Every finding on record at Pennsylvania Soldiers and Sailors Home

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of three residents reviewed (Residents R1, R5, and R9).Findings include: Review of facility policy entitled Transfers and Discharge dated 2/2/26, revealed For a transfer/discharge to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for the care of the resident,Resident representative information.Advance directive information.All other information necessary to meet the residents needs, which includes, but may not be limited to:Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs.Diagnoses and allergies.Medications (including last received); andMost recent relevant labs, other diagnostic tests, and recent immunizations.All special instructions and/or precautions for ongoing care, as appropriate such as:Treatments and devices (oxygen, implants, IVs, tubes/catheters). Transmission based precautions such as contact, droplet. or airborne.Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions.The resident's comprehensive care plan goals. Additional information, if there is any, outlines in the transfer agreement with the acute care provider. Review of Resident R1's clinical record revealed an admission date of 2/6/25, with diagnoses that included hypertension (high blood pressure), chronic pain, and heart disease. Review of Resident R1's progress notes revealed notes dated 11/16/25, 12/2/25, 12/14/25, 1/11/26, 1/27/26, 2/15/26, and 3/8/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R5's clinical record revealed an admission date of 9/20/23, with diagnoses that included hypertension, hyperlipidemia (high cholesterol), and chronic pain. Review of Resident R5's progress notes revealed notes dated 6/10/25, 11/5/25, and 12/20/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R9's clinical record revealed an admission date 11/25/25, with diagnoses that included hypertension, hyperlipidemia, and hypothyroidism (a condition where the thyroid gland does not produce enough hormones causing a slowed metabolism). Review of Resident R9's progress notes revealed notes dated 12/23/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 3/12/26, at 12:32 p.m. the Nursing Home Administrator confirmed that Resident R1, R5, and R9's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and that when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to ensure recommendations made from the consultant pharmacist were acted upon for one of five residents reviewed (Resident R66).Review of facility policy entitled Medication Regimen Review [MRR] dated 2/2/26, indicated The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities., The pharmacist shall communicate any irregularities to the facility., The facility shall provide the licensed pharmacist. answers to the previous month's pharmacy recommendations. and Facility staff shall act upon all recommendations. Review of Resident R66's clinical record revealed an admission date of 9/29/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of pharmacist MRR dated 11/18/25, revealed recommendations for the following medications Meloxicam (anti-inflammatory) from PRN (as needed) to routine daily, extend and increase Lorazepam (antianxiety), add Melatonin (sleep aid), and evaluate the continued need for Carbidopa/Levodopa (Parkinson medication). The pharmacist MRR recommendations lacked evidence that they were reviewed and addressed by the physician. During an interview on 3/12/26, at 11:30 a.m. with the pharmacist, he/she confirmed that Resident R66's pharmacist MRR recommendations dated 11/18/25, lacked evidence that they were reviewed or addressed by the physician. During an interview on 3/13/26, at 10:00 a.m. the Nursing Home Administrator (NHA) confirmed the pharmacist MRR recommendations dated 11/18/25, were not addressed by the physician. The NHA also confirmed that all pharmacist MRR recommendations should be reviewed and addressed by the physician. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 211.9(k) Pharmacy services

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure adequate safety measures were implemented per physician's orders by not attaching leg rests (supportive device attached to a wheelchair for the feet to rest upon) to the wheelchair during transport for four residents reviewed (Residents R45, R73, R75, and R101).Findings include: Review of facility policy entitled Medical Provider Orders dated 2/2/26, revealed .the written physician orders are to provide the essential care needs to the resident, consistent with their mental and physical status.physician orders are administered and carried out in accordance with the written or verbal orders of the attending medical provider. Review of Resident R45's clinical record revealed an admission date of 10/3/25, with diagnoses that included muscle spasm, hypothyroidism (a condition where the thyroid gland does not produce enough hormones causing a slow metabolism), and pain.Review of Resident R45's clinical record revealed a physician's order for B (Bilateral) leg rest for transport only dated 10/3/25. Review of Resident R73's clinical record revealed an admission date of 12/21/23, with diagnoses that included restless leg syndrome, muscular degeneration, and lumbar disc degeneration.Review of Resident R73's clinical record revealed a physician's order for BL (Bilateral) leg rest to PRN (as needed) wheelchair for transport only dated 12/10/24. Review of Resident R75's clinical record revealed an admission date of 10/18/23, with diagnoses that included arthritis, age related physical debility, and heart failure.Review of Resident R75's clinical record revealed a physician's order for Leg rest for transport dated 10/18/23. Review of Resident R101's clinical record revealed an admission date of 7/17/23, with diagnoses that included atrial fibrillation (irregular heartbeat), muscle weakness, and heart failure.Review of Resident R101's clinical record revealed a physician's order for Leg rest for transport dated 8/16/23. Observations on 3/11/26, at 10:15 a.m. in the hallway revealed Resident R45 was being pushed by a staff member down the hallway in his/her wheelchair without leg rests and his/her feet were dragging on the ground; at 11:16 a.m. Resident R45 was being pushed by a staff member to the dining room in his/her wheelchair without leg rests and his/her feet were dragging on the ground; at 11:18 a.m. Resident R101 was being pushed by a staff member to the dining room in his/her wheelchair without leg rests and his/her feet were dragging on the ground; at 11:21 a.m. Resident R73 was being pushed by a staff member to the dining room in his/her wheelchair without leg rests and his/her feet were dragging on the ground; and at 11:24 a.m. Resident R75 was being pushed by a staff member to the dining room in his/her wheelchair without leg rests and his/her feet were dragging on the ground. During an interview on 3/11/26, at 11:40 a.m. the Director of Nursing confirmed that the wheelchair leg rests should have been in place per physician's orders to ensure safe transport for Residents R45, R73, R75, and R101. During an interview on 3/11/26, at 12:45 p.m. the Director of Rehab confirmed that it is unsafe for a resident to be transported in a wheelchair without leg rests with their feet dragging on the ground. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R100).Review of facility policy entitled Psychotropic Medication Use & GDR Process dated 2/2/26, indicated Residents who use psychotropic medications shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. And non-pharmacological interventions will be utilized and documented in the EMAR [electronic medication administration record]. Review of Resident R100's clinical record revealed an admission date of 4/18/25, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R100's physician's orders revealed an order for Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every four hours PRN for anxiety. Review of Resident R100's March 2026 medication administration record revealed that the PRN Lorazepam was used on 3/7/26, 3/8/26, and twice on 3/9/26, and lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam for four administrations. During an interview on 3/12/26, at 12:32 p.m. the Nursing Home Administrator (NHA)confirmed that Resident R100's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam. The NHA also confirmed that non-pharmacological interventions should be attempted prior to administering psychotropic medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and infection control records, and staff interviews, it was determined that the facility failed to ensure measures were in place to monitor and prevent legionella in the facility water. Findings include: A facility policy entitled, Prevention of Healthcare-Associated Legionella Disease, dated 3/03/25, revealed The State Veterans' Homes must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention of Healthcare-Associated Legionella (L. pneumophila) Disease - If environmental testing detects L. pneumophila then the environmental actions in this sub-paragraph are required. Any amount of L. pneumophila detected in a sample is considered a positive result. Implement remedial action using the criteria below. This remedial action approach uses a graded response for addressing L. pneumophila-positive samples detected through routine water testing. After environmental remediation is completed, promptly retest the water in the areas that tested positive for L. pneumophila to determine if the remediation procedures were successful at reducing L. pneumophilia to undetectable levels. If the remediation procedures were successful, then the quarterly water environmental validation cycle is complete. Review of facility water management records, Legionella Testing dated 12/04/24, revealed positive results for Legionella non-pneumophila species in Unit B - First Floor - Kitchenette Faucet - Hot Water. The facility lacked evidence of further testing for Legionella of the facility water system after 12/04/24. An interview with the Facility and Grounds Director on 3/07/25, at 9:10 a.m. revealed the facility received the positive findings for Legionella in the above noted area on 12/04/24; Flushing of the facility water system with bleach/water was completed, but no further testing of the water system for Legionella was completed after 12/04/24. An interview with the Nursing Home Administrator on 3/07/25, at 10:30 a.m. confirmed that testing for Legionella should have been completed promptly after 12/04/24, date of positive results of Legionella, to ensure the usage of facility water was safe for all persons. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in a resident pantry in one of two refrigerators reviewed (Unit A pantry). Findings include: Review of facility policy entitled Resident Rights; Visitation dated 3/3/25, indicated Perishable food . brought in will be permitted to be placed in the unit refrigerator for 24 hours. The food must be labeled with resident's name date and time. Perishable items not of a leftover nature, may be placed in the unit refrigerator/freezer up through package expiration date. Observations on 3/5/25, at 11:40 a.m. of a refrigerator in the Unit A pantry used for residents revealed three zip lock bags containing snap peas, two of the zip lock bags had a date of 1/21/25, and the third zip lock bag lacked a date. Observation of one of the zip lock bags revealed the snap peas were soft and there was a liquid substance in the bottom of the zip lock bag. Further observations revealed a plastic container of blackberries that lacked a name and date, a jar of pepper rings with a date of 9/9/24, and no expiration date on the jar, and a jar of mixed vegetables that lacked a date and no expiration date on the jar. During an interview with Nursing Assistant Employee E3 at the time of observation, he/she confirmed that one zip lock bag of the snap peas was lacking a date, and the other two zip lock bags of snap peas were beyond their use by date, the blackberries lacked a name and date, the jar of pepper rings lacked an expiration date and the jar of mixed vegetable lacked a date and an expiration date. He/she also confirmed that food items should be discarded by their expiration or use by date. During an interview on 3/5/25, at 1:07 p.m. the Director of Nursing confirmed that food items in the resident refrigerator should have a resident name and opened date and should be discarded before or by their use by date. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical record review, and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of 14 days for one of 23 residents reviewed (Resident R4). Findings include: A facility policy entitled Resident Care/Pharmacy Services dated 3/2023, revealed that PRN orders for psychotropic medications (antipsychotic, anxiolytic, antidepressant and sedative/hypnotic) will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Resident R4's clinical record revealed an admission date of 4/28/18, with diagnoses that included dementia (a disease of the brain that affects decision making, memory, mood and behavior), aneurysm of iliac artery (a bulge or dilation in the wall of the iliac arteries, located in the pelvis), benign neoplasm of colon (a non-cancerous growth that originated in the large intestine), and benign prostatic hyperplasia (an age related condition in which the prostate gland grows larger than normal). Resident R4's clinical record revealed a physician's order dated 7/29/24, for Xanax (Alprazolam) 0.25 milligram (mg) by mouth every one-hour PRN as needed for anxiety or shortness of breath. During an interview on 3/07/25, at 9:45 a.m. the Nursing Home Administrator confirmed there was no clinical rationale documented by the physician for the extended time-period of Resident 4's PRN Xanax usage beyond 14 days. 28 Pa. Code 211.12 (d)(1)(3) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for three of five residents reviewed regarding respiratory care equipment (Residents R6, R30, and R38). Findings include: A facility policy dated 3/3/25, entitled Supplemental Oxygen Therapy revealed Turn the Flow Meter to the prescribed setting. DO NOT select a different setting unless the Provider has prescribed a change and The Nursing staff shall be responsible to clean filters (located at the back / side of the concentrators), wipe down machine, change all tubing, distilled water canisters (if applicable) and bags weekly. Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included Chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), high blood pressure, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R6's clinical record revealed a physician's order dated 8/29/23, for oxygen at 2 liters per minute (lpm) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) PRN (as needed) for SOB (Shortness of Breath). Observation on 3/6/25, at 11:00 a.m. revealed Resident R6 seated in his/her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. During an interview on 3/6/25, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed that Resident R6's oxygen concentrator was on and set at 4 lpm and was not in accordance with the physician's order dated 8/29/23, for oxygen at 2 lpm. Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included COPD, high blood pressure, and depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Resident R30's clinical record revealed a physician's order dated 4/22/24, to clean filter on oxygen concentrator weekly on Wednesday 7-3, and another physician's order dated 4/29/24, for oxygen at 3 lpm via nasal cannula continuous. Observation on 3/5/25, at 10:25 a.m. revealed Resident R30 lying in bed with oxygen being delivered via nasal cannula at 3 lpm. Oxygen concentrator had a filter on the back of the concentrator that contained a gray dusty substance, and the actual concentrator was dusty with dried white substance noted down the front and on the sides. During an interview on 3/5/25, at 10:43 a.m. LPN Employee E2 confirmed that Resident R30's concentrator filter was dusty and the concentrator itself was dusty with dried substance noted down the front and sides. Resident R38's clinical record revealed an admitted [DATE], with diagnoses that included COPD, lung cancer, and high blood pressure. Resident R38's clinical record revealed a physician's order dated 8/7/24, for oxygen at 3 lpn via nasal cannula prn for SOB. Observations on 3/4/25, at 1:08 p.m. and 3/5/25, at 9:53 a.m. revealed Resident R38 lying in bed with oxygen being delivered via nasal cannula at 3 lpm. Oxygen concentrator had a filter on the back of the concentrator that contained a gray dusty substance, and the actual concentrator was dusty and with a dried white and brown substance down the front and on the sides. During an interview on 3/5/25, at 10:15 a.m. Registered Nurse Employee E1 confirmed that Resident R38's concentrator filter was dusty and the concentrator itself was dusty with dried substance noted down the front and sides. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for two of 22 residents reviewed (Residents R27 and R57). Findings include: Review of a facility policy dated 3/2/24, entitled Comprehensive Care Plans (Nursing Care) indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment. Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included paraplegia (injury to your spinal cord or brain causes paralysis to your lower body), high blood pressure, and diabetes (condition of improper insulin/blood sugar levels). Review of Resident R27's comprehensive care plan with a problem category of Pressure Ulcer / Injury revealed an outstanding target date (a date that the resident's care plan must be updated by) of 3/14/24. Resident R57's clinical record revealed an admitted [DATE], with diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities), diabetes, and congestive heart failure (condition when your heart does not pump the blood as well resulting in difficulty breathing, tiredness, and swelling). Review of Resident R57's comprehensive care plans revealed that of the 24 care plans present, 22 had an outstanding target date of 2/21/24. The care plans included the problem categories of: ADL Function / Rehabilitation Potential - COVID, Communication, ADL Function / Rehabilitation Potential - Restorative Nursing, ADL Function / Rehabilitation - Elopement, Psychosocial Well-Being, Cognitive Loss / Dementia, Behavioral Symptoms - Disruptive, Behavioral Symptoms - Wandering, Behavioral Symptoms - Abusive, Behavioral Symptoms - Refusal, Mood State, Psychotropic Drug Use, ADL Function / Rehabilitation Potential - Care, ADL Function / Rehabilitation - Bleeding, Visual Function, Communication, Dental Care, Pain, Falls, Dehydration / Fluid Maintenance, Urinary Incontinence, and Integumentary. During an interview on 4/24/24, at 11:42 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that Resident R27 and R57's care plans were not reviewed and/or revised as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 22 residents reviewed was free of neglect during care. (Resident R11) Findings include: Review of facility policy entitled Administrative Services dated 3/2/24, revealed Neglect: The failure of the home, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitled Clinical Care dated 3/2/24, revealed Basic Elements of Lift, Gait Belts, and Slider Boards Use, 1.maintains a no manual body lift directive to minimize risk of injury to the resident . Review of Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and essential tremor (a condition that causes involuntary shaking of any part of the body most often in the hands). Review of Resident R11's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], revealed under section GG 0170 E, that Resident R11 was dependent on staff for transfer from chair to bed. Review of Resident R11's active physician orders revealed an order for transfers by use of knee lift ([NAME]) with size medium sling. Review of Resident 11's Care Plans under Activities of Daily Living (ADLs) revealed resident transfers with the knee lift ([NAME]) and medium sling. Review of information submitted by facility dated 4/23/24, and interview with the Nursing Home Commandant revealed Resident R11 was incorrectly transferred and that he/she was transferred to his/her chair by one staff member physically lifting him/her. Review of the facility's investigation revealed that Nurse Aide (NA) Employee E2 confirmed on 4/20/24, he/she transferred Resident R11 by physically picking him/her up. Further review of facility investigation revealed NA Employee E2 put one arm under the resident's knees and one arm behind the residents back then transferred him/her to the chair. Review of documentation submitted by the facility dated 4/23/24, revealed that the facility initiated and investigation, regarding resident neglect on 4/20/24. The investigation revealed that NA Employee E2 was suspended pending investigation. During an interview on 4/25/24, at 2:53 p.m. the Nursing Home Commandant confirmed that NA Employee E2 transferred Resident R11 by physically lifting him/her and not using the knee lift as ordered. He/she also confirmed that the resident should have been transferred as care planned with the use of the knee lift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to safely administer electrical stimulation (E-Stim- sends mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) during therapy that resulted in second degree burns (includes blisters, a darker tone and a shiny, moist appearance) to two of 11 residents (Resident R1, R2), and failed to remove faulty equipment from service and created an Immediate Jeopardy situation for nine other residents (Residents R3-R11) for E-Stim therapy. Findings include: Review of the facility policy entitled, Electrical Stimulation dated 1/2022, indicated that E-Stim may be proved to patients upon physician's order in a manner consistent with established safe practices, and that prior to use the equipment is to be checked by testing the unit on yourself to ensure safe and efficient operation, do not use frayed conducting or line cord, and lacked evidence of guidance to staff should an adverse outcome result from the applied therapy. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses including Alzheimer's Disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), stroke with right-sided weakness, artificial left knee, and pain in the right knee, and a physician's order dated 3/09/23 (re-ordered 4/05/23), to receive E-Stim in physical therapy three times per week for four weeks to address mobility and strength. Resident R1's Physical Therapy Treatment Encounter Notes revealed that his/her post-treatment skin condition was intact on 3/23/23, and there was no evidence of documentation related to Resident R1's pre-treatment or post-treatment skin condition on 3/28/23, and therapy did not continue to administer the E-Stim. Resident R1's progress notes lacked documentation regarding burn/injury to his/her right knee until 4/30/23 (33 days after the burn occurred), when nursing staff was made aware by the resident that the scab over the burn re-opened, and that he/she had been burned by the E-Stim device when staff hit the wrong button and it went zap. Review of Resident R2's clinical record revealed and admitted [DATE], with diagnoses including Multiple Sclerosis (potentially disabling disease of the brain and spinal cord (central nervous system)), muscle spasms, abnormal gait and mobility, and malaise- debility (general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), and a physician's order dated 4/12/23, to receive E-Stim in physical therapy three times per week for four weeks to address mobility and spasms. Resident R2's progress notes dated 4/19/23, revealed that therapy informed nursing of burns to Resident R2's back during therapy from the E-Stim pads, and the physician was notified of blisters caused by e-stim pads. Review of facility documents revealed that on 4/19/23, the facility launched an investigation into the Resident R2's burns and discovered through interviewing that Resident R1 had received burns from the E-Stim on 3/28/23, and that the E-Stim machine was taken out of service on 5/01/23, or 12 days after Resident R2 received his/her burns. Review of a facility document entitled, Service Code Usage by Patient dated 5/15/23, indicated that between 3/01/23, and 5/01/23, nine additional residents (Residents R3-R11) received E-Stim therapy and were also placed at an increased risk of harm/injury. Review of facility work orders revealed on 5/01/23, that the facility scheduled an inspection of the E-Stim units on 5/04/23, which revealed the discovery of one bad cord (meaning it had an open condition), and that it was defective and discarded. Review of facility purchase order dated 5/08/23, that the expected delivery date of the new E-Stim machine is 5/19/23. During an interview on 5/15/23, at 11:35 a.m. the Director of Nursing confirmed that the facility was unaware of the burn on Resident R1 until they started investigating the burn on Resident R2 on 4/19/23, the facility took the E-Stim machine out of service on 5/01/23, and there was no evidence that therapy staff had completed the safety checks of the machinery prior to applying it to residents. During an interview on 5/15/23, at 2:30 p.m. the Commandant confirmed that the facility had not updated the E-Stim policy to include guidance for therapy staff should an adverse outcome occur after a resident receives E-Stim. The Commandant and Director of Nursing were made aware that Immediate Jeopardy existed on 5/15/23, at 3:25 p.m. and an action plan was requested. On 5/15/23, an acceptable Corrective Action Plan was approved which included the following interventions: 1. Estim modality is not current being utilized in the facility since 5/01/23. 2. The estim policy will be updated to provide necessary guidance to therapy staff on how to respond to adverse outcomes related to estim. 3. Therapy staff will be educated on the updated estim policies and procedures. Updates of policies to include: a. Therapy staff will be educated upon hire, annually, and as needed on completing and documenting proper safety protocols prior to estim treatment according to equipment manufacturer guidelines. b. I adverse outcomes related to estim therapy occurs, therapy staff will immediately stop therapy and notify nursing supervisor/nursing admin for clinical assessment, treatment and physician notification and direction. 4. New estim equipment ordered 5/05/23. 5. If estim modality is reinstated, therapy will be reeducated on completing and documenting proper safety protocols prior to applying the electrical stimulation. 6. Therapy staff will be educated when the new estim devices are received prior to new estim devices being put into service. 7. Residents receiving estim will be audited for adverse reactions related to estim. Audits will be performed once new equipment arrives. 8. New estim equipment will be services by contracted vendor quarterly and as needed. 9. Therapy staff will be educated on new estim equipment upon arrival, then upon therapy new hire, annually, and as needed. 10. Therapy competencies for estim and other therapy modalities will be reviewed and updated if needed to reflect appropriate equipment usage, and evaluations of residents during modalities. Therapy employees will be reeducated on the updated competencies with new estim equipment arrival, upon hire, annually, and as needed. 11. Results of these audits will be forwarded to the facility Quality Assurance committee to monitor ongoing compliance. The facility corrective action plan to mitigate the risk of residents receiving E-Stim resulting in burns was implemented on 5/15/23, and will be finalized receipt of the new E-Stim machine, as evidenced by the action steps above. Review of facility documents on 5/16/23, between 12:30 p.m. and 2:30 p.m. revealed that the facility implemented their corrective action plan by updating the E-Stim policy to include the appropriate pre and post treatment resident assessments and safety protocols, and guidance to staff related to post treatment adverse outcomes, and evidence that staff were educated on the updated policy. The facility provided evidence that there is a plan to implement the remaining steps of the corrective action plan upon receipt of the new E-Stim machines. The Immediate Jeopardy was removed on 5/16/23, at 2:43 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility records and job descriptions, it was determined that the Commandant (Nursing Home Administrator) and Director of Nursing (DON) failed to effectively manage the facility to make certain that proper safety procedures were implemented by staff to prevent actual harm/injury to residents during the administration of electrical stimulation (e-stim- sends mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) during therapy. Findings include: Review of the job description for the Commandant revealed that the Commandant is responsible for managing, directing, and controlling all health-care activities and management functions at the facility (including nursing, personal, and domiciliary care, treatment, and restorative and rehabilitative services), and identify actual and potential safety and health hazards for residents and staff and take appropriate actions. Review of the job description for the DON revealed that the DON is responsible for directing all nursing care activities and participates in the administration of the multidisciplinary and nonclinical aspects of resident care, monitoring clinical aspects of Part B therapy contracted services, and identify actual and potential safety and health hazards for residents and staff and take appropriate actions. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent actual harm/injury for their residents under the care of therapy, the Commandant and DON failed to fulfill their essential job duties to manage and direct all aspects of nursing care activities. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms/disases from one area to another) as related to the failure to post appropriate signage, alerting someone that a unit was a designated Red Zone (designated area housing residents who tested positive for COVID-19 to help prevent transmission and contain the infection) that required wearing appropriate PPE (personal protective equipment) upon entrance for three of three entrances to Unit E. Findings include: Observation on 5/17/22, at 2:30 p.m. revealed that there was no signage to alert anyone entering Unit E that it was a designated Red Zone and those entering would be required to wear appropriate PPE, which included an N95 mask, eye shield and a disposable gown. During an interview at that time, Licensed Practical Nurse Employee E1 and Activities Employee E2 confirmed the lack of necessary signage. During an interview on 5/17/22, at approximately at 3:30 p.m. the Nursing Home Administrator confirmed that there were no signs posted to identify that Unit E was designated as a Red Zone to alert/caution anyone entering the unit to wear all necessary PPE. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of facility policies and staff interviews, it was determined that the facility failed to implement thorough infection control measures regarding the screening process of visitors as related to COVID-19 prior to entrance to the facility for one of two visitors. Findings include: The Facility Screening Process For COVID19, dated 4/28/20, revealed for staff, volunteers, and contracted personnel, here after referred to as staff will be screened prior to entering the facility and when leaving the facility: (1) All staff will receive an initial screening upon implementation of this process. The policy indicates that screening is completed prior to entering the facility and exiting the facility. The screening form utilized includes a temperature, a list of symptoms ie fever, cough, headache .and if there was contact with a person with coronavirus. During entrance to the facility property on 6/23/20, at 10:30 a.m., Security Employee E1 approached the window of the Department of Health (DOH) Surveyor 1's vehicle. DOH Surveyor 1 announced that they were from the DOH and Security Employee E1 did not perform temperature testing or a questionnaire form but instructed the surveyor to go ahead in. Continued observation of Security Employee E1 revealed that the employee handed a clipboard and a pen to the occupant of the next vehicle, and took their temperature. The occupant handed the supplies back to Security Employee E1 and proceeded to park. Security Employee E1 did not remove their gloves nor sanitize their hands between vehicles. The next vehicle was then approached by Security Employee E1 (occupant was DOH Surveyor 2) and handed the clipboard with a questionnaire to DOH Surveyor 2. During an interview on 6/23/20, at 10:50 a.m. the Nursing Home Administrator confirmed that all persons entering the facility grounds must have a temperature done and questionnaire completed prior to entering the facility. During an interview on 6/23/20, at 12:30 p.m., Security Employee E1 stated that they had not performed the screening on the DOH employee because they were instructed certain personal were not to be screened when entering the facility such as ambulance, fire, police and environmental protection agency persons and thought that DOH was not to be screened. When questioned about sanitizing the clipboard and the pen used to sign the screening paper, Security Employee E1 stated that until today, they had not been sanitizing the clipboard or the pen between persons during the screening process 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations, review of clinical records, facility policies and facility documentation and staff interviews, it was determined that the facility failed to properly transfer residents and maintain a safe environment for two of four residents (Closed Record Resident CR1 and Resident R2). Findings include: The facility policy entitled, Lift/Transfer Policy: Mechanical Lift/Transfer Devices, dated 3/18/2019, indicated to utilize at least two staff members or more as needed for resident/staff safety. Resident CR1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident CR1's clinical record revealed a physician's orders [REDACTED]. Resident CR1's care plan entitled, Self-Care Deficit Related to Decreased Mobility included an intervention to transfer using a full lift and assistance of two staff. Review of information dated 4/05/19, submitted by the facility revealed the discovery of a 10.5 centimeter (cm) x 5.7 cm bruise on Resident CR1's right upper arm. The report further identified that Resident CR1 was a transfer status with a full body lift with two assist and that the care plan was not followed. A witness statement dated 4/08/19, from Nurse Aide (NA) Employee E3 revealed that he/she transferred Resident CR1 without using the full lift and without the assistance of another staff member. Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R2's clinical record revealed a physician's orders [REDACTED]. Resident R2's care plan entitled, Self-Care Deficits Related to Impaired Mobility, included the intervention to transfer using a knee lift and assist of two staff. Observations on 4/17/19, at 9:55 a.m. revealed NA Employee E2 transferring Resident R2 using a Sit-to-Stand (knee lift) without the assistance of a second staff member in the [NAME] Unit shower room. During an interview at the time of observation, NA Employee E2 stated that he/she does not obtain the assistance of a second staff member while using the knee lift with Resident R2. During an interview on 4/17/2019, at 10:30 a.m. the Director of Nursing confirmed that all lift transfers require the assistance of two staff members and that Residents CR1 and R2 had not been properly transferred. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 211.12(d)(1)(5) Nursing Services

Based on record review and review of the Resident Assessment Instrument (RAI) User's Manual (provides direction for the completion of the Minimum Data Set (MDS - periodic assessment of resident care needs)) and staff interview, it was determined that the facility failed to document required information regarding the additional assessment performed on the care areas triggered by the completion of the MDS for six of 17 residents. (Residents R1, R2, R8, R9, R4 and R5). Findings include: The RAI User's Manual provides the instruction that the documentation related to the Care Area Assessments (CAAs) should indicate the basis for the care plan decision, why the finding requires an intervention, and the rationale for selecting specific interventions. For each triggered care area, the facility must indicate the date and location of where the information related to the CAAs can be found in the resident's clinical record. Resident R1's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. Resident R2's Significant Change MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. During a interview on 11/01/17, at 11:55 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E2 confirmed that the CAA summaries did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. Resident R8's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. Resident R9's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. During an interview on 11/01/17, at 4:30 p.m., RNAC Employee E3 confirmed that the CAA summaries did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. Resident R4's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. Resident R5's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date of where the information related to the CAA could be found in the clinical record. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(5) Nursing Services Previously cited 12/02/16

Based on review of facility records, it was determined that the facility failed to implement their written policies and procedures for the misappropriation of resident property and notify the Department of Health, Division of Long Term Care reportable incident for eight of eight residents (Resident R24 through R31). Findings include: The Resident Property and Missing Items policy dated 3/31/16, indicated that it is the policy of the facility to assist all residents in safeguarding their property and that security will investigate and documentation of the investigation will be done including witness statements of all parties including the resident and all staff working on the unit at the time of the complaint. The Department of Military and Veterans Affairs (DMVA) Prevention of Resident Abuse policy dated 3/31/16, indicated that a complete and thorough investigation will be conducted into all alleged violations involving misappropriation of resident property and that the facility is responsible to ensure that it is operating within all applicable state and federal regulations, including the Department of Health. Resident Missing Property/Incident Reports revealed that the facility had taken statements of concerns related to misappropriation of resident property as follows: 6/29/16 Resident R24 reported a wallet containing approximately $40.00 and change purse containing approximately $3.00 to $5.00 missing. 9/13/16 Resident R25 reported a wallet containing $5.00 and two forms of Identification missing. 9/21/16 Resident R26 reported $55.00 missing. 9/27/16 Resident R27 reported a wallet containing $35.00 and forms of Identification missing. 9/28/16 Resident R28 reported $50.00 missing from a wallet. 10/19/16 Resident R29 reported $26.00 missing from their room. 11/02/16 Resident R30 reported $47.00 and a little change missing from their room. 11/01/16 Resident R31 reported a gold wedding ring missing. There was no documentation to indicate that the facility implemented their written policies and procedures for the misappropriation of resident property and thoroughly investigated the above incidents or reported the above incidents involving Resident R24 through R31 to the Department of Health Division of Nursing Care Facilities. During an interview on 12/02/16, at 10:10 a.m., the Director of Nursing confirmed the failure to thoroughly investigate the above incidents or report the above incidents to the Department of Health Division of Nursing Care Facilities as required. 28 Pa. Code 201.14(c)(e) Responsibility of licensee 28 Pa. Code 201.18(a)(2) Management

Based on review of the clinical record and facility policy and staff interview, it was determined that the facility failed to prevent significant medication errors for 30 days, for one of 22 residents (Resident R12). Findings include: The facility Medication & Treatment Order Transcription policy dated 3/31/16, stated that at the end of each shift nursing would review all new orders to ensure that processing/transcription had occurred. The face sheet revealed that Resident R12 was admitted to the facility on [DATE]. The physician orders, dated 11/09/16, revealed [DIAGNOSES REDACTED]. A physician order [REDACTED].) twice daily to 40 mg. daily. Review of the August 2016 Medication Administration Record [REDACTED]. twice daily, rather than once daily as ordered. During an interview on 12/01/16, at 2:20 p.m., the Nursing Home Administrator confirmed that Resident R12 received the [MEDICATION NAME] 40 mg. twice daily, rather than once daily as ordered from 8/02/16 to 8/31/16, and that the error occurred because the physician order [REDACTED]. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/04/15, 11/06/15

Based on observation, clinical record review and resident and staff interview, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: The face sheet revealed that Resident R12 was admitted to the facility on [DATE]. The physician orders, dated 11/09/16, revealed [DIAGNOSES REDACTED]. Observation on 12/01/16, at 9:40 a.m. revealed that Resident R12 was not wearing the right hand splint as ordered. At that time Resident R12 stated that the splint was broken and had been broken for a long time. During an interview on 12/02/16, at 9:40 a.m., Nurse Aide Employee E2 confirmed that Resident R12 was not wearing the right hand splint as ordered, located the hand splint in a night stand drawer and found that there was a metal piece missing from the splint. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/04/15, 11/06/15

Based on observation, review of facility policies, and staff interview, it was determined that the facility failed to maintain appropriate infection control measures during a dressing change related to handwashing for one of 23 residents (Resident R23). Findings include: The Wound Care policy, dated 3/31/16, indicated to Wash hands after removal of an old dressing and prior to placing clean dressing. During observation of a dressing change for Resident R23 on 11/30/16, at 10:00 a.m., Licensed Practical Nurse Employee E1 did not perform handwashing after removal of the soiled dressing and before application of the clean dressing. During an interview on 11/30/16, at 12:55 p.m., Director of Nursing confirmed that handwashing should have occurred after removal of the soiled dressing and before application of the clean dressing. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 11/06/15.

Based on review of facility policy, clinical records, facility documentation and staff interviews, it was determined that the facility failed to provide adequate interventions and monitoring for the prevention of pressure ulcers, resulting in actual harm for one of eight residents reviewed with pressure ulcers (Resident R4). Findings include: The Skin Monitoring policy dated March 2015, indicated, CNAs (Certified Nurse Aide) will fully review the resident's skin for any redness, rashes, bruises, pressure areas or any other skin abnormality on the resident's bath days. The Resident Admission Record revealed that Resident R4 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Initial Comprehensive Minimum Data Set (MDS- periodic review of resident care needs) assessment, dated 3/17/14, revealed that Resident R4 was not at risk of developing a pressure ulcer. The clinical record did not reveal any evidence of skin breakdown at that time. Nurses' notes dated 05/26/15, revealed that Resident R4 was noted to have an approximate 3.0 cm (centimeter) in diameter size Stage I (persistent reddened area) pressure ulcer to the coccyx (small bone at the base of the spinal column) area. physician's orders [REDACTED]. The nurses' note dated 06/04/15, indicated that the Stage I to the coccyx was no longer red but a bony prominence (projecting outward) remained. A physician's orders [REDACTED]. Resident R4's pressure ulcer care plan updated on 06/01/15, identified an intervention to keep the area clean and as dry as possible and to minimize skin exposure to moisture. Review of the Treatment Administration Records for August and September 2015, revealed that Resident R4's Duoderm was changed on 08/28/15 and was not changed again until 09/02/15, a period of six days. Resident R4's nursing and physician's notes from 06/04/15 through 09/08/15, lacked documentation regarding the skin condition over the coccyx with the Duoderm removals and the new dressing applications. Review of the Treatment Flowsheet for September 2015, revealed that Resident R4 did not have a skin check on 09/04/15, with their bath as scheduled. There was no evidence that the coccyx area was assessed for any changes in skin integrity for a period of six days from 09/02/15 through 09/08/15. On 09/08/15, the nurses' notes revealed that upon removal of the Duoderm to the coccyx area, a Stage III (full thickness tissue loss) pressure ulcer was discovered and measured approximately 3.0 cm length by 1.5 cm width. physician's orders [REDACTED]. The Wound Clinic classified the coccyx wound as a Stage III pressure ulcer with measurements of 2.0 cm length by 2.5 cm width by 1.0 cm depth with tunneling 2 cm deep. During an interview on 11/05/15, at 1:30 p.m., the Certified Registered Nurse Practitioner from the consulted Wound Clinic indicated that: 1) Duoderm was discouraged for Stage I pressure ulcers as its use may increase risk for skin breakdown due to the entrapment of moisture underneath the dressing leading to erosion of the skin, 2) that the skin should be evaluated daily especially when a resident is at high risk for skin breakdown, and 3) it would be more appropriate to off-load pressure as prevention with a Stage I pressure ulcer to maintain skin integrity. Facility wound observation notes dated 10/23/15, indicated that the coccyx wound had progressed from a Stage III to a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer with measurements of approximately 3.2 cm length by 2.0 cm width by 1.5 cm depth. During an interview on 11/06/15, at 8:45 a.m., the Wound Team Registered Nurse, Employee E2, confirmed that Resident R4's skin integrity was not monitored upon removal and application of Duoderm skin treatments to identify the condition of the coccyx skin until 09/08/15, when the Stage III pressure ulcer was discovered and the treatment and interventions were not effective in preventing harm to Resident R4 in the development of a Stage III pressure ulcer that worsened to a Stage IV. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/11/14.