Every finding on record at Pine Run Health Center

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent wandering and accidents for one of five sampled residents. (Resident 1) In addition, the facility failed to conduct an investigation into an incident.Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, panic disorder, and anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required supervision for ambulation (walking). A review of the care plan identified that the resident was at risk for wandering with interventions for staff to engage Resident 1 in purposeful activity and to provide reorientation to the surroundings and environment. On June 5, 2026, a nurse documented that Resident 1 was walking the hallways and going to the exit door. On June 10, 2026, a nurse noted that Resident 1 was pacing the hallways and kitchen and becoming increasingly anxious. On June 12, 2026, a nurse noted that Resident 1 was restless, had increased anxiety, was walking up and down the halls, going into other resident rooms, and that redirection was not effective. On June 13, 2026, a nurse documented that Resident 1 was pacing the hallways and was unsteady. On June 13, 2026, Resident 1 was noted to be lowered to the floor by staff due to losing her balance while walking. On June 15, 2026, a nurse noted Resident 1 was wandering throughout the unit for the entire morning, pacing the hallways and kitchen area, and going in and out of other resident rooms, and that Resident 1 remained restless despite attempts at redirection. On June 28, 2026, nurses documented that Resident 1 was pacing all day, entering other resident rooms, and was difficult to redirect. On June 29, 2026, it was noted that Resident 1 was wandering throughout the halls. On July 1, 2026, a nurse documented that Resident 1 was found in the hallway crawling on the floor. On July 4, 2026, nurses noted that Resident 1 was pacing the hallways, wandering into other resident rooms, and spilling water in another resident's room. On July 7, 2026, Resident 1 was noted to be very unsettled and anxious, pacing and breathing rapidly. On July 11, 2026, a nurse noted that Resident 1 was found in the personal laundry room (used by residents), upset and unable to exit the room by herself due to becoming tangled in the soap dispensing cord. On July 13, 2026, a nurse documented that Resident 1 was not able to be redirected from other resident rooms, causing other residents to become upset. In an interview on August 5, 2026, at 12:06 p.m., the Administrator confirmed there was no investigation completed related to the circumstances surrounding the resident incident in the personal laundry room. The facility failed to provide adequate supervision to prevent a resident from wandering into other resident rooms and areas, failed to prevent accidents, and failed to conduct an investigation into an incident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and in two of three country kitchens. (Second and Third floors) Findings include:Observations during the tour of the dietary department and in the country kitchen on the second floor on March 10, 2026, at 10:25 a.m., revealed the following:In the Emergency Food Storage section, there was one box of six large cans of green beans that was expired on December 25, 2025, nine cans of corned beef that were labeled with a use by date of July 1, 2025, four large boxes of oatmeal that were labeled with a use by date of September 8, 2025, four large boxes of apple juice dated use by date of December 9, 2025, two large boxes of cranberry juice that were labeled with a use by date of October 16, 2025, six large cans of tomatoes labeled with a use by date of June 17, 2025, and six large cans of fruit cocktail that were noted to be expired on May 28, 2025.In the country kitchen on the second floor, there was a container of half a gallon milk with a use by date of March 7, 2026. There was a container of grape tomatoes that was not dated. In an interview on March 10, 2026, at 10:45 a.m., the Dining Services Assistant Director confirmed the expired foods should have been removed in the Emergency Food Storage and in the second floor country kitchen and that they were not. Review of the facility's policy entitled, Uniform Standards, dated March 1, 2026, revealed that all staff was to cover all of their hair with a hair and/or beard restraint in all food service areas. Observation during lunch meal service in the country kitchen on the third floor on March 11, 2026, from 12:00 p.m. to 12:30 p.m., revealed Dietary Employee (DE) 1 was serving and plating food with hair and facial hair that was not covered. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for six of 21 sampled residents. (Residents 3, 11, 29, 37, 42, and 56) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypotension (low blood pressure) and chronic kidney disease. A physician's order dated February 26, 2026, directed staff to administer 5 milligrams (mg) of a blood pressure medication (midodrine) two times daily. The physician ordered that staff was not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was higher than 130 millimeters of mercury (mm/Hg). Review of Resident 3's Medication Administration Record (MAR) for February and March 2026, revealed that the staff withheld the medication once in February, when Resident 2's blood pressure was below 130mm/Hg and administered midodrine once in March, when Resident's 3's SBP was higher than 130 mm/Hg. Clinical record review revealed that Resident 11 had diagnoses that included heart failure and kidney disease. On February 2, 2026, the physician ordered that staff weigh the resident every Monday and Thursday and to notify the physician of weight gain greater than two pounds between weights or five pounds in a week. Review of Resident 11's February and March 2026, Treatment Administration Records revealed no evidence that staff weighed Resident 11 on February 5 and March 5, 2026. Clinical record review revealed that Resident 29 had diagnoses that included hypertension. On January 4, 2026, the physician ordered staff to administer a medicine (hydralazine) two times a day as needed for hypertension. Staff was to administer the medication if the resident's SBP was greater than 160 millimeters of mercury (mm/Hg) or if the diastolic blood pressure (DBP, is the pressure in the pressure in the arteries when the heart is relaxed and filling with blood between beats) was greater than 90. Review of Resident 29's February and March 2026 MAR revealed that staff administered the hydralazine 17 times in February and five times in March, when the resident's SBP was less than 160 mm/Hg or the DBP was less than 90 mm/Hg. Clinical record review revealed that Resident 37 had diagnoses that included dementia and diabetes. A physician's order dated December 19, 2025, directed staff to administer 30 milliliters (ml) of milk of magnesia for constipation on day four if the resident had no bowel movement in the previous three days. A physician's order dated December 19, 2025, directed staff to administer a Dulcolax suppository as needed for constipation if the milk of magnesia was ineffective and to give it to the resident on day five. A physician's order dated December 19, 2025, directed staff to administer a Fleet Saline Enema as needed for constipation if the Dulcolax suppository was ineffective and to give it to the resident on day six. Review of bowel movement tracking documentation for Resident 37 revealed that there were no bowel movements recorded from December 24, 2025, through January 2, 2026, and January 13, through January 18, 2026. Review of the MAR for December 2025 and January 2026, revealed that the resident was not provided the milk of magnesia, suppository and/or the enema as ordered. Clinical record review revealed that Resident 42 had diagnoses that included dementia and diabetes. A physician's order dated June 3, 2025, directed staff to administer 30 ml of milk of magnesia for constipation on day four if the resident had no bowel movement in the previous three days. A physician's order dated June 3, 2025, directed staff to administer a Dulcolax suppository as needed for constipation if the milk of magnesia was ineffective and to give it to the resident on day five. Review of bowel movement tracking documentation for Resident 42 revealed that there were no bowel movements recorded from November 25 through 30, 2025. Review of the MAR for November 2025, revealed that the resident was not provided the milk of magnesia, and/or the suppository as ordered. Clinical record review revealed that Resident 56 had diagnoses that included hypertension (high blood pressure) and chronic kidney disease. A physician's order dated February 26, 2026, directed staff to administer 20 mg of a blood pressure medication (Furosemide), along with one 20 milliequivalent (mEq) tablet of potassium chloride, once daily as needed for SBP greater than 160 mm/Hg. Review of Resident 3's MAR for February and March 2026, revealed that the staff withheld the medication three times in February and twice in March, when Resident 56's blood pressure was above 160 mm/Hg. A physician's order dated March 9, 2026, directed staff to administer 12.5 mg of a blood pressure medication (hydrochlorothiazide) to Resident 56 once daily as needed for SBP greater than 160 mm/Hg. Review of Resident 3's MAR for March 2026, revealed that the staff withheld the medication once when Resident 56's blood pressure was above 160mm/Hg. A physician's order dated March 10, 2026, directed staff to administer 25 mg of a blood pressure medication (hydralazine) twice daily to Resident 56. The physician ordered that staff were not to administer the medication if the resident's SBP was lower than 130 mm/Hg. Review of Resident 56's MAR for March 2026 revealed that the staff administered the medication once when Resident 56's blood pressure was below 130mm/Hg. In an interview on March 12, 2026, at 9:52 a.m., the Director of Nursing confirmed that nursing was to follow the physicians' orders and that there was no documented evidence that Resident 11 was weighed in accordance with the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, group interview, resident interviews, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for six of 18 sampled residents. (Residents 3, 6, 56, 68, 83, 96)Findings include:Review of the facility policy entitled Call Bell Response, dated January 5, 2026, revealed that all nursing personnel must be aware of call lights/alerts at all times, and answer bell/alert promptly. During an interview on March 11, 2026, at 1:17 p.m., the Administrator stated that staff were expected to respond to call bells in less than 20 minutes. Clinical record review revealed that Resident 3 had diagnoses that included chronic kidney disease and recovery from recent digestive system surgery. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 6 had diagnoses that included congestive heart failure, diabetes and recovery from recent limb surgery. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing.Clinical record review revealed that Resident 56 had diagnoses that included chronic kidney disease and recovery from hip replacement surgery. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 68 had diagnoses that included chronic kidney disease and congestive heart failure. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting.Clinical record review revealed that Resident 83 had diagnoses that included heart disease, chronic kidney disease, and recovery from wounds on his feet. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting.Clinical record review revealed that Resident 96 had diagnoses that included congestive heart failure and recovery from recent spinal surgery. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing.During a confidential group interview on March 11, 2026, at 10:00 a.m., seven residents reported that it often took 30 minutes or more for staff to answer their call bells and get assistance.Review of the facility form entitled, Device Activity Report, for Residents 3, 6, 56, 68, 83, 96 from February 10, 2026, through March 10, 2026, revealed that there were 87 occurrences when the call bell response time exceeded 20 minutes which included: March 7, 2026, at 4:42 a.m., when Resident 3 waited 96 minutes; February 14, 2026, at 11:33 a.m., when Resident 6 waited 125 minutes; February 22, 2026, at 12:07 p.m., when Resident 56 waited 38 minutes; March 4, 2026, at 8:27a.m., when Resident 68 waited in the bathroom for 93 minutes; March 1, 2026 at 10:31 am., when Resident 83 waited 130 minutes; and March 7, 2026, at 9:53 a.m., when Resident 96 waited 109 minutes.During an interview on March 11, 2026, at 1:17 p.m., the Administrator confirmed that the aforementioned residents waited more than the expected response time of 20 minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 21 sampled residents. (Residents 9 and 37)Findings include: Clinical record review revealed that on September 14, 2025, the consultant pharmacist made a recommendation to review and assess the orders for Resident 9's Celexa and Remeron. On November 17, 2025, the consultant pharmacist made a recommendation to evaluate and adjust the dose of Tylenol. There was no documented evidence that the attending physician had acknowledged or acted upon these recommendations. Clinical record review revealed that on December 24, 2025, the consultant pharmacist made recommendations to evaluate Resident 37's seroquel for a dose reduction and to consider adding a stimulant laxative such as Senna to this resident's regiment to prevent constipation. On January 13, 2026, the consultant pharmacist again made recommendations to evaluate Resident 37's seroquel. There was no documented evidence that the attending physician had acknowledged or acted upon these recommendations. In an interview on March 12, 2026, at 10:07 a.m., the Director of Nursing confirmed that the medication review recommendations were not addressed by the physician. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and interview, it was determined that the facility failed to provide restorative nursing services to improve or maintain walking mobility on a consistent basis for one of 21 sampled residents. (Resident 4) Findings include:Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, generalized muscle weakness, and difficulty in walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required limited assistance from staff for activities of daily living. On February 10, 2026, the physical therapist had recommended a Restorative Nursing Program (RNP) for walking with a rolling walker for ambulation up to 200 feet. In an interview on March 12, 2026, at 12:37 p.m., the Director of Therapy stated the program consisted of Resident 4 using a front wheeled walker to go to and from the dining room for each meal and that it was to maintain his mobility status. There was a lack of documentation to support that the resident was offered restorative ambulation on eight of 30 days.In an interview on March 12, 2026, at 12:15 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident 4 was offered the restorative nursing program daily and it should have been.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, staff interview, and review of facility policy it was determined that the facility failed to store respiratory equipment appropriately for one of three sampled residents who received oxygen therapy. (Resident 42) Findings include: Review of the facility policy entitled, Oxygen Protocol, dated January 5, 2026, revealed that oxygen cannulas and masks were to be changed weekly and labeled with the date. When oxygen tubing was not in use it was to be kept in a plastic bag. Staff were to place a new bag with the resident's name and date on the side of the concentrator or portable oxygen tank weekly to hold the tubing. Clinical record review revealed that Resident 42 had diagnoses that included chronic obstructive pulmonary disease and respiratory failure. On September 5, 2025, the physician ordered that staff administer oxygen therapy via nasal cannula (a tube with two prongs where each prong is inserted into each nostril of the nose) at a rate of two liters per minute at bedtime. On September 5, 2025, the physician ordered for staff to administer oxygen therapy via nasal cannula as needed. Observations on March 10, 2026, at 11:50 a.m., and 12:45 p.m., revealed the resident seated in her wheelchair with a portable oxygen tank in the back pouch with an attached nasal cannula. The oxygen was not in use, and the tubing was not dated and was not stored in the attached storage bag. Observations on March 10, 2026, at 11:05 a.m., and 1:21 p.m., revealed a second set of oxygen tubing that was not dated and attached to the oxygen concentrator in the resident's room. The tubing was not in use and was not stored in the storage bag attached to the oxygen concentrator. An observation on March 11, 2026, at 8:25 a.m., revealed the oxygen tubing attached to the oxygen concentrator in the resident's room was not in use and was not stored in the storage bag. During an interview on March 12, 2026, at 10:04 a.m., the Director of Nursing confirmed that the oxygen cannula and tubing should have been dated and placed in a bag when not in use. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and/or the resident's representative of their appeal rights and the contact information for the Office of the State Long-Term Care Ombudsman in writing upon transfer from the facility for six of six sampled residents who were transferred to the hospital. (Residents 2, 3, 7, 8, 10 and 11) Findings include: Clinical record review revealed that Resident 2 was transferred to the hospital on January 28, 2026, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 3 was transferred to the hospital on January 13, 2026, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 7 was transferred to the hospital on March 9, 2026, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 8 was transferred to the hospital on December 13, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 10 was transferred to the hospital on January 17, 2026, February 22, 2026, and March 3, 2026, after changes in conditions. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. Clinical record review revealed that Resident 11 was transferred to the hospital on December 27, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and contact information for the Office of the State Long-Term Care Ombudsman upon transfer to the hospital. In an interview on March 11, 2026, at 1:20 p.m., the Administrator confirmed that the identified residents and/or their representatives were not provided with transfer notices that included the required information.

Based on clinical record review, observation, staff interview, and review of facility policy, it was determined that the facility failed to safely administer medications for one of 14 sampled residents. (Resident 2)Findings include: Review of the facility policy entitled, Medications, Administration (Self), last reviewed January 2025, revealed that a written physician's order for self-administration of medications and bedside storage was obtained and kept in the resident's medical record.Clinical record review revealed that Resident 2 had diagnoses that included muscle wasting, dysphagia, need for assistance with personal care, and hearing loss. Review of the resident's self-administration of medications assessment dated [DATE], revealed that she required assistance storing medications in a secured location, administering oral medications, naming medications and prescribed use, and she was not approved to self- administer her own medications. On November 10, 2025, at 11:10 a.m., Resident 2 was observed in her room and there was a cup of medications on her bedside table. In an interview at that time, nurse aide (NA) 1 stated that the cup contained the resident's morning medications. There was a lack of evidence to support that Resident 2 had a physician's order to self-administer medications. In an interview on November 10, 2025, at 3:57 p.m., the Director of Nursing confirmed that Resident 2 did not have a physician's order to self-administer medications. 211.10(d) Resident care policies. 211.12(d)(1)(5) Nursing services.

Based on facility policy review and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on the nursing unit. (Fourth floor) Findings include: Review of the facility policy entitled, Hand Hygiene, last reviewed January 2025, revealed that staff was to sanitize or wash their hands before and after each procedure or task and after handling resident belongings. On November 10, 2025, at 11:50 a.m., nurse aide (NA) 2 was observed exiting Resident 3's room carrying linens with ungloved bare hands. NA 2 disposed of the linens into the dirty linen receptacle. NA 2 did not perform hand hygiene after this task and proceeded to enter Resident 4's room without performing hand hygiene. NA 2 touched Resident 4's belongings, obtained clean linens from the clean linen cart, re-entered then exited Resident 4's room again, and did not perform hand hygiene at any time during the observation.28 Pa. Code 211.10(b)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in following the established policies and procedures of the facility set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of three sampled residents who were at risk for falls. (Resident 1)Findings include: Review of Pennsylvania Code Title 49, Chapter 21, Subchapter B. Practical Nurses, revealed guidelines which included that an LPN shall follow the written, established policies and procedures of the facility. Review of the facility policy entitled, Falls Management Program, last reviewed January 2025, revealed that when a resident sustained a fall, an examination by a licensed nurse was completed and a Registered Nurse (RN) must assess the resident post fall and document on the accident/incident report.Clinical record review revealed that Resident 1 had diagnoses that included orthostatic hypotension, history of stroke, and glaucoma. On September 13, 2025, LPN 1 noted that Resident 1 was found on the floor after a fall, the RN supervisor was notified but did not assess the resident, and the resident was placed back into his chair by LPN 1. Review of facility documentation indicated that the resident's family and physician were notified of the fall. There was no evidence in the clinical record or facility documentation that Resident 1 was assessed by an RN after the fall. In an interview on November 10, 2025, at 3:02 p.m., the Director of Nursing stated that LPN 1 did not directly notify the RN supervisor of the fall, LPN 1 should not have transferred the resident before an RN assessment, and Resident 1 was not assessed by an RN after the fall. 28 Pa. Code 211.10(c) Resident Care Policies.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on March 19, 2024, at 11:50 a.m. revealed the following: The bottom row of shelves in the reach-in freezer were missing. Multiple food items were stored on the bottom floor of the freezer. There was a box of raw chicken cheesesteak meat that was open, other food items were stored on top of the box. There was an open bag of French fries that was not dated. The slicer handle was broken. There was a muffin tin and round cake pan stored on top of a transformer. There were two muffin tins on the floor between the storage shelf and the transformer. There was water leaking from the nozzle of a hose behind the kettle while food was being cooked. There was an accumulation of debris under the stovetop and grille. There was cocktail sauce with a use-by date of March 15, 2024, and blue cheese dressing with a use-by date of March 16, 2024, in the walk-in refrigerator. There was a container of popcorn with a use-by date of January 23, 2024, in dry storage. There were two trays of croquettes in the walk-in freezer that were not completely sealed and were open to air. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was maintained for two of 18 sampled residents. (Residents 45, 222) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included stroke, hemiplegia to the left side, depression, and muscle weakness. Review of the care plan revealed that the resident preferred activities that identified with his prior lifestyle and staff were to include the resident's preferences in rendering care and services. On March 19, 2024, at 1:33 p.m., Resident 45 was observed in bed. The white board on the wall in his room displayed March 11, 2024, and identified an assigned nurse and nurse aide for that date. During the observation, the resident stated that he preferred the white board to be updated daily with accurate and current information and he does not recall the last time staff updated the board. Observations on March 20, 2024, at 11:52 a.m., and March 21, 2024, at 11:20 a.m., revealed that the resident's white board still displayed March 11, 2024, with the same staff names. Clinical record review revealed that Resident 222 had diagnoses that included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). Resident 222 was ordered by the physician to utilize a foley catheter for urination. Observations on March 19, 2024, from 11:04 a.m. through 1:00 p.m., and March 21, 2024, from 10:39 a.m. through 11:15 a.m., revealed Resident 222 sitting in a wheelchair in the common area. The foley catheter bag was not covered and contained urine. Multiple residents and staff were present in the same area during those time periods. During an interview on March 22, 2024, at 10:49 a.m., the Director of Nursing confirmed that Resident 222 had a foley catheter without a dignity bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 18 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included pleural effusion, dysphagia (difficulty swallowing), and lymphedema. Review of the care plan revealed that Resident 15 was at risk for dehydration and weight changes and staff were to monitor weights and report changes to the physician. On November 17, 2023, the physician ordered for the resident to be weighed daily. There was no evidence that weights were obtained on March 4, 7, 9, and 17, 2024. On January 19, 2024, there was an order for staff to notify the physician of a two pound (lb.) weight gain or loss in one day or a five lb. weight change in one week. Review of the resident's weight record revealed that she experienced weight changes of greater than two pounds in one day on the following dates: A loss of 3.6 lbs. from January 31, 2024, through February 1, 2024. A gain of 3.6 lbs. from February 15 through 16, 2024. A loss of 3.8 lbs. from February 18 through 19, 2024. A gain of 4.2 lbs. from February 19 through 20, 2024. A loss of 4.4 lbs. from February 20 through 21, 2024. A gain of 2.6 lbs. from February 26 through 27, 2024. A loss of 4.8 lbs. from March 5 through 6, 2024. There was no evidence that the physician was notified of the weight loss or increase of greater than two lbs. in one day as ordered. In an interview on March 22, 2024, at 11:08 a.m., the Director of Nursing confirmed that Resident 15's weights were not obtained as ordered and that the doctor was not notified of the weight changes as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s) in writing upon transfer from the facility for two of two sampled residents who were transferred to the hospital. (Residents 2, 23) Findings include: Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on December 30, 2023, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 23 was transferred and admitted to the hospital on March 6, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. In an interview on March 22, 2024, at 10:36 a.m., the Assistant Administrator confirmed that written notice regarding transfer from the facility was not provided.

Based on policy review, clinical record review and staff interview, it was determined that the facility failed to notify the Responsible Party of a change in a resident's behavior for one of four sampled residents. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the day of admission, the resident had some confusion and was disoriented. The resident was not considered a risk for elopement at that time. The resident was able to walk with his walker independently. On March 6, 2020, at 6:59 a.m., the resident was found outside of the building by a staff reporting for duty. Nursing documentation on March 6, 2020, at 9:34 a.m., and 11:07 a.m., noted that Resident CR1 was confused, had impaired memory and poor comprehension. There was no documentation that the first contact (the resident's son) was notified by the facility timely that the resident had eloped at 6:59 a.m., or that there were changes in his cognition. In an interview on March 10, 2020,at 5:00 p.m., the Adminstrator confirmed that staff did not notify the responsible party of the elopement and change in cognition. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review, observation, policy review and staff interview, it was determined that the facility failed to monitor fluid intake for six of 18 sampled residents reviewed for hydration concerns. (Resident 2, 29, 53, 54, 70, 223) Findings include: Review of the policy entitled, Fluid Restriction, dated (MONTH) 29, 2019, revealed that resident's were to receive adequate fluid intake within the limitations determined by the attending physician and nursing was to record the resident's fluid intake to ensure the total per 24-hour period did not exceed the specified limit. Observation during the initial tour on (MONTH) 3, 2019, at 11:32 a.m., revealed Resident 54 drinking water from a 20 ounce styrofoam cup. In an interview on (MONTH) 3, 2019, at 11:58 a.m., RN 1 stated that the resident was on fluid restriction and should not have received that amount of fluid. Clinical record review revealed that Resident 54 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 8, 2019, indicated that the resident required a therapeutic diet for identified nutritional deficits. A physician's orders [REDACTED]. The care plan dated (MONTH) 9, 2019, indicated the resident was at risk for weight change and directed staff to ensure the fluid restriction was followed. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. Observation on (MONTH) 4, 2019, at 11:31 a.m., revealed Resident 53 had a 20 ounce styrofoam cup of water and an 8 ounce cup of coffee in the room. On (MONTH) 5, 2019, at 11:22 a.m., a 7.5 ounce can of ginger-ale and a 6 ounce cup of water was observed on the night stand. Clinical record review revealed that Resident 53 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 14, 2019, indicated that the resident required a therapeutic diet for identified nutritional deficits. A physician order [REDACTED]. The care plan dated (MONTH) 6, 2019, indicated the resident was at risk for weight change, and directed staff to ensure the fluid restriction was implemented. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. Clinical record review revealed that Resident 2 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 22, 2019, indicated that the resident required a therapeutic diet for identified nutritional restrictions. A physician order [REDACTED]. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. Clinical record review revealed that Resident 29 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 15, 2019, indicated that the resident required a therapeutic diet for identified nutritional restrictions. A physician order [REDACTED]. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. Clinical record review revealed that Resident 70 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 10, 2019, indicated that the resident required a therapeutic diet for identified nutritional restrictions. A physician order [REDACTED]. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. Clinical record review revealed that Resident 223 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 27, 2019, indicated that the resident required a therapeutic diet for identified nutritional restrictions. A physician order [REDACTED]. There was no documentation to support that staff recorded the amount of fluid that the resident consumed per day to ensure the physician ordered fluid restriction was maintained. In an interview with the Director of Nursing on (MONTH) 6, 2019, at 12:30 p.m., confirmed the above mentioned physician's orders [REDACTED]. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 1/4/19

Based on review of facility policy, review of the facility assessment tool, clinical record and staff interview, it was determined that the facility failed to implement, conduct and document the necessary components to monitor and evaluate therapeutic dietary interventions for residents' assessed to be at cardiac risk with specific hydration needs. Findings include: Review of the Facility Assessment Tool dated (MONTH) 29, 2019, revealed a list of the types of care required by the resident population necessary to maintain, or attain the residents' highest practicable physical, mental and psychosocial well-being. Based on the findings of an annual Recertification and State Licensure survey completed on (MONTH) 6, 2019, it was determined that the Nursing Home Administrator and the Director of Nursing failed to ensure that therapeutic dietary interventions for residents' ordered by the physician on a fluid restriction had been implemented, monitored and documented as per facility policy. In an interview on (MONTH) 3, 2019, at 12:30 p.m., the Administrator and Director of Nursing confirmed that there was no documentation available to support that fluid restrictions had been implemented, or that staff was tracking the amount of fluid that the residents' had consumed. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 1/4/19 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 1/4/19 28 Pa. Code 201.18(b)(1) Management Previously cited 8/9/19, 10/9/19

Based on clinical record review and staff interview, it was determined that the facility failed to timely and accurately assess pressure sores and consistently provide treatment designed to prevent worsening and promote optimal wound healing for five of six residents reviewed with pressure sores (Residents 19, 3, 29, 71, CL1) and that resulted in actual harm to one of the five (Resident 19). Findings include: Clinical record review revealed that Resident 19 was admitted to the facility on (MONTH) 27, 2019, with [DIAGNOSES REDACTED]. Review of the care plan indicated that on (MONTH) 28, 2019, the resident was at risk for skin breakdown related to decreased mobility and fragile skin. The intervention was that staff check Resident 19's skin every week. On (MONTH) 1, 2019, nursing documented that the resident had no current skin problems. Review of the nurses notes revealed that on (MONTH) 9, 2019, Resident 19 developed an open area on her left upper and right upper buttocks, measuring 1.5 centimeters (cm) x 0.8 cm, that was dry with a small amount of drainage . On (MONTH) 9, 2019, the physician ordered staff to cleanse the area with normal saline, pat dry, cover with a foam dressing for protection every other day in the morning and as needed for 14 days. On (MONTH) 16, 2019, staff noted that the wound was on Resident 19's left and right middle buttock and was pink and scabbed, measuring 2 cm x 1.5 cm. Review of the medication administration records (MAR) for (MONTH) and (MONTH) 2019 revealed that the resident did not have any treatment ordered for her buttock wound from (MONTH) 22 through (MONTH) 10, 2019. On (MONTH) 10, 2019, the physician ordered staff to cleanse the area with normal saline, pat dry, cover with a foam dressing for protection every other day in the morning and as needed until the wound was resolved. Review of the MAR for (MONTH) 2019, revealed that the resident did not receive the physician ordered treatments on (MONTH) 12, 14, and 18, 2019. Further review of the nurses notes revealed that there was no assessment of the resident's buttock wound from (MONTH) 16, 2019, until (MONTH) 17, 2019, when the wound was noted to be reddened, worsened, with foul odor and drainage containing blood. There were no measurements of the wound at that time. The physician was not notified of the worsening condition of Resident 19's buttock wound until (MONTH) 20, 2019. On (MONTH) 20, 2019, the wound was noted as a Stage III pressure sore (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) that was becoming deeper and worsened, measuring 4.8 cm x 0.8 cm x 0.2 cm. At that time, the physician changed Resident 19's treatment order for her wound. Staff was to cleanse the area with normal saline, pat dry, apply Medi honey gel, cover with a foam dressing daily in the morning and as needed. Review of the MAR indicated [REDACTED]. The facility failed to assess and provide treatments to prevent the deterioration of a newly identified pressure ulcer. In an interview on (MONTH) 9, 2019, at 2:00 p.m. the Director of Nursing confirmed that there was no documented evidence that Resident 19's buttock wound was accurately assessed from (MONTH) 16, 2019 through (MONTH) 20, 2019, when the wound had deteriorated. She also confirmed there was no documented evidence that the physician ordered treatments were provided as ordered. Clinical record review revealed that Resident 3 was admitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan revealed that the resident was at risk for impaired skin integrity and staff was to check Resident 3's skin every week. On (MONTH) 13, 2019, Resident 3 was noted to have a 1 cm x 1 cm open area to her right outer buttocks. There was no further documentation in the clinical record of Resident 3's buttock wound as of (MONTH) 9, 2019. In an interview on (MONTH) 9, 2019, at 11:30 a.m. the Director of Nursing stated that wounds were to be assessed and documented weekly and that staff were to continue to assess residents' wounds for one week after the wounds healed. She confirmed that there was no further documentation of Resident 3's buttock wound. Clinical record review revealed that Resident 29 was admitted to the facility on (MONTH) 25, 2019, with [DIAGNOSES REDACTED]. Review of the care plan revealed that the resident was at risk for skin impairment and that she had a wound to her buttock. Review of the nursing notes revealed that on (MONTH) 25, 2019, Resident 29 was noted to have a Stage II pressure sore (partial-thickness skin loss with exposed dermis) to her right middle buttock. There were no documented measurements of the wound at that time. On (MONTH) 25, 2019, the physician ordered for the wound to be cleansed with normal sailine, apply duoderm (a [MEDICATION NAME] dressing) every three days and as needed. There was no documented evidence that the wound was assessed after (MONTH) 25, 2019 through (MONTH) 15, 2019. Clinical record review revealed that Resident 71 was admitted to the facility on (MONTH) 2, 2019, with [DIAGNOSES REDACTED]. Review of the care plan revealed that the resident had areas of skin impairment and staff was to check Resident 71's skin weekly. Review of the nursing notes revealed that on (MONTH) 2, 2019, it was noted that Resident 71's bilateral toes were necrotic. On (MONTH) 3, 2019, the resident was noted to have suspected deep tissue injuries (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or skin separation revealing a dark wound bed or blood filled blister) to both his heels. There were no documented measurements of the wounds at that time. There was no documented evidence that the wounds were measured from (MONTH) 2, 2019 through (MONTH) 9, 2019. Clinical record review revealed that Resident CL1 was admitted to the facility on (MONTH) 18, 2019, with [DIAGNOSES REDACTED]. On admission the resident was noted to have a deep tissue injury to his right upper buttock measuring 3 cm x 4 cm. Review of the care plan revealed that the resident had impaired skin. On (MONTH) 18, 2019, the physician ordered staff to apply foam dressing to the area every other day in the morning and as needed until resolved. There was no documented evidence that the wound was assessed from (MONTH) 19, 2019 through (MONTH) 2, 2019, when the resident was discharged home. In an interview on (MONTH) 9, 2019, at 1:30 p.m. the Director of Nursing confirmed that there was no documented evidence that Residents 29, 71 and CL1's wounds were accurately assessed and measured after they were initially identified. 28 Pa. Code 201.14 (e)(1) Management. 28 Pa.Code 211.12 (d)(1)(5) Nursing services. Previously cited 3/21/19, 1/4/19, 2/23/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the attending physician and responsible party were notified of a change in medical status for one of four sampled residents. (Resident CL1) Findings include: Clinical record review revealed that Resident CL1 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 28, 2019, indicated that the resident had some memory impairment and required extensive assistance from staff for activities of daily living including transfers, dressing and bathing. Review of the resident's weight record revealed that the resident experienced a weight loss on (MONTH) 4, 2019, of approximately 30 pounds. Review of a dietary note on (MONTH) 7, 2019, revealed that the weight loss was noted as significant. There was no documented evidence that the physician had been notified of the resident's significant weight loss. Review of nursing documentation dated (MONTH) 2, 2019, revealed that the resident appeared tearful and was speaking slowly. A nurse's note on (MONTH) 3, 2019, indicated that the resident was withdrawn with a change in his mood that was now documented as a flat affect. There was no documented evidence that the responsible party was notified of the change in the mental status nor was there documented evidence that the responsible party was notified of the significant weight loss that was noted on (MONTH) 4, 2019. In an interview on (MONTH) 21, 2019, at 12:00 p.m., the Administrator stated that there was no documented evidence that the physician or the responsible party was notified when there was a change in the resident's medical status. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/4/19