofessional situation. Despite completing required annual Code of Ethics and Corporate Compliance training, neither Employee 1 nor Employee 2 reported these unethical solicitations to facility leadership or the compliance hotline, in direct violation of facility policy and their mandatory reporting responsibilities. The facility failed to effectively implement and enforce the facility's compliance and ethics program, to be effective in preventing and detecting criminal, civil, and administrative violations. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations, review of the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including scabies for two of 21 residents reviewed (Resident 7 and Resident 54) and failed to maintain an environment conducive to infection prevention. Findings include: A review of the current facility policy for Infection prevention and control, last June 6, 2024, revealed, the infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. Outbreak management to include the following: a. Outbreak management is a process that consists of: 1. determining the presence of an outbreak 2. managing the affected residents 3. preventing the spread to other residents 4. documenting information about the outbreak 5. reporting the information about the outbreak 6. educating the staff and public 7. monitoring for recurrences 8. reviewing the care after the outbreak has subsided 9. recommending new or revised policies to handle similar events in the future. b. Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. c. The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. A review of the facility's infection control data conducted during the survey ending November 21, 2024, revealed the facility's infection control tracking did not reflect evidence of a functional tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of infection control data revealed the following infections were tracked as noted: August 2024: 5 urinary tract infections (UTI), 2 eye infections, 1 ear infection, 2 skin infections and 5 upper respiratory infections (URI). September 2024: 3 UTI, 1 ear infection, 8 upper respiratory infection and 1 skin infection. A separate tracking log for September 2024 revealed 16 residents tested positive for COVID-19. There was no tracking or trending for the noted COVID-19 positive residents. October 2024: 3 UTI, 3 upper respiratory infections, 8 skin infections and 1 unidentified infection. November 2024: 4 UTI, 2 upper respiratory infection, 3 skin infection and 2 GI (gastro-intestinal infection) and 1 unidentified infection and 2 residents notes as rash/scabies and 8 additional with rash. A review of November 2024 tracking and trending documentation did not include any further information or documentation of any treatments. The facility's infection control log revealed no documented evidence of detailed data collection that could be used by the facility to track these infections and to identify any potential trends contained in the tracking data. The data did not include resident room location, the infectious organism or treatment. There was no documented evidence at the time of the survey that based on the available tracking data the facility had identified any possible trends to implement specific interventions to prevent the spread of any of the infections. There was no documentation by the facility of the any of the infection start dates, resolution date, symptoms, complete culture information for any of the infections noted in the facility's monthly infection control tracking logs and the treatments required, if any. It could not be determined if any of the noted infections required isolation protocols to be implemented. There was no indication the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of the infections. During an interview conducted on November 20, 2024, at approximately 1:00 PM the Director of Nursing confirmed the infection control tracking was incomplete and failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., HAI healthcare associated infections and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need to for corrective action. A review of a facility policy entitled Scabies Identification, Treatment and Environmental Cleaning reviewed June 6, 2024, revealed, the purpose of the policy and procedure is to treat residents infected with scabies and to prevent the spread of scabies to other residents and staff. Scabies is an itchy skin rash caused by a tiny burrowing mite called Sarcoptes scabiei. Intense itching occurs in the area where the mite burrows. The need to scratch may be stronger at night. Scabies is contagious and can spread quickly through close person-to-person contact. The policy indicated Scabies is spread by skin to skin contact with the infected area through contact with bedding, clothing, privacy curtains and some furniture. Diagnosis may be established by recovering the mite from its burrow (under the skin) and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because on one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. Affected residents should remain on Contact precautions (used in addition to routine infection control practice for residents known or suspected to be infected with microorganisms that can be transferred by direct or indirect contact to include, wearing gown, gloves, and a mask during care) until 24 hours after treatment. Family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. During a scabies outbreak among residents and/or personnel, the infection Preventionist or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. Control of an epidemic depends on treating all residents at risk. Specific drug selection for each resident will depend on that individual's risk factors, possible medication interactions etc. Treatment with Permethrin (Scabicide): Bathe the resident. Allow the body to cool. Apply Permethrin cream into the skin from the chin to the soles of the feet. Dress the resident in clean clothing. Use freshly laundered bed linens and towels. Leave the cream on for at least 8 hours but no more than 12 hours, and then shower or bathe the resident in warm water. Put on clean clothing. Re-launder towels and bed linens used during treatment. Environmental Control: Typical Scabies Place residents with typical scabies on contact precautions during the treatment period. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at least 10-20 minutes. Use the hot cycle of the dryer for at least 10-20 minutes. Place non-washable blankets and articles in a plastic bag for at least 72 hours. Vacuum mattresses, upholstered furniture, and carpeting. Documentation: The date and time the care was provided. The name and title of the individual who assisted with the care. If the resident refused the treatment, the reasons why and the interventions taken. The signature and title of the person recording the data. Infection control documentation revealed that on October 29, 2024, 13 residents and 3 nursing staff members presented with itchy rashes. A review of infection control documentation dated October 28,2024 indicated Resident 54 was noted with a rash on his trunk. There was no further description of the area. The Physician was called and ordered Triamcinolone cream, a glucocorticoid, steroid used to treat certain skin diseases, allergies, and rheumatic disorders. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnosis to include heart disease and chronic kidney disease. A review of an annual (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 8, 2024, revealed, the resident to be cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. A score of 13-15 indicates intact cognition) and required staff assistance for activities of daily living. A review of a care plan dated October 29, 2024, revealed, the resident had a rash on body. Interventions to include, avoid scratching and keep hands and body parts from excessive moisture., give anti-pruritic medication as ordered by the Physician, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected. Nursing documentation dated October 25, 2024, at 12:05 P.M., revealed, Resident 7 made nursing aware of itch to her upper back, lower abdomen, bilateral upper legs, and all over her abdomen. The rash was described as red raised areas. Nursing documentation dated Friday October 25, 2024, at 1:29 P.M. revealed, the Physician was notified of a rash on Resident 7 and indicated nursing to continue to monitor the resident until seen again on October 28, 2024. Nursing documentation dated October 28, 2024, at 12:28 P.M., revealed, the Physician was in to see the resident and ordered triamcinolone Acetonide External cream (Triamcinolone is a glucocorticoid used to treat certain skin diseases, allergies, and rheumatic disorders among others) 0.1%, apply to itchy body rash, topically every 12 hours, as needed for body rash for 2 weeks. The resident was placed on contact precautions and isolation precautions related to the rash. Nursing documentation dated October 29, 2024, November 2, 2024, November 3, 2024, revealed the itchy rash continued all over Resident 7's body. A physician's order dated November 4, 2024, at 10:40 A.M. revealed a new order for, Cetirizine (an antihistamine medication, used to treat allergies and allergic reactions) HCL oral tablet, 10 mg, 1 tablet by mouth one time a day for pruritus (itching) for 2 weeks. Nursing documentation dated November 4, 2024, at 1:07 P.M., indicated that contact precautions were discontinued by the infection control Preventionist. Further documentation at 6:46 P.M. that day indicated that Resident 7 complained of itchy skin. Nursing documentation dated November 7, 2024, at 1:49 P.M., revealed that Resident 7 still complained of itch despite treatment and new order for Cetirizine. Nursing documentation dated November 8, 2024, revealed, Resident 7 continues to complain of itchy rash. The resident placed back on contact precautions and a dermatology consult appointment was ordered. A review of a dermatology consult dated November 14, 2024 (no time indicated) revealed, the resident was seen for complaint of rash, located on the arms and trunk. The rash is itchy and mild in severity. The rash has been present for one month. The resident reports no household contacts (people in close contact with the resident) with similar rash, no new medications, no new personal care products, and no recent infections. She is not currently on any treatment. Patient was treated for scabies at the facility 2 weeks ago with Permethrin treatment. The diagnosis included, Scabietic nodules (lumps that appear after scabies treatment, may be secondary to persistent infection). Recommended treatment to include, Permethrin cream applied neck down to feet, leave on for 8 hours, shower off and repeat in one week. Facility expectations to include, household contacts should be treated. Contaminated clothing should be isolated for 72 hours and wash and dried on high heat. Contact the dermatology office if scabies fails to resolve after several weeks of treatment. Nursing documentation dated November 14, 2024, at 9:05 P.M. revealed, Resident 7 had Permethrin cream applied. There was no documentation of the removal (bathing or shower) 8 hours after the application of the Permethrin cream application. There was also no documentation of environmental interventions, linen change, washing clothing etc. Nursing documentation dated November 16, 2024, at 4:06 A.M., revealed Resident 7's rash remains unchanged. An interview with Resident 7 on November 21, 2024, at approximately 12 P.M., revealed she still had a rash on her abdomen, back and arms and complained of an itch. An observation of the resident's skin at the time of the observation revealed a red rash on her abdomen, back and bilateral arms. The areas on her back were noted to have crusted with fresh scabbed areas. The resident stated that her skin is very itchy, and she scratches sometimes until the areas bleed. She stated the itching is very distressing to her. A review of a medication administration record for October 2024 and November 2024 revealed that Resident 7 received the steroid cream (Triamcinolone) twice daily as ordered. A review of weekly skin integrity forms (completed by nursing staff on resident shower days) dated October 28, 2024, October 31, 2024, November 4, 2024, November 18, 2024, indicated that Resident 7's skin was intact with a rash. A review of Infection control documentation, (a line listing of residents with body rashes) dated October 29, 2024, revealed 12 additional residents were noted with itchy body rashes. Nursing documentation dated October 29, 2024, at 2:53 P.M. revealed, the Medical Director was contacted and deemed it necessary to treat all the residents who were symptomatic and preventative treatment to all the residents in the facility due to the current rash outbreak. The facility census on October 29, 2024, was 104. Infection control documentation indicated, -October 29, 2024, 17 residents were treated with Permethrin cream -October 30, 2024, 31 residents were treated with Permethrin cream -October 31, 2024, 40 residents were treated with Permethrin cream -November 1, 2024, 11 residents were treated with Permethrin cream The infection control documentation indicated that 5 residents were newly admitted to the facility or hospitalized at that time. Infection control documentation indicated that on October 29, 2024, after the initial 12 residents presented with the itchy rash, the Infection Preventionist informed the facility nursing staff of the resident rashes and offered staff Permethrin cream treatment. At that time, three nursing staff stated to the Infection Preventionist that they had itchy rashes and these staff along with an additional 5 nursing staff accepted the Permethrin cream treatment. There was no evidence at the time that any staff were examined by a physician during or after treatment for scabies. Nursing documentation for all the above treated residents indicated the residents and or responsible party were notified of the rash outbreak in the facility, however there was no evidence that possible side effects and or a consent for treatment was obtained. An interview with the DON (director of nursing) on November 21, 2024, at 1:00 PM, confirmed the unresolved rashes have been discussed with the Medical Director and the decision was made to treat all residents at the facility. She stated that staff did not come forward with rashes until after residents had been treated. She could not confirm that residents or responsible party's or staff were presented with possible side effects or the opportunity to consent to treatment. She further confirmed there were no consistent nursing assessments regarding resident rashes as well as no documentation regarding staff rashes and treatments. An interview with the DON on November 21, 2024, at approximately 1:00 PM also verified the facility failed to implement proper infection control practices, including the facility's established policy and procedures, to prevent and mitigate further spread of scabies after Resident 7 began treatment for scabies and the other residents' rashes continued. An environmental tour of the facility central supply room (a storage area for resident care supplies, over the counter medication storage as well as clean resident care equipment) on November 20, 2024, at approximately 12 P.M., in the presence of the central supply clerk, revealed the floor to be dirty with visible dirt and paper and plastic debris. There were leaves on the floor near the exit door. There were cardboard boxes directly on the floor. There were 4 unbagged oxygen concentrators, 5 tube feeding poles with dried liquid on the bottom. There were 9 unbagged mattresses piled up in the middle of the floor. Holiday decorations in a box as well as on a metal shelving. There was a shopping cart with 2 cardboard boxes containing unbagged plastic suction canisters and an opened bag of resident briefs. There were multiple commode chairs as well as additional unclean tube feeding poles in this area. There were 3 unbagged suction machines on a shelving unit. There was an open cardboard box which contained multiple pieces of Styrofoam directly on the floor. An interview with the DON on November 21, 2024, at approximately 1:00 PM confirmed that infection control practices were not maintained in the facility central supply area. 28 Pa Code 211.10 (c)(d) Resident Care Policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1)(e)(1) Management

Based on a review of clinical records, resident council meeting minutes, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of 21 sampled (Residents 25 and 74) and experiences reported by five out of the nine residents during a resident group interview (Residents 24, 28, 31, 55, and 57). Findings include: A review of Resident Council meeting minutes dated October 2, 2024, revealed that residents in attendance had concerns regarding call bell response wait times. The meeting minutes contained no further documentation regarding the residents' concerns. A grievance dated October 2, 2024, revealed residents had concerns regarding call bells not answered timely. The document indicated individual concerns would be addressed as needed and reviewed during resident council. A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included chronic heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs). A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2024, revealed that Resident 25 is moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08-12 indicates moderate cognitive impairment). During an interview on November 19, 2024, at 12:00 PM, Resident 25 indicated she experiences long wait times for care. She indicated she sometimes waits 20 minutes or longer for staff to respond to her call bell after she rings for assistance. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 4, 2024, revealed that Resident 74 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on November 19, 2024, at 12:55 PM, Resident 74 indicated that he experiences long wait times for care. He explained that he waits from 15 minutes to two hours for assistance. He explained that a few days ago he told the nurse aide that he was having pain and would like his medication, but he had to wait 2 hours before the nurse checked in on him. Resident 74 indicated he is frustrated regarding the wait times for assistance. During a resident council group interview on November 20, 2024, at 10:00 AM, five alert and oriented residents out of nine in attendance indicated they experience distress because of the long wait times for care (Residents 24, 28, 31, 55, and 57). During the group interview, Resident 24 indicated that she waits 20 to 30 minutes for staff to respond to her call bell after she rings for assistance. She expressed that she is frustrated and upset that it takes so long before someone responds to her when she needs help. During the group interview, Resident 28 indicated she waits 30 minutes for staff to respond to her call bell after she rings for assistance. She explained the wait time is the worst in the evening and indicated she is upset when no one responds when she needs to use the bathroom. During the group interview, Resident 31 indicated she often waits 30 minutes or more for staff to respond after she rings her call bell for assistance. Resident 31 explained that sometimes staff will initially respond and turn off her call bell, then tell her they will be right back to provide care but then do not return. Resident 31 expressed that she is upset when she must wait and wait for assistance. During the group interview, Resident 55 indicated she has been left on the toilet for 30 minutes before staff responded to her call bell for assistance. She explained that waiting that long for care is frustrating and upsetting. During the group interview, Resident 57 indicated she often waits 30 minutes for staff to respond to her call bell after she rings for assistance. She explained that she needs assistance to safely ambulate to the bathroom. Resident 57 indicated that when staff do not respond after 30 minutes, she transfers herself to the bathroom even though she knows it is not safe. During an interview on November 21, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one out of 21 residents sampled (Resident 74). Findings include: A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on June 6, 2024, revealed the facility provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition and goals. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 4, 2024, revealed that Resident 74 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Review of the comprehensive plan of care indicated Resident 74 is on the restorative nursing program for ambulation and active range of motion to maintain mobility, initiated on April 16, 2024, and discontinued on November 20, 2024. Interventions in place included encouraging the resident's participation in the restorative nursing program, monitoring progress, and referring the resident to therapy services as needed. A review of the documentation survey report from October 1, 2024, through November 20, 2024, revealed no documented evidence that Resident 74 received or was offered his scheduled restorative nursing program on 18 occasions: October 11, 12, 19, 20, 22, 23, 25, 26, 27, 28, 2024, or on November 2, 3, 5, 6, 7, 16, 17, or 19, 2024. A physical therapy discharge summary dated November 4, 2024, revealed Resident 74's prognosis to maintain the current level of function is excellent with participation in the restorative nursing program, and the discharge recommendations indicated discharge from the restorative nursing program. During an interview on November 19, 2024, at 12:55 PM, Resident 74 indicated that he is not receiving therapy or restorative nursing services. He explained it is frustrating because his goal is to regain his independence and ambulatory abilities. During an interview, on November 21, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure residents receive appropriate services and assistance to maintain or improve mobility. The NHA was unable to provide documented evidence that Resident 74 received restorative nursing services as planned. 28 Pa. Code 211.5(f)(xi) Medical records. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and select facility investigative reports, observation and resident and staff interview it was determined the facility failed to consistently provide care and services to prevent the development of a pressure sore for two residents out of 21 sampled (Residents 19 and 26). Findings include: A review of facility policy titled Unavoidable Pressure Injury, last reviewed by the facility on June 6, 2024, revealed it is the facility's policy that a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's risk factors demonstrate they were unavoidable. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 7, 2024, revealed that Resident 19 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A comprehensive care plan indicating Resident 19 has the potential impairment to skin integrity with a goal to maintain clean and intact skin was initiated on July 20, 2023. An intervention implemented by the facility to achieve this goal included ensuring oxygen tubing has ear padding to prevent skin breakdown, initiated on February 16, 2024. The care plan indicated the resident had a history of skin breakdown due to oxygen tubing rubbing against Resident 19's ear, including the development of a Stage II pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed and may also present as an intact, open, or ruptured blister) dated February 16, 2024. A Braden Scale for Predicting Pressure Sore Risk form dated June 6, 2024, identified Resident 19 as at risk for the development of pressure injuries. Further clinical record review revealed a skin impairment assessment report dated August 27, 2024, indicating staff observed a new Stage II pressure injury on the top of Resident 19's left ear due to oxygen tubing. The report indicated Resident 19 said that her left ear is tender from oxygen tubing rubbing. A pressure ulcer wound round report dated August 28, 2024, described Resident 19's left ear wound as a Stage II pressure injury measuring 1.5 cm x 1.5 cm x 0.0 cm with firm edges, no drainage, and a wound bed with slough (accumulation of dead cells usually yellow or white). The surrounding wound area was red with intact skin. A progress note dated September 12, 2024, at 11:04 AM indicated Resident 19's Stage II left ear wound was resolved and staff were continuing to ensure the oxygen tubing was padded to prevent further skin breakdown. A review of weekly skin integrity documentation dated November 16, 2024, at 4:25 PM indicated Resident 19 had no current skin conditions noted, and preventative treatment for skin breakdown was ongoing. During an observation on November 21, 2024, at 10:40 AM, Employee 2, Licensed Practical Nurse (LPN), removed a 2.0-inch x 2.0-inch gauze pad from Resident 19's left ear in the area where the oxygen tubing would be present, revealing an open wound measuring 0.7 cm x 0.3 cm x 0.1 cm. The gauze pad contained yellow and brown discolorations. The wound bed had small amounts of clear yellow liquid present. The wound edges were intact. There was no odor from the wound detected. Resident 19 indicated she did not feel any pain associated with the wound. During an interview on November 22, 2024, at 11:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed it is the facility's responsibility to prevent the development of pressure injuries. The NHA and DON confirmed that the facility failed to consistently implement effective interventions such as consistently padding the oxygen tubing to prevent Resident 19 from developing a pressure injury to her left ear. A review of Resident 26's clinical record revealed the resident was most recently readmitted to the facility on [DATE], with diagnoses that include a left hip fracture, reduced mobility, and Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown). A review of the resident's significant change Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the resident had a BIMS of 7, which indicated severe cognitive impairment, always incontinent of bladder and bowel, and dependent with substantial/maximum assistance for toileting, showering, upper and lower dressing, and personal hygiene. Additionally, she was dependent with partial to moderate assistance with bed mobility. A review of Resident 26's clinical record a form entitled Pressure Ulcer Wound Rounds completed by Employee 1, a Registered Nurse (RN), dated October 27, 2024, at 10:33 AM, indicated the resident had a pressure area to her left buttock that measured 0.5 cm in length by 0.5 cm in width and no documented depth Stage II pressure area (the sore has broken through the top layer of the skin and part of the layer below and typically results in a shallow, open wound and may appear as a shallow, crater-like wound or a blister containing a clear or yellow fluid), wound was bed pink, wound edges firm, no redness, no drainage. Further review of a Pressure Ulcer Wound Round documentation completed by Employee 1(RN) on October 27, 2024, at 11:14 AM, revealed a second pressure area to her sacrum that measured 1.0 cm in length by 1.0 cm in width with depth not noted, Stage II pressure area, wound bed pink, wound edges firm, no redness, no drainage, peri area intact. There was no documentation to determine if the physician or responsible party of the resident was notified at the time of discovering the new pressure ulcers. A facility investigation for skin impairment completed by Employee 2, a RN/Unit Manager, dated October 28, 2024, at 7:00 AM, revealed Resident 26 was assessed following a report of the aforementioned open area on the sacrum over the weekend. Stage II wound present 4.0 cm by 3.0 cm area measured as one area with three separate superficial openings. The treatment was changed to wound gel twice per day. Immediate action was to provide topical treatment initiated, turn and repositioning every two hours, and every two-hour check and change program. Noted predisposing factors included incontinence and Gait (walking pattern) imbalance. A review of the resident's task summary reports (reports that capture care related tasks completed by nurse aides) dated August 28, 2024, through October 28, 2024, failed to reveal that staff performed pressure ulcer prevention tasks, such as scheduled turning and repositioning and more frequent incontinence care/management to prevent the development of pressure areas. Resident 26's clinical record review failed to reveal that licensed nursing staff developed and implemented interventions for prevention of the development of pressure areas related to the resident's declined mobility post left hip fracture. A review of a Pressure Ulcer Wound Round form completed by Employee 2, dated November 13, 2024, at 12:57 PM, revealed the Stage II on the resident's sacrum was showing a depth at 0.01 cm with granulation (formation of new tissue) present in the wound bed, no drainage or odor. Wound gel was recommended by the physician. Additionally, a nurses' progress notes in Resident 26's clinical record dated November 18, 2024, at 10:45 AM, revealed the sacral wound progressed to an unstageable pressure area (full-thickness tissue loss with the base of the ulcer covered by slough a yellow, tan, gray, green, or brown substance) in the wound bed that measured 4.0 cm in length, by 4.5 cm in width, with 0.1 cm depth. A review of the facility's contracted wound nurse practitioner assessment dated [DATE], revealed Resident 26 was seen for a follow-up of a Stage II pressure area to the sacrum and indicated that staff reported the area had deteriorated throughout the week. Treatment was changed to Santyl (is a topical enzyme medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin). During an interview with the Director of Nursing (DON) on November 22, 2024, at 2:00 PM, confirmed the facility failed to implement consistent and appropriate measures to prevent the development and worsening of pressure sores for residents. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide necessary care to promote healing, and prevent worsening of a pressure sore, resulting in deterioration and clinical complications with the resident's pressure sore for one resident out of 24 sampled (Resident 94). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of facility policy entitled Skin and Wound dated as reviewed by the facility May 9, 2024, revealed it is the policy to provide a system for identifying risk and implementing resident centered interventions to promote skin health and the prevention and healing of pressure injuries. The facility policy entitled Pressure Injury Record dated as reviewed by the facility May 9, 2024, revealed that residents will have a pressure injury record competed for each skin impairment that is related to pressure. The staff will mark the pressure area on the body description identifying the site. The staff then will enter the date, stage of the pressure injury, the size of the pressure injury, the tissue type and color, the wound edges, drainage, and peri-wound information. A review of the clinical record of Resident 94 revealed admission to the facility on [DATE], with diagnoses, which included Type 2 diabetes, a pressure ulcer to the right heel, a non-pressure ulcer to the right lower leg, and a non-pressure ulcer to the left lower leg. An Admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident needed partial to moderate assistance in rolling to the left and right, from sitting to lying, lying to sitting, sitting to standing, transferring from the bed to chair, and toileting. The resident was at risk for developing pressure ulcers and had unhealed pressure ulcers. Admission assessment dated [DATE], revealed that the resident had a 3 cm x 3 cm unstageable pressure wound to the right heel that appeared necrotic (dead black tissue). No further assessment was documented upon admission to include any other wound characteristics, to include any drainage, odor, the wound edges, or appearance of surrounding tissue. A review of the resident's baseline plan of care dated June 28, 2024, revealed the resident had a pressure wound to the right heal. The care plan did not include measures to reduce pressure to the unstageable pressure ulcer to the right heel, such as offloading pressure to the heels, turning and repositioning, or floating heels while in bed. A Non-Pressure Skin Condition assessment was conducted June 30, 2024, but this assessment did not include a complete assessment of the resident's pressure wound, the unstageable pressure wound to the resident's right heel. The wound was noted as right heel 3 cm x 3 cm, but no further assesment details were documented, to include stage of the pressure wound and current appearance and wound characteristics (drainage, appearance, wound bed, surrounding tissue, and any odor) of pressure wound to the resident's right heel. A review of a Non-Pressure Skin Condition assessment dated as completed on July 5, 2024, revealed no evidence that nursing staff conducted a thorough assessment of the pressure wound to the right heel. The wound had increased in size, noted as right heel 3.5 cm x 4 cm x 0.1 cm. but no further assesment details were documented, to include stage of the pressure wound and current appearance and wound characteristics (drainage, appearance, wound bed, surrounding tissue, and any odor) of pressure wound to the resident's right heel. A review of a wound consult note dated July 10, 2024, revealed the resident's right heel pressure sore was an unstageable pressure sore measuring 3 cm x 7 cm x 0.5 cm and the wound base was 100 percent eschar (dead tissue). The wound consultant indicated that the facility should implement a repositioning schedule per protocol for pressure prevention and float the resident's heels while in bed with use of prevalon boots (a device applied to the foot to reduce pressure). The wound consultant noted that the resident's right heel appeared boggy (soft and spongy) with foul odor and soft eschar and recommended an x-ray of the right heel due to deterioration. Following this wound consult completed on July 10, 2024, there was no documented evidence that the facility implemented the recommendations for a turning and repositioning schedule or use of prevalon boots. A nursing progress note dated July 11, 2024, at 12:00 PM revealed an x-ray of Resident 94's right heel was completed. A review of a Radiology Result Report dated July 11, 2024, at 2:06 PM revealed the resident had a calcaneus erosion consistent with osteomyelitis (bone infection caused by bacteria or fungi). A review of a change in condition assessment dated [DATE], five days after the resident was identified with a bone infection, revealed the resident has increased pain and osteomyelitis. The physician was notified on July 16, 2024, at 3:00 PM and recommended to send the resident out to the hospital for treatment. A review of hospital records dated July 17, 2024, revealed the resident presented to the hospital with worsening right heel pain and a non-healing worsening wound with osteomyelitis. The resident had a low grade temperature of 100 degrees Fahrenheit and IV (intravenous) antibiotics were initiated. The hospital records noted that the resident's wounds were extensive and with wound debridement and dressing changes they may temporarily improve but the underlying bone infection wound not resolve even with months of IV antibiotics. The wounds will colonize with antibiotic resistant organisms and without debridement of dead bone the chances to cure the osteomyelitis are nil. The facility failed to demonstrate timely implementation of recommended measures to promote healing of the pressure sore, including pressure reducing measures and devices, Prevalon boots and repositioning. The facility failed to timely notify the physician of the results of the xray identifying the bone infection to assure prompt treatment. Nursing staff failed to consistently document thorough assessment of the pressure sore to timely identify declines in the wound's condition. An interview with the Nursing Home Administrator on July 18, 2024, at approximately 10:30 AM confirmed the facility was unable to provide evidence of timely development and implementation of measures necessary to promote healing of a pressure ulcer. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and investigative reports, and staff interviews, it was determined that the facility failed to ensure that the resident's environment was free of potential accident hazards, resulting in a fall with injury, a fractured clavicle, to one resident out of three sampled residents (Resident 18). Findings include: A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses, which included adult failure to thrive, left, and right knee contracture, abnormal posture, and dementia. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 3, 2023, revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information) revealed that the resident had both short and long term memory problems, and required extensive assistance with bed mobility, transferring, dressing, eating, toilet use, and personal hygiene. A review of the resident's care plan initiated August 28, 2021, for the resident's problem of activity of daily living (ADL) self-care performance deficit related to activity intolerance, dementia and impaired balance, revealed that as of June 8, 2023, the resident required the use of a mechanical lift with two staff assistance for transfers. A Physical Therapy (PT) discharge summary, dated May 8, 2023, included discharge recommendations for the resident to use a wheelchair, transfers total mechanical lift and a restorative nursing program for range of motion. A nursing note, dated June 5, 2023, at 5:38 PM revealed that the resident was self-propelling wheelchair down the hallway and slid forward out of the wheelchair onto her left side (on the floor). The resident sustained a bump on left side of her head and ice was applied. An RN assessed the resident to have full range of motion as prior to fall. It was noted that the resident was tearful, returned to bed, and medicated for pain. A review of facility fall incident investigation dated June 5, 2023, revealed that the resident was rolling herself down B-wing and her feet caught under the wheelchair and the resident fell forward onto left side of her body. The resident's feet were wrapped in the sling straps of the mechanical lift. The resident landed on left side of her body with the wheelchair in the upright position. The total mechanical lift sling on was on the chair and slippy. The lift sling is to be removed from wheelchair after the resident is transferred into the chair. The resident's range of motion was as prior to the fall, both legs contracted under wheelchair sling, which was caught around the resident's feet. Other information: Total mechanical lift sling on the wheelchair causing a slippery surface and the resident's contracted legs were under the wheelchair with the lift slings straps dangling. A Witness Statement dated June 5, 2023, from Employee 1, Registered Nurse (RN), indicated that the resident was self-propelling down B wing, and Employee 1 heard a thump. The resident fell out of the wheelchair with both legs tangled in the lift sling, the wheelchair was in the upright position. Lift sling on chair and slippy. Intervention: to remove sling once in the wheelchair. A Witness Statement dated June 5, 2023, from Employee 2, Licensed Practical Nurse (LPN), indicated that the resident was seen self-propelling in her wheelchair previous to incident. While at nurses station, Employee 2 heard a thump and noticed the resident on the floor on (B) hall with both contracted legs under wheel chair, laying on her left side, Hoyer (lift) sling straps on floor. A nursing note, dated June 6, 2023, at 12:47 AM indicated that the resident had a left elbow bruise from the fall on June 5, 2023. Tylenol was offered, but the resident refused. Active range of motion all extremities was noted at that time. An Interdisciplinary Team (IDT) note, dated June 6, 2023, at 9:26 AM revealed that the resident sustained a fall during which the resident slid out of the wheelchair onto the floor due to her feet getting caught in the Hoyer lift sling that remained under the resident while seated in the wheelchair. The planned intervention was to remove the Hoyer sling from under the resident when in the wheelchair. A referral was sent to therapy for positioning in wheelchair A nursing note, dated June 6, 2023, at 11:23 AM revealed that the resident was tearful and holding her left arm close to her body. Staff observed a raised bony prominence on the resident's left clavicle area. Tylenol was provided and the MD made aware. A new order was received dated June 6, 2023, at 11:56 AM for chest and left clavicle x-ray. The results of the x-ray dated June 7, 2023, at 4:49 PM indicated that the resident had sustained an acute clavicle (collar bone) fracture distal - third with displacement (distal clavicle fractures are traumatic injuries usually caused by direct trauma to the shoulder from a fall). Interview on October 26, 2023, at approximately 10:15 AM, with Employee 3 (Physical Therapist - Director of Therapy) revealed that Employee 3 stated that the resident does have contracted left and right lower extremities (knees) resulting in her legs being under the wheelchair when she is self-propelling. Employee 3 also confirmed that Resident 18 was not evaluated for safety when self-propelling in the wheelchair, and while sitting on the mechanical lift sling. During an interview on October 26, 2023, at approximately 10:55 AM, the Nursing Home Administrator (NHA) confirmed the circumstances of the resident's acute fracture, and verified that facility failed to ensure that the resident's environment was free from an accident hazard, the mechanical lift pad on the seat of the resident's wheelchair, resulting in a fall and fractured clavicle. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing Services

Based on review of clinical records, the facility's diet manual and menus, and select facility investigative reports and staff interviews, it was determined that the facility failed to ensure that a resident identified with chewing and swallowing difficulties was consistently served food in a form to meet this resident's individual needs resulting in choking episode requiring hospitalization for [CONDITION(S)] for one resident out of five sampled (Resident 1). Findings include: A review of the clinical record of Resident 1 revealed admission to the facility on [DATE], with diagnoses, which included dysphagia (difficulty swallowing) and cerebral infarction (stroke). A review of an admission Minimum Data Set (MDS - federally mandated assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed that Resident 1 was severely cognitively impaired, required staff assistance with activities of daily living, including the assistance of one staff for eating and was on a mechanically altered diet. The resident had a physician order dated July 26, 2022 for a regular dysphagia puree texture diet (A pureed diet is an eating plan where all the foods have a soft, pudding-like consistency) with nectar thick consistency fluids (Nectar consistency means an apricot or tomato juice consistency; some liquids will require a thickening agent to be added to reach nectar consistency). A review of a speech therapy evaluation dated with an end of therapy service date of August 5, 2022, revealed that the resident's goal was met for improving mastication (chewing) and swallowing function to upgrade the resident's diet to dysphagia advanced textures. (This type of diet requires that foods that are difficult to chew are chopped, ground, shredded, cooked or altered to make them easier to chew and swallow according to the facility's diet manual, last reviewed by the facility September 3, 2021.) The speech therapy evaluation noted that the resident's diet has been upgraded from a pureed texture to a Dysphagia advanced texture as of August 4, 2022. Speech therapy noted that progress was seen, as the resident was improving in swallow function for thin liquids, but the resident continued with Nectar thick liquids at this time as coughing was noted after swallowing. A physician order was noted dated August 4, 2022, at 9:55, AM for a Regular Dysphagia advanced texture diet with Nectar thickened fluids. A facility incident report dated August 5, 2022, indicated that a nurse aide answered Resident 1's room call light 6:33 p.m. to find him in his bed with the head of the bed elevated. He was having difficulty speaking, then put his hands to his throat. The nurse aide ran to get the LPN and she responded immediately. The LPN observed Resident 1 hit his chest with the palm of his hand. The LPN performed abdominal thrusts and instructed the nurse aide to get the other LPN (on duty at that time) when a small piece of meat came out of the resident's mouth forcefully. The LPNs together performed additional thrusts (the [MEDICATION(S)] maneuver a first-aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the [MEDICATION(S)] maneuver compresses the lungs and forces air up into the windpipe {trachea}) until cleared and the resident begins breathing) and back slaps. The LPNs instructed the aide to get the RN Supervisor. The RN responded immediately, finding Resident 1 unresponsive and without respirations. He was cyanotic (bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) The RN called 911 (emergency response). O2 (oxygen) was applied at 5 liters and ambu bag (bag valve mask, a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) and crash cart (a cart on wheels used for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols). There was initially a carotid pulse (pulse over your carotid artery in your neck to the side of your windpipe) and then it was no longer palpable. Chest compressions initiated. The ambulance personal arrived and the paramedic dislodged a piece of a hot dog from the resident's throat using a laryngoscope (a thin tube with a light, lens and a video camera that helps providers look closely at your larynx) The paramedic then intubated (insertion of a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) Resident 1 and continued with ambu bag and chest compressions. The paramedics performed additional care then took him to the hospital. A review of hospital documentation dated August 5, 2022, at 6:53 PM revealed received {Resident 1} from EMS (emergency medical services) intubated. The resident was placed on a ventilator and admitted to the intensive care unit (ICU). Further review of hospital documentation, a respiratory therapist note, dated August 9, 2022 at 8:04 AM revealed patient admitted to the hospital secondary to out of hospital [CONDITION(S)] after choking on hot dog. Ventilator day five. (A ventilator is a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently) A review of an employee witness statement obtained as part of the facility's investigation into the incident, no date or time indicated from Employee 1(nurse aide) noted that I passed the trays with the help of Employee 2 (LPN). I was finished passing the trays and I had a resident ask for a sandwich, on [MEDICATION(S)] back (from the kitchen) I noticed that there was a call light on in room 225 (Resident 1's room), so I went to answer it. I looked at the resident and he appeared to be having a hard time speaking, then he put his hands to his throat. That's when I turned and ran to the nurse. I yelled to her that there was a resident choking really bad. She ran in the room and started abdominal thrusts on the resident. A review of a witness statement dated August 5, 2022, no time indicated, from Employee 2 (LPN) noted that Employee 1 nurse aide came to me while I was at the nurses station charting on the computer, stating that the other LPN (Employee 3 LPN) needed help with a resident that was choking in room 225. I ran to the room, Employee 3 (LPN) was performing abdominal thrusts on Resident 1. A small amount of food came out of his mouth. Employee 1 (nurse aide) got the RN supervisor, when arrived, she told us he was a full code, she got the crash cart and called 911. A review of a witness statement dated August 5, 2022, (no time indicated) from Employee 3 (LPN) noted that Employee 1 (nurse aide) came to this nurse and said that {Resident 1} is choking. I went in Resident 1's room, he knocked his tray on the floor. Resident 1 was hitting his chest with the palm of his hands. I (Employee 3,LPN) started performing abdominal thrusts on the resident. I asked Employee 1 (na) to get the other LPN on duty Employee 2 (LPN) came in the room. We alternated abdominal thrusts and a small amount of food came out of his mouth. Employee 1 got the RN supervisor, when she arrived she said Resident 1 was a full code and we needed the crash cart. The RN supervisor called 911. We continued to perform the necessary measures until 911 arrived. There was no witness statement from the staff member who passed the meal tray to Resident 1 at the evening meal on August 5, 2022, or from the staff who may have provided the resident any required assistance in setting up this meal for the resident prior to his choking incident that evening. A review of interviews that had been conducted with the facility's dietary kitchen staff via telephone revealed an interview dated August 8, 2022, (no time indicated) with Employee 7 (cook) indicating that On Friday August 5, 2022, I received a diet requisition form upgrading {Resident 1} from A Dysphagia Puree diet to a Dysphagia Advanced diet. I manually altered the printed ticket, crossing off Puree on each item. A review of a witness statement dated August 5, 2022 (no time indicated) from Employee 4( cook ) noted that I prepared the tray ( for Resident 1). I looked at the card and it said Regular (diet). I thought it was a regular because the word for the texture was crossed out. I don't know who crossed it out or why. The DYS (dysphagia) was there, but I didn't know it was Dysphagia. The ticket for tomorrow morning is also wrong. Employee 5 (dietary aide) and Employee 6 (dietary aide) were on the line with me. We were short a person. We were all to blame, but we definitely didn't do it on purpose. I can't say how sorry I am. A review of a witness statement dated August 5, 2022 (no time indicated) from Employee 5 (dietary aide) noted that Tickets (meal tray) were saying what was on the trays and gave each resident the precise drinks, foods, condiments ans other items for the meals given to them. Sometimes the tickets have things written on it that they (residents) can or can't have or sometimes there is a typo error that may have mistaken the meal for something else or they are getting something we may not know about or we run out of stock supply to provide with. Overall, the tickets say what they say, unless somebody made a misunderstanding on the ticket. A review of a witness statement dated August 5, 2022 (no time indicated) from Employee 6(dietary aide) noted I was doing top (of the tray line) and the ticket said regular, which I thought it was (Resident 1's diet) and they forgot to cross out ADS (Dysphagia Advanced). It wasn't my intention to do it. A review of a printed meal tray ticket for Resident 1 dated Friday August 5, 2022 Dinner meal, revealed the ticket stated Regular Dys, Nectar Thickened Liquid. The ticket noted the following: Hot Dog for Bun Puree was printed on the ticket but crossed out; Baked Beans Puree was printed on the ticket and crossed out, Hot Dog Bun Puree was printed on the ticket and crossed out, 'Marinated mixed vegetable salad puree was printed on the ticket and crossed out and Chilled Pears puree was printed on the ticket and crossed out. A review of the facility's planned dinner menu for evening meal on Friday August 5, 2022 (the facility Week-at-a-Glance, week 4 menu) revealed that the regular diet meal served was a Hot dog on a bun, confetti coleslaw and chilled pears. A review of the facility's planned dinner menu for the evening meal on Friday August 5, 2022, (the facility, Week-at-a-Glance, week 4 menu) revealed the Regular Dysphagia Advanced Texture diet served was a Ground Hot Dog on a bun, baked beans, Marinated mixed vegetable salad and chilled pears. During an interview August 9, 2022, at approximately 10:30 AM Employee 8 (Dietary manager in Training) stated that resident meal tray tickets are printed on the evening shift, prior to the next days meals. The meal tickets printed are for the next 24 hour meal period. Employee 8 stated that prior to Resident 1's choking incident, there was no established procedure for manually altering/updating the meal tray tickets. After the incident, the CDM (certified dietary manager) or Employee 9 are now responsible for printing and checking the accuracy of the residents' meal tickets. If the meal ticket is incorrect or is there is a diet change prior to the next meal, the CDM or Employee 9 will cross out the incorrect data and write in the correct data. She stated that there is no written policy or procedure at the facility directing dietary staff on this procedure, but this was the protocol they were using in response to Resident 1's choking incident. She confirmed that Employee 7 (cook) manually altered Resident 1's diet ticket on August 5, 2022. The facility investigation revealed that there was no policy or procedure or any staff training for the manual alteration of meal tickets with changes in diet consistency to ensure that dietary staff maintained standards and that residents received correct meal items and food consistencies promptly. Resident 1 was served a regular hot dog instead of a mechanically altered ground hot dog as planned for a dysphagia advanced texture diet. The CDM was not available for interview at the time of the survey. During an interview August 9, 2022, at approximately 12 PM, the facility's Registered Dietitian confirmed that at the time of the choking incident, there was no system in place in the dietary department to ensure accurate, timely and efficient updates to meal tray tickets to ensure that residents receive the correct diet consistency according to their assessed needs and diet order to assure that their food is cut, chopped, ground, or pureed for individual resident's needs. Interview with the DON (a director of nursing) on August 9, 2022, confirmed that the facility failed to ensure that Resident 1 had been served food prepared in a form designed to the resident's meet individual needs resulting in a choking incident and the resident's hospitalization , admission to ICU and placed on a ventilator. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services. 28 Pa Code 211.6 (a)(d) Dietary services

Based on a review of clinical records and select facility fall investigation reports and staff interviews, it was determined that the facility failed to implement individualized effective fall prevention interventions and necessary staff supervision, of a resident identified at high risk for falls to prevent repeated falls, including a fall resulting in a serious injury, a [CONDITION(S)], sustained by one resident out of two residents reviewed for accidents/falls (Resident 71). Findings include: A review of Resident 71's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a type of brain disease that causes a long-term and often gradual decrease in the ability to think and remember how to perform normal activities such as bathing, dressing and eating) hypertension, and depression. A quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 28, 2021, indicated Resident 71 was severely cognitively impaired with a BIMS (brief interview for mental status, a tool to assess cognitive function) score of 3. The resident required the assistance of one staff member for transfers and ambulation. Facility completed fall risk assessments dated July 12, 2021, and September 1, 2021, identified Resident 71 at high risk for falls, with scores 80 and 65 respectfully. According to the facility's fall risk assessment, a high risk is a score greater than 51, and the facility will implement High Risk Fall prevention Interventions. A review of the resident's care plan for the problems of falls and injury revealed that a tabs alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident). was in place since August 17, 2020. Review of the facility fall investigation dated November 5, 2021, revealed that Resident 71 was found on the floor, on his right side in front of his wheelchair in his room. An IDT (interdisciplinary team) note dated November 8, 2021, at 10:47 a.m. noted that from investigation, the facility concluded that resident was reaching for his cup. The cup spilled and the resident fell out of his wheelchair. According to the investigation report the resident was to remain on 30 minute checks by staff during quarantine (the resident was being quarantined at this time due to COVID-19 mitigation efforts). It was also noted that staff replaced the sensor pad alarm (alarm pad is placed under resident. When resident gets up from pad, a wireless signal is sent to the monitor setting off the pad alarm to alert caregiver) on the resident's wheelchair with a tabs alarm, although the resident's plan of care indicated that a tabs alarm had been in place since August 17, 2020. At the time of the survey ending January 21, 2022, there was no documented evidence that staff were conducting 30 minute checks of the resident while during the resident's quarantine period as noted in the investigation report. Review of the facility fall investigation report dated November 15, 2021, indicated that Resident 71 was found in his room, observed lying on his side on the floor. IDT note dated November 16, 2021, at 2:44 p.m. indicated that from investigation it appeared that the resident fell while attempting to get his pretzels from on the dresser. It was noted that at times, the resident was non compliant with his transfer status, as the resident required the assistance of one staff for transfers, and is provided frequent reminders to not self-transfer without staff assistance, although the resident is severely cognitively impaired. Interventions implemented following this fall, was to conduct a therapy screen for a reacher and a basket for resident snacks so they can be easily moved closer to the resident to obtain them when desired. However, the resident's care plan was not revised to include the use of the basket as noted in the fall investigation report. Review of the facility investigation dated November 20, 2021, at 5:45 PM indicated that Resident 71 was found seated on the floor of his room, on his buttocks, with the wheelchair locked behind him. The resident stated I wanted to go to bed. An IDT note dated November 22, 2021, at 9:16 a.m. indicated that the new intervention put in place was offer the resident a nap after supper daily. Review of the facility fall investigation report dated December 15, 2021, at 4:55 PM indicated that Resident 71 was found on floor in his room, lying on his back, with his head leaning against the wall and the resident's upper back partially off the floor. According to the report the resident had been seated in his wheelchair, on the other side of the bed, before he fell . The resident told staff that he was trying to get into bed. A dycem (non-skid pad) was in place on the wheelchair The investigation report also indicated that the alarm box was not on the resident's wheelchair and no alarm sounded to alert staff that the resident was standing up unassisted. The report noted that staff were educated for checking for alarm placement and function when they first arrive on their shift. Review of staff tasks completed for Resident 71 on December 15, 2021, indicated on that on the 3 PM to 11 PM shift the resident's tabs alarm on the chair was not checked until 7:01 p.m. for placement and function (one hour and 15 minutes after the resident's fall). There was no evidence that the resident's tabs alarm had been checked for placement and function prior to the fall on the 3 PM to 11 PM shift. The resident's plan of care for falls/injury was updated on December 15, 2021, to educate staff to check alarm placement and function at the beginning of the shift. The resident's care plan also revealed that the intervention to offer the resident a nap after supper daily, planned after the last fall on November 20, 2021, was discontinued on December 8, 2021, prior to the fall on December 15, 2021. The facility's fall investigation report further indicated that the resident had no injury identified at the time of the fall on December 15, 2021. However, a nurse's note on December 15, 2021, at 5:50 p.m. indicated that the resident complained of left hip pain and a x-ray was ordered. A Nurse's note dated December 15, 2021, at 10:36 p.m. indicated that the results of the x-ray were received and there was no evidence of misalignment or fracture. A Nurse's note dated December 16, 2021 at 11:06 a.m. indicated that the resident was difficult to transfer with complaint of left upper leg pain. Nurse's note dated December 16, 2021 at 1:06 p.m. indicated that the physician was made aware of continued complaints of left hip/buttock pain and a new order for a x-ray of the pelvis and left femur was obtained. A Nurse's note dated December 16, 2021 at 6:00 p.m. indicated that the resident's daughter requested further diagnostic testing, preferably a CT (CT scan or computed tomography scan is a medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) Scan or MRI (Magnetic resonance imaging is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body) of the left hip. A Nurse's note December 16, 2021, at 6:15 p.m. indicated that the resident complained of pain in the left leg and the resident had increased left lower extremity (LLE) weakness. Nurse's note December 17, 2021, at 1:25 p.m. indicated that the physician ordered a CT scan of bilateral (both sides) hips and pelvis, and the procedure was scheduled for December 20, 2021 at 12:30 p.m. The resident continued to complain of pain. Pain was being managed by Tylenol and [MEDICATION(S)]. Nurse's note December 20, 2021 at 2:09 p.m. indicated that the resident was out of the facility for the CT of the pelvis. Nurse's note December 22, 2021 at 10:13 a.m. indicated that the result of the CT report showed a non-displaced posterior wall left acetabular fracture (a break in the socket portion of the ball-and-socket hip joint) as the result of the resident's fall on December 15, 2021. There was no indication in the resident's clinical record that the resident had sustained any other falls or incidents since the fall on December 15, 2021, through the time the resident's fractured was eventually diagnosed on [DATE]. The alarms planned for the resident's use were both inconsistently used and ineffective in preventing repeated falls. The facility failed to provide effective fall prevention measures including necessary staff supervision, at the level and frequency required, to prevent repeated falls and resultant serious injury for this resident identified at high risk for falls, a history of unsafe behavior resulting in falls and known unassisted transfer attempts. Interview with the Director of Nursing on January 21, 2022 at 9:30 a.m. verified that the interventions planned were not consistently implemented and also ineffective in prevent the resident's falls and subsequent hip fracture. 28 Pa. Code: 211.11(d) Resident Care Plans Previously cited 2/26/21, 10/25/19 28 Pa. Code: 211.12(a) Nursing Services Previously cited 2/26/21, 11/10/20, 12/15/20, 8/4/20, 10/25/19 28 Pa. Code: 211.12(c)(d)(5) Nursing Services Previously cited 2/26/21, 11/10/20, 12/15/20, 9/9/20, 8/4/20, 10/25/19 28 Pa. Code: 211.12(d)(3) Nursing Services Previously cited 2/26/21, 8/4/20

Based on a review of clinical record, select facility incident reports, and resident and staff interview, it was determined that the facility failed to provide sufficient staff supervision and assistance during the provision of resident care to prevent a fall with serious injury, a [CONDITION(S)], for one of four residents reviewed (Resident A1). Findings include: A review of the clinical record revealed Resident A1 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] ([CONDITION(S)]-a chronic disease that causes obstructed airflow from the lungs) and anxiety. Resident A1's admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 3, 2020, revealed that the resident had a BIMS score of 15 (Brief Interview for Mental Status- a tool to assess cognitive status; a score of 13-15 indicates cognitively intact), required extensive two person physical assistance for bed mobility (which includes how move to and from lying position and turning side to side), toileting and hygiene. The MDS assessment indicated that the resident was 62 inches tall and weighed 240 pounds with a body mass index of 43.9 (BMI- a measure of body fat based on weight and height; greater than 30 is considered obese and greater than 40 is considered morbidly obese). A physician order dated May 28, 2020, was noted for a bariatric air mattress (designed for overweight and obese residents and provides alternating pressure therapy to prevent, treat, and manage pressure ulcers). A review of the resident's baseline care plan (a baseline care plan must be developed and implemented within 48 hours of admission to the facility and includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care and the minimum healthcare information necessary to properly care for each resident and addresses health and safety concerns to prevent injury and provide assistance with activities of daily living as necessary) dated May 27, 2020, revealed that the resident was to be turned and repositioned every two hours. The section of the baseline care plan labeled Self-Care Deficit- ADL (activities of daily living) Function Rehab Potential, which listed ADLs such as bed mobility and the amount of staff assistance required was left blank and not completed. Interview with the Director of Nursing (DON) on August 4, 2020, at 10 AM, revealed that if the resident's level of assistance is not specified on the initial care plan, completed prior to the MDS assessment, it is assumed that the resident requires only one person staff assistance. However, this resident's baseline care plan and Self-Care Deficit-ADL Function Rehab Potential also did not address the resident's [CONDITION(S)] and bariatric air mattress (initiated the day after the resident's admission) to ensure the resident was provided necessary staff assistance to safely perform activities of daily living, such as bed mobility. The resident was also identified as cognitively intact and there was no indication that the facility had asked the resident about her needs for ADL assistance for the development of the baseline care plan. Review of a facility report dated June 1, 2020, at 10:07 PM, revealed Resident A1 rolled out of bed during care while the resident was turned on her side. At the time Employee 1 (nurse aide) was providing care to the resident by herself. Further review of the facility report revealed the facility did not include a statement from Resident A1 who is cognitively intact. Interview the DON on August 4, 2020, confirmed that the facility failed to interview the cognitively intact resident at the time of the fall to obtain the resident's account of the incident. A review of Employee 1's written statement indicated the resident was positioned on her left side for care and the mattress started sliding off the bed frame. As a result, the resident lost her balance and fell over (off the bed) and landed on her right side. The report indicated that the resident was assessed by Employee 2 (registered nurse) and there was no injury to the resident identified. The new planned intervention was to provide the assistance of two staff for all care in bed and rolling side to side. An audit was completed to review all mattresses for proper placement on June 2, 2020, as part of the follow up to the resident's fall. A nurses note dated June 4, 2020, at 11:00 AM, indicated that during morning care the resident requested an x-ray due to her complaints of pain after the fall of June 1, 2020. A physician order dated June 4, 2020, was noted for an x-ray of the resident's right limb. Review of the x-ray report dated June 4, 2020, revealed an acute displaced right femoral neck fracture (one type of hip fracture, which occurs just below the ball-and-socket hip joint, the region of the thighbone called the femoral neck). A SBAR (Situation Background Assessment Recommendation) Communication Form dated June 4, 2020, at 11:00 PM revealed that the physician ordered the resident to be transferred to the emergency room for evaluation and treatment based on the results of the x-ray and her complaint of right leg pain. A nurses note dated June 5, 2020, at 12:05 AM noted the ambulance arrived to transfer the resident to the emergency room . The resident was readmitted to the facility on [DATE], status post ORIF (open reduction internal fixation) surgery for a fracture of the right hip. During an interview with Employee 1 (nurse aide) on August 4, 2020, at 2:10 PM, Employee 1 stated the facility was made aware that, at times, Resident A1's mattress would slide. However, Employee 1 stated that on the day of the fall, the mattress seemed to be positioned properly. Employee 1 stated on the day of the fall the resident was positioned on her left side facing away from Employee 1 when the mattress began sliding and the resident began falling off the bed. Employee 1 was standing on the opposite side of the resident and was unable to prevent the resident's fall. Interview with Resident A1 on August 4, 2020, at 9:40 AM and again at 11:35 AM, (in the presence of the director of nursing) revealed that the resident continues to have a concern that two staff are not consistently being used to roll her on her side and provide care, which requires her to be on her side (such as changing her brief) in bed. The resident stated that when two staff do provide assistance, her care can be delayed due to the need to wait for two staff to be available at the same time. The resident stated that she needs help to roll on her side. Resident A1 was able to recall the fall from bed on June 1, 2020, Resident A1 stated that at the time of the fall she was having her brief changed and there was only one staff member present. She relayed that the mattress was slippery and she recalled yelling out I'm falling and then landed on the floor. The resident stated that she felt pain at the time of the fall and thought she might have done damage. The resident stated the physician ordered an x-ray a few days later due to her pain, which showed a fractured right hip. The resident stated that she had to be admitted to the hospital for surgery to repair the injury. An interview with the Director of Nursing (DON) on August 4, 2020, at 12:00 PM, failed to provide documented evidence that the resident's baseline care plan was fully completed to include this bariatric resident's assistance needs with activities of daily living, including bed mobility. The facility failed to provide documented evidence that the facility had timely determined the level of staff assistance needed for the provision of safe care upon the resident's admission to the facility to ensure the resident's safety and prevent injury. The facility failed to provide documented evidence that the planned intervention, after the resident's fall, for two staff to provide assistance when performing bed mobility and providing resident care, which involves rolling the resident side to side in bed, had been consistently implemented to prevent incidents of a similar nature 483.25 (d)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/25/19, 4/22/19 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 10/26/18, 1/31/19, 4/22/19, 10/25/19 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/26/18, 4/22/19, 10/25/19

Based on review of clinical records, observations and staff interviews it was revealed that the facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) by one of 22 residents reviewed (Resident 37). Findings include: A review of an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 18, (YEAR), revealed that Resident 37 was severely cognitively impaired, was not at risk for developing pressure sores and required maximum assistance for activities of daily living including bathing, mobility, transfers and toileting. A review of the clinical record revealed that Resident 37 was readmitted to the facility on (MONTH) 8, (YEAR), with a history of a fall with a fractured left hip and surgical repair. At the time of readmission, the facility assessed the resident to be at moderate risk for development of pressure sores. The resident had additional [DIAGNOSES REDACTED]. Readmission physician orders [REDACTED]. A review of nursing documentation and a facility investigation report dated (MONTH) 23, (YEAR), at 7:50 p.m. revealed that while providing care, a nursing assistant discovered an impaired area on Resident 37's left heel and informed the licensed nurse. The investigative report noted that there were two new dark blisters identified on the resident's left heel measuring 4.5 cm (centimeter) x 3.0 cm with a hard dark center. The report identified that this area was a new pressure area. A review of a facility pressure injury record dated (MONTH) 23, (YEAR), noted the finding of an unstageable pressure area on the resident's left heel measuring 4.5 cm x 3 cm blister with black eschar (thick, leather-like dead skin) in the middle. Physicians orders obtained on that date included to elevate the resident's heels at all times, skin prep (a protective film placed on the heels to prevent skin breakdown) to both heels BID (twice a day). Further review of the resident's clinical record revealed that since the resident's readmission to the facility on (MONTH) 8, (YEAR), the resident was utilizing a standard pressure reduction mattress. A review of treatment administration records (TAR) dated from the resident's readmission (MONTH) 8, (YEAR) to (MONTH) 23, (YEAR), revealed that nursing staff signed the TAR each shift indicating that this resident was turned and repositioned every two hours and waffle boots were in place while the resident was in bed. Nursing staff had signed the TAR and activities of daily living records reflecting the provision of daily care to this dependent resident, including personal care, turning and repositioning and application of waffle boots, but there was no nursing documentation indicating any impairment to the skin on the resident's left heel prior to the identification of the unstageable pressure area on the resident's left heel area. There was also no documented evidence of the use of pressure relieving measures specifically for the resident's feet when the resident was out of bed. A review of wound care physician documentation dated (MONTH) 28, (YEAR), revealed that Resident 37's left heel pressure area measured 2 cm x 3 cm x not measurable depth; unstageable necrosis (dead skin), no drainage noted and thick adherent black tissue (eschar). The wound care physician recommendations at that time were to continue with the skin prep treatment to the heel and to off load (remove pressure) her heels and to float the resident's heels while in bed (a patient's heel should be positioned in such a way as to remove all contact between the heel and the bed). There was no documented evidence that the facility's investigation into the development of the unstageable pressure sore on the resident's heel had included an evaluation of the adequacy of the use of pressure relieving measures for the resident's heels, both in and out of bed. Observations of the resident on (MONTH) 23, (YEAR) and (MONTH) 24, (YEAR), at approximately 10:30 AM revealed the resident seated in a wheelchair in front of the nurses station wearing non-skid socks. During these observations the resident's feet were observed to be positioned directly on the floor. Interview with the Director of Nursing and the Assistant Director of Nursing on (MONTH) 26, (YEAR), at 10:00 a.m. revealed that the facility was unable to determine when the condition of the resident's skin on the resident's heel began to decline and the pressure sore began to develop. The facility was unable to demonstrate that they had timely identified declines in skin integrity and had implemented prompt and adequate measures to prevent the development and worsening of a pressure sore on the resident's heel for a resident identified as a moderate risk for pressure sore development upon readmission to the facility on (MONTH) 8, (YEAR). 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcer Previously cited 10/4/16 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services. Previously cited 9/9/18, 9/8/17, 10/4/16

Based on review of select facility policy and clinical records, observation and staff interview, it was determined that the facility failed to promptly identify changes in skin integrity and consistently implement necessary measures to prevent further decline and the development of new pressure ulcers for one of 24 residents reviewed (Resident 63). Findings include: A review of the facility's policy for Pressure Ulcer (also called pressure sores are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) Record reviewed by the facility January 2016, revealed that it was the facility's policy to document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is healed (a weekly wound assessment form is used for this pressure sore tracking). A review of the clinical record revealed that Resident 63 was admitted to the facility on Mach 2, 2016, with [DIAGNOSES REDACTED]. The resident's plan of care dated March 3, 2016, for the problem of skin/wounds revealed interventions planned to prevent impaired skin integrity included turning and repositioning the resident every 2 hours, to handle and position the resident to reduce friction and a pressure reducing mattress. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2016 revealed Resident 63 to be severely cognitively impaired, require maximum assistance from staff for activities of daily living (routine activities that people tend do every day without needing assistance, including eating, bathing, dressing, toileting, transferring (walking) and continence of bowel and bladder) and was at risk for developing pressure sores.A Braden scale assessment (a standardized tool used to predict risk of developing skin breakdown) dated July 27, 2016, indicated that the resident was at high risk for the development of pressure sores.A review of a resident accident/incident report, nursing notes and weekly wound sheets dated August 21, 2016, at 11:00 AM revealed that the resident had a Stage I pressure ulcer (Stage I pressure ulcers/sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger)) described as a red and nonblanchable (skin does not lose the red color briefly when you press your finger on it and then remove your finger) area on her left heel measuring 3 cm (centimeter) x 3 cm. Nursing notified the physician and the physician ordered Skin Prep (a protective barrier sprayed onto the skin) to both heels twice a day and a heels-up device on the resident's bed (a device placed under the legs to raise the feet and heels off the bed). A review of the resident's Treatment Administration Record (TAR) for August 2016 revealed that on the 7:00 AM to 3:00 PM shift on August 28, 2016 and on the 3:00 PM to 11:00 PM shift from August 21, 2016, through August 25, 2016, and also on August 27, 2016, and August 28, 2016, the heels-up device was not utilized as a preventative measure to promote healing of the pressure sore. The TAR also revealed multiple occasions during the month of August 2016, on which the resident was not turned and repositioned every two hours. The weekly wound assessment dated [DATE], indicated that the Stage I pressure ulcer on the resident's left heel measured 0.2 cm x 0.2 cm with eschar (thick scab like dead skin) and the surrounding skin was red and boggy (abnormal texture of tissues characterized by sponginess). The next weekly wound assessment was dated September 4, 2016, and indicated that the pressure ulcer on the resident's left heel was now a Stage II pressure ulcer (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion) or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid) and measured 3 cm x 1 cm with pink surrounding skin. According to the nursing notes dated September 4, 2016, an additional area of skin impairment was found at 10:30 AM and the nursing staff notified Resident 63's responsible party of the new area of skin impairment, a 6 cm x 7 cm blood filled blister, on the bottom of the resident's left foot. The pressure ulcer record for this skin impairment identified this area as unstageable (full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green, or brown tissue) separating from healthy tissue) and/or eschar (thick scab like dead skin). There was no documentation that the resident's physician had been notified at that time of the new area of skin impairment on the bottom of the resident's left foot. Weekly skin assessments of the blood blister on the bottom of the resident's left foot continued and this area, described as an unstageable pressure ulcer first discovered on September 4, 2016, was noted to be healed on September 26, 2016. A review of a weekly wound assessment record dated September 13, 2016, indicated that the pressure ulcer on the resident's heel was now an unstageable wound with eschar measuring 4 cm x 4 cm. The physician was notified on September 13, 2016, and a new treatment was ordered. The physician discontinued the Skin Prep and initiated [MEDICATION NAME] (antiseptic solution) to the resident's left heel and to the blistered area on the bottom of the resident's foot, twice a day.According to the weekly wound assessment record, on September 19, 2016, the pressure ulcer on the resident's left heel measured 4 cm x 1.8 cm with eschar, but no drainage was noted.On September 26, 2016, the unstageable left heel pressure ulcer was documented as measuring 0.8 cm x 0.6 cm x 0.2 cm with eschar and no drainage. The physician was called on September 26, 2016, at 2:30 p.m. with new orders received to discontinue [MEDICATION NAME] to the resident's left heel and to start Santyl (a [MEDICATION NAME] agent used to remove dead tissue from the wound and clean the wound) to the resident's left heel; cover with a dressing, twice a day, after cleaning with soapy wash.Nursing documentation dated September 28, 2016, at 2:15 PM revealed that the physician also ordered [MEDICATION NAME] 875 mg by mouth, twice daily (antibiotic medication) for treatment of [REDACTED]. There was no documented description of the resident's heel pressure ulcer,which indicated the presence of any drainage from the wound (pressure ulcer) or other signs of infection at the time the physician prescribed antibiotic therapy ([MEDICATION NAME]) on September 28, 2016, or documentation of a significant change in the condition of the resident's pressure ulcer upon assessment on September 26, 2016, other than the presence of (0.2 cm) depth to the wound. There was no new entry on the weekly wound record to indicate further decline in the condition of the resident's pressure ulcer or inclusion of the new physician order [REDACTED].An observation was made of the resident while in bed on October 4, 2016, at 10:30 AM. The left heel pressure ulcer measured 2.1 cm x 3.5 cm and most of the wound was covered with eschar. There was a small amount of bloody drainage observed on the dressing as well as a moderate amount of dried red drainage observed to be smeared across the resident's bed sheet in the location where the resident had appeared to have moved his feet and/or the location where the resident's feet were moved when staff repositioned him in bed. This smeared red drainage on the resident's bed sheet was confirmed by Employee 8, Licensed Practical Nurse (LPN), at the time of the observation on October 4, 2016. The physician prescribed twice daily treatment to the pressure ulcer on the resident's left heel, which the facility's licensed nursing staff documented as completed twice a day. However, the nursing staff failed to promptly identify the decline in the resident's pressure ulcer and the new area of skin breakdown before the pressure ulcer was identified as unstageable. Nursing continued to document tracking of the resident's pressure ulcers only on a weekly basis, which failed to demonstrate timely identification of deterioration of the pressure sore on the resident's heel. The nursing staff did not document the presence of drainage or signs of infection to the wound nor did the resident's clinical record contain documentation of the clinical necessity for the addition of antibiotic therapy for treatment of [REDACTED]. When interviewed on October 4, 2016, at 12:00 PM the Director of Nursing was unable to explain why the decline in the condition of the resident's existing pressure ulcer on the resident's heel and new pressure ulcer on the bottom of the resident's foot were not identified in a more timely manner. 28 Pa. Code 211.10 (a)(d) Resident care policies Previously cited 1/20/16, 9/11/15 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12(a)(d)(1)(3) Nursing services Previously cited 3/1/16, 9/11/15 28 Pa. Code 211.12(c)(d)(5) Nursing services Previously cited 3/1/16, 1/20/16, 9/11/15