Every finding on record at Pine View Healthcare and Rehabilitation Center

Based on interview, observation, and clinical record review, the facility failed to administer pain medication in accordance with physician's orders for 1 out of 8 residents reviewed (Resident 91).Findings include:Review of Resident 91's quarterly MDS (minimum data set - a mandatory assessment of a resident's physical condition and care needs) dated April 9, 2026, revealed that Resident 91 received scheduled pain medication for frequent pain that frequently interfered with sleep and participation in rehabilitation therapy sessions, and frequently caused them to limit their day-to-day activities. The RAI (Resident Assessment Instrument - a tool that helps facility staff gather information on a resident's strengths and needs for the MDS) defines frequent as pain that is present and interferes with activities such as sleep, participation in rehabilitation therapy or day-to-day activities over the last five days of the resident's MDS assessment period. The pain was recorded as severe in the MDS.Review of provider History and Physical dated February 18, 2025, revealed Resident 91's diagnoses included: alcoholic polyneuropathy (a progressive nerve disorder that leads to pain and weakness in the arms and legs) and multilevel degenerative disc disease (age-related wear and tear affecting several areas of the spine that causes pain and stiffness).Review of the July 2026 MAR (medication administration record) revealed Resident 91 had orders for Amitriptyline HCl at bedtime for neuropathic (nerve) pain, Celebrex for pain management, Valium for muscle spasms, Tylenol Extra Strength for pain, Gabapentin for neuropathy pain, and oxycodone HCl 10 mg every 6 hours (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) for pain management.Review of nursing progress notes dated June 8, 2026, at 11:00 p.m. revealed that Resident 91's oxycodone HCL order was increased from 5mg to 10mg every 6 hours for pain management.Review of Resident 91's MAR revealed that Resident 91 did not receive scheduled oxycodone on the following days:July 11, 2026: 12:00 p.m.Jul7 11, 2026: 6:00 p.m.July 12, 2026: 12:00 a.m.July 12, 2026: 6:00 a.m.July 12, 2026: 12:00 p.m.July 12, 2026: 6:00 p.m.July 13, 2026:12:00 a.m.Review of Resident 91's July 2026 TAR (treatment administration record) revealed that Resident 91's pain was to be assessed each shift utilizing a numeric pain scale (a tool to measure pain levels from zero to ten with zero indicating no pain and ten being the most severe pain). Resident 91's pain was assessed as follows:July 11, 2026, 7 a.m. to 3:00 p.m. pain level = 0/10July 11, 2026, 3:00 p.m. to 11:00 p.m. pain level = 0/10July 11, 2026, 11:00 p.m. to 7:00 a.m. pain level = 0/10July 12, 2026, 7 a.m. to 3:00 p.m. pain level = 8/10July 12, 2026, 3:00 p.m. to 11:00 p.m. pain level = 0/10July 12, 2026, 11:00 p.m. to 7:00 a.m. pain level = 8/10July 13, 2026, 7:00 a.m. to 3:00 p.m. pain level = 8/10Review of nursing progress note dated July 11, 2026, at 6:00 p.m. for oxycodone HCL 10mg, revealed: Awaiting pharmacy delivery.Review of nursing progress note dated July 12, 2026, at 1:11 a.m., for oxycodone HCL 10mg, revealed: No medication in the building, supervisor aware, MD (physician) and RP (responsible party) aware.Review of nursing progress note dated July 12, 2026, at 3:58 a.m. revealed: resident was notified that there were no more oxycodone, resident was very upset and asked how we can get it, informed resident that we needed order from MD to get a new script.Review of nursing progress note dated July 12, 2026, at 7:01 a.m. for oxycodone HCL 10mg, revealed: Medication still not received. MD and RP made aware.Review of nursing progress note dated July 12, 2026, at 2:54 p.m. for oxycodone HCL 10mg revealed, Med not available. MD made aware. Resident is [there] own RP.Review of nursing progress note dated [DATE], at 2:19 p.m. revealed: Resident's oxycodone is expected to arrive on the first pharmacy delivery run today.at this time, resident appears comfortable.Review of the facility's list of on-site medication provided by the pharmacy, on July 23, 2026, revealed that Resident 91's oxycodone was not kept in inventory.Interview with the Director of Nursing on July 23, 2026 at approximately 12:30 p.m., revealed that because the pharmacy's servers were experiencing downtime, it wasn't possible to determine if the delay in receiving Resident 91's medication was related to the provider not requesting a refill in a timely manner or the facility not requesting the refill.The facility failed to provide Resident 91 with scheduled pain medication resulting in physical discomfort for the resident over multiple shifts.This finding was shared with the Director of Nursing and the Nursing Home Administrator on July 23, 2026 at approximately 2:30 p.m. 28 Pa. Code 211.12(d)(5) Nursing Services

Based on observations and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for one of the five medication carts observed (2 [NAME] back medication cart). Findings: An observation of the 2 [NAME] back medication cart was conducted on July 21, 2026, at 10:00 a.m., in the presence of licensed nurse Employee E3. The observation revealed the following: 27 scattered pills of different colors and shapes in the second drawer; 9 scattered pills of different colors and shapes in the third drawer; a medicine cup containing 7 tablets; and a medicine cup containing crushed medication. An interview was conducted with Employee E3 on July 21, 2026, at 10:03 a.m. Employee E3 reported that the two-medication cup containing unlabeled medications belongs to two different residents who were not yet ready to take their medications.The above was conveyed to the Director of Nursing on July 23, 2026, at 10:00 1:00 p.m.The facility failed to ensure medications on the 2 [NAME] back medication cart were properly stored and labeled. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a review of the facility's policy, clinical records review, observations, and staff interview, it was determined that the facility administered an as-needed anti-anxiety medication without appropriate indications and non-drug interventions and failed to monitor and report psychotropic side effects for two of five residents reviewed (Resident 8 and 225). Findings: A review of the facility's policy titled Psychotropic Medication Use, undated, revealed the following: Residents will not receive medications that are not clinically indicated to treat specific conditions; Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible; Residents receiving psychotropic medications are monitored for adverse consequences, including anticholinergic effects-flushing, blurred vision, dry mouth, altered mental status, difficulty urinating etc.; neurologic effects-agitation, distress, and extrapyramidal symptoms (EPS-are drug induced movement disorders). A review of Resident 8's Psychiatric Evaluation & Consultation dated November 5, 2025, revealed the resident had the following diagnoses: Bipolar Disorder (A Disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and schizoaffective disorder (A chronic mental health condition that combines symptoms of Schizophrenia with a mood disorder). The same report revealed residents observed hand tremors with recommendations to continue monitoring tremors and reporting any changes or additional symptoms. Further review revealed an AIMS (A test used to assess and monitor involuntary movements) was completed on November 6, 2025. The same report revealed the resident was on the following psychotropic medications: Depakote (A medication used to treat seizure disorder, manic episodes with bipolar disorder), 125 mg twice daily; Sertraline, 125 mg daily (Anti-depression medications); Risperdal, 2.5 mg twice daily (anti-psychotic medications); and Benztropine (A medication used to treat extrapyramidal disorders caused by antipsychotic drugs). A review of the Resident 8 June 2026 Medications Administration Record (MAR) revealed the residents' behaviors and side effects were monitored until June 15, 2026. A review of the nursing readmission notes dated June 23, 2026, revealed the resident was readmitted to the facility post hospitalizations (June 15, 2026) for diagnosis of Hypernatremia (elevated sodium level). A review of Resident 8's admission physician orders dated June 23, 2026, revealed the following orders: Seroquel 5 mg (Anti-psychotic medication) at nighttime, Sertraline 125 mg daily, and Depakote 125 mg twice daily. An observation conducted on July 20, 2026, at 1:27 p.m., revealed the resident was lying on the bed. Attempted to interview the resident, but they were confused and disoriented; however, while talking, the resident was observed with lip smacking and tongue thrusting. An observation was conducted on July 21, 2026, at 10:45 a.m. in the presence of a Speech Therapist, Employee E4. Observation revealed the resident was lying in bed and, while talking, observed lip smacking and tongue thrusting. An interview was conducted with Employee E4 on July 20, 2026, at 10:45 a.m. Employee E4 reported observing the residents with tongue thrusting when evaluated on July 24, 2026. Employee E4 reported that it was the resident's baseline. An observation was conducted on July 21, 2026, at 12:30 p.m., in the presence of licensed nurse Employee E6. Observation revealed the resident was lying in bed and, while talking, observed lip smacking and tongue thrusting. An interview was conducted with Employee E6 on July 21, 2026, at 12:30 p.m. Employee E6 reported that they were the residents' morning full-time nurse. Employee E6 reported noticing the residents with lip smacking since last Saturday (July 18, 2026). Employee E6 reported that the resident was monitored for dry mouth. There was no documented evidence that Resident 8 was monitored for medication side effects since the Seroquel was started on June 23, 2026. Further review also revealed that there were no documentation that the physician was notified of the possible medications side effects observed by Employee E4 and Employee E6. The psychotropic side effects monitoring was ordered on July 22, 2026, at 1:03 p.m., and started at 3:00 p.m. A review of Resident 225's physician's order dated June 26, 2026, revealed an order for Lorazepam (An anti-anxiety medication) 0.5 mg every eight hours as needed for anxiety. A review of Resident 225's July 2026 Medication Administration Record (MAR) revealed that from July 1, 2026, until July 22, 2026, the resident was administered as-needed Lorazepam nine times. A review of Resident 225's nursing progress notes from July 1, 2026, until July 22, 2026, revealed the resident was administered as-needed Lorazepam six times without appropriate indications and five times without providing non-pharmacological interventions. The above was conveyed to the Director of Nursing on July 23, 2026, at 1:00 p.m. The facility failed to ensure Resident 8 was monitored for psychotropic medication side effects and Resident 225 was administered as-needed anti-anxiety medication without appropriate indications and non-pharmacological interventions. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to treatments and observations for two of five residents reviewed (Resident 15, and Resident 217). Findings include: Resident 15 has medical diagnoses that include Dysphagia (difficulty swallowing) following Cerebral Infarction (a condition that occurs when blood flow to a part of the brain is interrupted), Aphasia (impaired speaking and understanding), following Cerebral Infarction, Gastrostomy (a medical procedure that creates an opening from the abdominal wall into the stomach to provide nutrition), Hemiplegia (a neurological condition characterized by paralysis or severe weakness affecting one side of the body) and Hemiparesis (weakness or partial paralysis affecting one side of the body, often caused by brain, spinal cord, or nerve damage) following other Cerebrovascular Disease affecting right dominant side. Review of Resident 15's care plan revealed a focus initiated on November 5, 2025, revised on July 17, 2026, documenting the resident has a nutritional problem or potential nutritional problem related to age, need for therapeutic/mechanically altered diet, need for enteral feed (a soft, flexible tube that delivers nutritionally complete liquid feeds, including protein, carbohydrates, fats, vitamins, minerals, and water, directly into the gastrointestinal tract to meet nutrition and hydration needs), risk for malnutrition, on hospice care, and historic need for oral nutritional supplements secondary to malnutrition risk. Further review of Resident 15's care plan revealed a focus dated November 14, 2024, documenting the resident has Aphasia related to Cerebral Infarction. Review of Resident 15's physician orders revealed an order dated July 17, 2026, for Enteral Feed every 4 hours (hr.) for Enteral Nutrition/Hydration flush Percutaneous Endoscopic Gastrostomy (PEG tube) (a small, flexible tube placed through the abdominal wall into the stomach to deliver nutrition, fluids, and medications) with 200 milliliters (ml) of water every 4 hours, total volume of flush to equal 1200 ml every 24 hrs. (excluding medication flushes). Total volume of nutrient plus flush to equal 1980 ml every 24 hrs. Review of Resident 15's July 2026 Medication Administration Report (MAR) revealed total daily flush amounts as follows: July 18, 2026, total volume of 2768 ml. for the day.July 19, 2026, total volume of 1620 ml. for the day.July 21, 2026, total volume of 1065 ml. for the day. On July 17, 2026, at 1:00 p.m. the resident's MAR documents a flush volume of 400 ml. Per Resident 15's July MAR, there were three days in July 2026, when the resident's total volume of flush every four hours exceeded the physician ordered amount. There was one day when the resident's total volume of flush was less than the physician ordered amount. Interview conducted with the Director of Nursing (DON) on July 22, 2026, at 1:20 p.m., when the above was presented, the DON confirmed there were days when the resident did not receive the accurate daily total flush amounts. The DON stated the order was probably being misunderstood by the staff and the wording would be changed to avoid confusion. Resident 217 has medical diagnoses that include Heart Failure, Cerebral Infarction, Cirrhosis of Liver (advanced scarring of the liver), and Major Depressive Disorder, Adjustment Disorder, Thigh Pain, and Muscle Weakness. Review of Resident 217's care plan revealed a focus initiated on January 19, 2026, documenting the resident has a diagnosis of depression. Review of Resident 217's care plan revealed a focus initiated on January 19, 2026, documenting the resident has potential for pain related to arthritis and neuropathy. Review of Resident 217's physician orders revealed an order dated February 3, 2026, for Tramadol (medication for moderate to severe pain) HCl Oral Tablet 50 milligrams (mg) give 1 tablet by mouth every 12 hours as needed for severe pain. Review of Resident 217's physician orders revealed an order dated January 23, 2026, for Sertraline (medication used to treat depression) HCl Oral Tablet 25 mg give 1 tablet by mouth one time a day for depression. Review of Resident 217's physician orders revealed an order dated January 17, 2026, for Observation: Pain - Observe every shift. If pain is present complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the progress notes. Review of Resident 217's July MAR revealed the following: July 4, 2026, pain level of 7 during 2nd shift.July 5, 2026, pain level of 5 during 2nd shift and 3rd shift.July 17, 2026, pain level of 9, during 2nd shift.July 21, 2026, pain level of 4, during 3rd shift. Review of Resident 217's progress notes revealed no non-pharmacological interventions documented. During interview conducted with the DON on July 22, 2026, at 1:20 p.m., the DON stated the facility does not utilize pain flow sheets, the MAR is considered their pain flow sheet. Review of Resident 217's physician orders revealed an order dated January 17, 2026, for Observation: Antidepressant Medication - Observe for behavior of depression. Observe for side effects: GI upset, insomnia, fatigue, dizziness, dry mouth, headache. Document Y if resident is free of side effects. Document N if the resident is NOT free from side effects. If N document side effects in the progress notes every shift for protocol. Review of Resident 217's July MAR revealed the following: July 1, 2026, No was documented for the 2nd and 3rd shifts.July 2, 2026, No was documented for all shifts.July 3, 2026, No was documented for all shifts.July 4, 2026, No was documented for 1st and 2nd shifts.July 5, 2026, No was documented for 1st and 3rd shifts.July 6, 2026, No was documented for all shifts.July 7, 2026, No was documented for all shifts.July 8, 2026, No was documented for all shifts.July 9, 2026, No was documented for all 2nd and 3rd shifts.July 10, 2026, No was documented for all shifts.July 11, 2026, No was documented for 3rd shift.July 12, 2026, No was documented for 2nd and 3rd shifts.July 13, 2026, No was documented for all shifts.July 14, 2026, No was documented for 1st and 3rd shifts.July 15, 2026, No was documented for all shifts.July 16, 2026, No was documented for all shifts.July 17, 2026, No was documented for all shifts.July 18, 2026, No was documented for 1st and 3rd shifts.July 19, 2026, No was documented for all shifts.July 20, 2026, No was documented for all shifts.July 21, 2026, No was documented for 1st shift.July 22, 2026, No was documented for 1st shift. Review of Resident 217's progress notes revealed no side effects were documented for the antidepressant observations. Interview conducted with the Director of Nursing (DON) on July 22, 2026, at 1:20 p.m., when the above was presented, the DON stated the order was probably being misunderstood by the staff and the wording would be changed to avoid confusion. 28 Pa. Code 211.5(f)(h) Clinical records. 28 Pa. code 211.12(d)(1)(3)(5) Nursing services.

Based on interview with staff, observation, and review of clinical records, the facility failed to implement a recommendation from the Registered Dietitian that was signed by the Primary Care Provider in a timely fashion and failed to follow a physician's order for two of 16 residents reviewed (Resident 80, 165). Findings include: Review of Resident 80's admission MDS (Minimum Data Set – a mandatory assessment of a resident's physical condition and care needs), dated May 22, 2026, revealed that Resident 91 was admitted to the facility on [DATE] from the hospital with diagnoses that included anemia (abnormally low red blood cell count) and malnutrition (when the body does not receive the nutrients it needs to function). Review of hospital consultation records dated May 11, 2026 revealed Severe malnutrition with BMI (body mas index – a measure of health using weight to height ratios) 12.85. Review of Resident 80's weights revealed the following: May 15, 2026: 77.4 pounds May 16, 2026: 77.6 pounds May 20, 2026: 73 pounds May 27, 2026: 79.8 pounds June 3, 2026: 79.2 pounds June 10, 2026: 79.0 pounds June 17, 2026: 75.6 pounds July 7, 2026: 82.4 pounds Review of the facility's dietary assessment dated [DATE], revealed that Resident 80 met the criteria for severe protein-calorie malnutrition due to meeting two or more criteria: Unplanned weight loss of greater than 5% in one month, BMI less than 20 for a resident more than [AGE] years old, and muscle mass loss. Interventions included a nutrition supplement, Ensure (a nutritional drink and protein supplement) daily. This assessment was signed by the Registered Dietitian and the Primary Care Provider on May 22, 2026. Interview with the Registered Dietitian (E6) on July 23, 2026, at approximately 11:50 a.m. revealed that a dietary recommendation signed by the provider should be implemented within a day. Review of Resident 80's medication administration record revealed that the order for Ensure was not added to the resident's orders until June 20, 2026, placing the resident at risk for additional weight loss and malnutrition. This finding was shared with the Director of Nursing and Nursing Home Administrator on July 23, 2026 at approximately 2:15 p.m. A review of Resident 165's wound consults note dated June 10, 2026, revealed Wound care has been consulted for evaluation and treatment recommendation regarding Stage 4 (Full-thickness skin and tissue loss) pressure ulcer to right hip, with history of osteomyelitis (bone infection) and hardware exposure. Patients have pain that increases with pressure and dressing changes, relieved with offloading, rest, and pain meds. Patient is declining any further surgical intervention at this time; currently taking Doxycycline (antibiotic) 100mg BID prophylactic per ID (Infectious Disease) recommendations. The same report revealed as follows: ASSESSMENT/PLAN: Right Hip-Stage 4-no healing expected/poor prognosis per surgeon (patient needs surgery but not a candidate)- goals of care to prevent infection and reduce pain-due to maceration of peri wound and increase in wound size. A review of Resident 165's primary physician's notes dated June 12, 2026, at 5:23 p.m., revealed R (right) Hip Pain-continue Tylenol--follow up with Ortho (Orthopedics- a medical doctor that specializes in diagnosing, and treating bone disease) [Physician's name]. There was no documentation indicating that the physician's order for a follow-up with the Orthopedic doctor was followed from June 12, 2026, until July 22, 2026. On July 23, 2026, at 11:45 a.m., the Director of Nursing (DON) handed the surveyor an Appointment Slip paper with information indicating that Resident 165's Orthopedic consult is scheduled for July 24, 2026, at 10:50 a.m., after the surveyor had asked regarding the consult. When asked when the schedule was made, the DON replied, I don't know, I'll ask the scheduler. At 1:00 p.m., a follow-up was done with the DON to determine when the consult schedule was made; no answer was provided. At 2:10 p.m., a follow-up was made with the DON. The surveyor asked again if they were able to talk to the scheduler; the DON replied No. When asked why, they replied, I called but [they] are not answering. When asked if the scheduler was in the building, the DON replied, I don't know. The surveyor asked if they could find out. The DON did not come back to provide an answer. The above was conveyed with the Nursing Home Administrator on July 23, 2026, at 2:45 p.m. The facility failed to ensure Resident 165's physician's order for a follow-up with an Orthopedic doctor was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a review of pharmacy consultants' monthly medication review (MMR), clinical records review, and staff interview, it was determined that the facility failed to act on the pharmacist's recommendations for one of five residents reviewed (Resident 59). Findings: A review of Resident 59's physician's order dated January 5, 2025, revealed an order for Sertraline HCL (antidepressant medication), one tablet daily, related to Major Depressive Disorder (Characterized by a low mood or loss of interest in activities that last for a long time that can interfere with normal functioning). A review of Resident 59's physician order dated April 2, 2025, revealed an order for Remeron tablet (antidepressant medication) 30 mg, one tablet by mouth at bedtime for depression. A review of Resident 59's April 16, 2026, Pharmacy consultant review revealed: As per CMS (Centers for Medicare & Medicaid Services) guidelines, a taper of Sertraline and Remeron may be indicated. If a taper of this medication is contraindicated, please document the clinical rationale. The response was Accepted with a check mark on the physician's signature line. A review of Resident 59's physician's order from May 2026 until July 2026 revealed that there were no changes made to the resident's Sertraline and Remeron order. An interview was conducted with the Director of Nursing (DON) on July 24, 2026, at 1:00 p.m. The DON confirmed that the pharmacy recommendations made on April 16, 2026, to taper the Sertraline and Remeron were not addressed/followed. The facility failed to ensure Resident 59's Pharmacy consultants' recommendations made on April 16, 2026, to taper the resident's antidepressant medications were addressed/followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, clinical records review, and staff interviews, it was determined that the facility failed to ensure infection control and prevention were implemented during a wound care treatment for two of the two residents reviewed (Resident 1 and 2).Findings: A review of Resident 1's physician's order dated March 8, 2026, revealed an order to cleanse the right buttocks with normal saline solution (NSS), pat dry, apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), and secure with silicone border twice daily for the wound. An observation of Resident 1's right buttock wound care treatment was conducted on March 9, 2026, at 10:40 a.m., with licensed nurse Employee 3. The observation revealed Employee E3 placed tissue paper on the bed beside the resident and laid the wet gauze, Medihoney in a cup and bordered dressing on top of it. Employee E3 proceeded to clean the right buttock wound with a wet gauze, then discarded it in a trash can. Employee E3 continued to apply Medihoney into the wound and applied the newly opened border without changing their gloves and performing hand hygiene. A review of Resident 2's physician's order dated November 13, 2026, revealed an order to cleanse the sacrum (The triangular bone just below the lumbar vertebrae), NSS apply Medihoney daily. An observation of Resident 2's sacrum wound care treatment was conducted on March 9, 2026, at 10:50 a.m., with Employee E3. The observation revealed Employee E3 opened the resident's incontinence brief and assisted in repositioning the resident to their side. Employee E3 laid the cup with a wet gauze inside, the Medihoney (in a medicine cup), and bordered gauze on top of the resident's used incontinence brief in the bed. Employee E3 removed the resident's old sacrum dressing and placed it beside the clean prepared supplies on top of the resident's saoiled incontinence brief. Without changing gloves and washing hands, Employee E3 proceeded to clean the sacrum wound with a wet gauze from the cup, then discarded it back in the same cup. Employee E3 continued applying Medihoney to the wound, then covered it with bordered gauze. Employee E3 did not change gloves and did not perform hand hygiene during the entire procedure. An interview was conducted with Employee E3 on March 9, 2026, at 12:00 noon. Employee E3 confirmed that wound supplies were placed on the residents' beds because there were no available side tables. Employee E3 also confirmed they were not changing gloves and performing hand hygiene during wound care treatment because they forgot but knew it should have been done. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on March 9, 2026, at 12:30 p.m. The facility failed to ensure infection control and management were implemented during wound care treatment for Resident 1's right buttock wound and Resident 2's sacral wound. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to accurately and comprehensively assess and timely provide a wound treatment for two of three residents, reviewed (Resident 1 and 2).Findings: A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised in April 2018, revealed that the nursing staff will assess and document an individual's significant risk factor for developing pressure ulcers. The nurse shall describe and document /report a full assessment of the pressure ulcer, including location, stage, length, width, and depth. A review of Resident 1's readmission skin assessment dated [DATE], revealed an identified skin impairment to the right buttock. The assessment failed to reveal a description of the area/wound and size. A review of the physician's progress notes dated February 10, 2026, at 2:56 p.m., reveals Pt (patient) has new small wound on buttock. Wound care follow-up. Wound assessment to the right buttock, identified on February 9, 2026, was not comprehensively assessed until seen by the wound doctor on February 18, 2026. The wound doctor identified the wound as MASD (Moisture Associated Skin Damage), measuring 2.0 x 1.4 x 0.1 cm, with partial thickness. A wound treatment of Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns). An interview with the Director of Nursing (DON) was conducted on March 9, 2026, at 1:00 p.m. The DON confirmed that Resident 1's right buttock wound, identified upon readmission on [DATE], was not comprehensively assessed until seen by the wound doctor on February 19, 2026. A review of Resident 2's readmission skin assessment dated [DATE], revealed scattered scabs on the resident's abdomen and left leg. A review of Resident 2's skin assessment notes dated November 10, 2025, completed by the wound nurse, licensed Employee E3, revealed a Stage 2 Pressure Ulcer (Partial-thickness skin loss with exposed dermis) to the Sacrum (The triangular bone just below the lumbar vertebrae). An interview with Employee E3, conducted on March 9, 2025, at 12:30 p.m., revealed that they recheck the resident's skin within 24 hours upon admission to ensure all skin impairments are identified and addressed. Employee E3 confirmed Resident 2 was admitted with a stage 2 to the sacrum on November 12, 2025. A review of Resident 2's physician's order dated November 13, 2026, revealed an order for Thera Honey (Medihoney) to be applied to the sacrum topically every day shift for the wound. A review of Resident 2's November 2025 Treatment Administration Record (TAR) failed to reveal that Resident 2's sacral wound was treated until November 15, 2026. A review of the wound NP's (nurse practitioner) notes dated November 17, 2025, at 8:40 p.m., revealed: The resident is being evaluated today for a comprehensive skin assessment. The same note revealed, The patient was noted to have intact skin upon assessment today. A review of the wound NP's notes dated November 19, 2025, at 5:30 p.m., documented by the same NP from November 17, 2025, revealed: Patient was seen and evaluated today for PU (pressure ulcer) stage 3 (full-thickness skin loss) to sacrum present on admission from hospital. The wound had a measurement of 3.0 x 2.0 x 0.2 cm. An order to continue Medihoney was ordered and followed. An interview was conducted with the DON on March 9, 2026, at 1:00 p.m. The DON confirmed that there was no documented evidence that Resident 2's sacral wound was provided with treatment from readmission [DATE]), until November 14, 2025. In addition, the DON was not aware of the wound NP's November 17, 2025, inaccurate wound assessment/documentation; they reported that the facility has a new wound NP due to multiple concerns/issues with the previous wound NP. The facility failed to ensure Resident 1 and 2 wounds were accurately and comprehensively assessed, and treatments were timely followed.28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to complete an air mattress safety assessment to identify potential safety hazards for 11 of 65 residents reviewed (Residents 1, 5, 7, 10, 13, 14, 19, 111, and 143) and failed to ensure that each resident received assistance devices to prevent accidents during transport in a wheelchair for one of 65 residents reviewed (Resident 172).Findings Include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 16, 2025, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had diagnoses that included prostate (gland located below the bladder in men) cancer. Physician's orders for Resident 1, dated August 25, 2023, included an order for the resident's bed to be equipped with a low air loss mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 1's bed. Care plan for Resident 1 dated July 30, 2024, included that the resident was at risk for falls and staff were to provide a bariatric (medical treatment and management of obesity, or being significantly overweight to a degree that is dangerous to health) bed and a bariatric air mattress. Observations on August 23, 2025, at 11:52 a.m. revealed that Resident 1 was in bed with an air mattress in place. A quarterly MDS assessment for Resident 5, dated July 15, 2025, 2025, revealed that the resident was cognitively intact, required assistance with care needs, has an indwelling catheter and ostomy, stage 3 pressure ulcer (pressure wound that forms as a result of prolonged pressure involving the fat layers beneath the skin), and had a pressure relieving device on her bed. A care plan for the resident, dated July 2, 2025, included an intervention for the resident to have an air mattress. Physician's orders for Resident 5, dated July 11, 2025, included an order for the resident to have an air mattress (an inflated mattress for pressure relief) for skin integrity. Observations on August 23, 2025, at 12:14 p.m. revealed that Resident 5’s bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. A quarterly MDS assessment for Resident 7, dated June 20, 2025, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, had a stage two pressure ulcer (damage to the skin or underlying soft tissue), and received hospice services. Observations of Resident 7 on August 23, 2025, at 12:27 p.m. indicated the resident was laying in bed with an air mattress. Physician's orders for Resident 7, dated April 1, 2025, included an order to check the settings and function of the air mattress. Care plan for Resident 7 dated April 14, 2025, indicated that her family requested that the resident stay in bed at all times and was to have a pressure reduction mattress to the bed, Interview with the Nursing Home Administrator on June 17, 2025, at 4:03 p.m. confirmed that there were no specific assessments completed to ensure that the use of an air mattress was safe for Residents 7. A quarterly MDS assessment for Resident 10, dated June 12, 2025, indicated that the resident was moderately cognitively impaired and was at risk for developing pressure ulcers. Physician's orders for Resident 10, dated November 20, 2024, included an order for the resident's bed to be equipped with a low air loss mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 10's bed. Observations on August 23, 2025, at 10:40 a.m. revealed that Resident 10 was in bed with an air mattress in place. A quarterly MDS assessment for Resident 13, dated May 23, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had an arterial/venous ulcer and surgical wound and had a pressure relieving device for his bed. A care plan for the resident, dated July 21, 2025, included an intervention for the resident to have an air mattress. Observations on August 23, 2025, at 11:04 a.m. revealed that Resident 13’s bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. A quarterly MDS assessment for Resident 14, dated July 9, 2025, indicated that the resident was cognitively impaired, was incontinent of bowel and bladder, had limited range of motion to her lower extremities, had a pressure ulcer, and had diagnoses that included dementia. Physician's orders for Resident 14, dated August 19, 2025, included an order for the resident's bed to be equipped with an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 14's bed. Observations on August 26, 2025, at 2:27 p.m. revealed that Resident 14 was in bed with an air mattress in place. An annual MDS assessment for Resident 19, dated July 23, 2025, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had diagnoses that included diabetes. Care plan for Resident 19 dated August 11, 2025, included that the resident was admitted with a stage two sacral wound (a shallow, open wound on the skin over the bony part at the base of the spine) and was to have an air mattress on his bed. There was no documented evidence in Residents 19’s clinical record to indicate that an air mattress safety assessment was completed to determine if the resident would be safe while on the mattress. A quarterly MDS assessment for Resident 111, dated August 28, 2025, revealed that he was cognitively impaired and required extensive assistance from staff for care. A care plan for the resident, dated May 13, 2025, revealed that he was at risk for skin breakdown and that he had an air mattress. A comprehensive MDS assessment for Resident 111, dated June 4, 2025, revealed that the resident was cognitively impaired and required extensive assistance from staff for care. A care plan for the resident, dated June 2, 2025, revealed that the resident was at risk for skin breakdown and that she had an air mattress. There was no documented evidence in Residents 111’s, clinical record to indicate that an air mattress safety assessment was completed to determine if the resident would be safe while on the mattress. A quarterly MDS assessment for Resident 143, dated May 12, 2025, indicated that the resident was moderately cognitively impaired and was at risk for developing pressure ulcers. Physician's orders for Resident 143, dated October 31, 2024, included an order for the resident's bed to be equipped with an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 143's bed. Observations on August 26, 2025, at 9:23 a.m. revealed that Resident 143 was in bed with an air mattress in place. An interview with the Nursing Home Administrator August 25, 2025 at 4:03 p.m. confirmed that the facility did not do a bed safety assessment on the residents before they were placed on the air mattresses. A quarterly MDS assessment for Resident 172, dated June 12, 2025, revealed that the resident was cognitively impaired, required staff assistance for all daily care needs, and used a wheelchair for mobility. Observations on August 24, 2025 at 9:46 a.m. revealed that Licensed Practical Nurse E3 pushed resident 172 from the table in the dining room through the hall and to his room while his feet, which had non-skid socks on, were dragging on the floor. Interview with Licensed Practical Nurse E3 on August 24, 2025 at 9:50 a.m. revealed that she pushed the resident back to his room so that she could give him his medications. She stated that he is able to self propel and that is why he did not have leg rests on his chair. She further stated that she didn't think that he needed leg rests to be pushed even though his feet were dragging on the floor. Interview with Nursing Home Administrator on August 24, 2025 at 3:51 p.m. confirmed that Resident 172 should have had leg rests on his wheelchair while being transported if his feet were dragging. He said that they do not keep leg rests on the residents that can self propel. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for two of 65 residents reviewed (Residents 6, 30), and failed to address physician recommendations from an outside appointment for one of 65 residents reviewed (Resident 25).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 25, 2025, indicated that the resident was severely cognitively impaired, had no speech, could rarely understand, and was rarely understood, required assistance from staff for care needs, had diagnoses that included Type II diabetes (body does not use insulin effectively or does not produce enough insulin to control blood sugar levels), and was administered insulin (medication to lower blood sugar). A care plan dated April 23, 2025, for Resident 6 indicated that he was an insulin dependent diabetic, staff were to assess and record blood glucose, and levels and administer insulin as ordered. Physician's orders for Resident 6, dated June 11, 2025 , included an order for the resident to receive 2 units Insulin Lispro (a rapid-acting insulin) before meals and bedtime. Staff were to call the physician if the blood glucose was less than 70 milligrams per deciliter (mg/dl) or above 400 mg/dl. The dose was to be held if the blood glucose was less than 110 mg/dl, if the tube feed was off, or the resident was not eating. Physician's orders for Resident 6, dated August 11, 2025 , included an order for the resident to receive 2 units Insulin Lispro before meals. Staff were to call the physician if the blood glucose was less than 70 mg/dl or above 400 mg/dl. The insulin was to be held if the blood glucose was less than 110 mg/dl or if the resident was not eating. Review of the Medication Administration Record (MAR) for Resident 6, dated July and August 2025, revealed that on July 4, 2025, at 4:30 p.m. the resident had a blood sugar of 103 mg/dl and was administered 2 units of Lispro; on July 4, 2025, at 9:00 p.m. the resident had a blood sugar of 103 mg/dl and was administered 2 units of Lispro; on July 10, 2025, at 4:30 p.m. the resident had a blood sugar of 103 mg/dl and was administered 2 units of Lispro; on July 11, 2025, at 11:00 a.m. the resident had a blood sugar of 107 mg/dl and was administered 2 units of Lispro; on July 14, 2025, at 7:30 a.m. the resident had a blood sugar of 100 mg/dl and was administered 2 units of Lispro; on July 16, 2025, at 9:00 p.m. the resident had a blood sugar of 108 mg/dl and was administered 2 units of Lispro; on July 17, 2025, at 7:30 a.m. the resident had a blood sugar of 107 mg/dl and was administered 2 units of Lispro; on July 17, 2025, at 11:30 a.m. the resident had a blood sugar of 96 mg/dl and was administered 2 units of Lispro; on July 17, 2025, at 4:30 p.m. the resident had a blood sugar of 103 mg/dl and was administered 2 units of Lispro; on July 18, 2025, at 9:30 p.m. the resident had a blood sugar of 101 mg/dl and was administered 2 units of Lispro; on July 21, 2025, at 11:30 a.m. the resident had a blood sugar of 102 mg/dl and was administered 2 units of Lispro; on July 22, 2025, at 7:30 a.m. the resident had a blood sugar of 102 mg/dl and was administered 2 units of Lispro; on July 24, 2025, at 7:30 a.m. the resident had a blood sugar of 102 mg/dl and was administered 2 units of Lispro; on July 25, 2025, at 7:30 a.m. the resident had a blood sugar of 107 mg/dl and was administered 2 units of Lispro; on July 26, 2025, at 7:30 a.m. the resident had a blood sugar of 96 mg/dl and was administered 2 units of Lispro; on July 26, 2025, at 11:30 a.m. the resident had a blood sugar of 102 mg/dl and was administered 2 units of Lispro; on July 28, 2025, at 7:30 a.m. the resident had a blood sugar of 96 mg/dl and was administered 2 units of Lispro; on July 28, 2025, at 11:30 a.m. the resident had a blood sugar of 94 mg/dl and was administered 2 units of Lispro; on July 30, 2025, at 7:30 a.m. the resident had a blood sugar of 107 mg/dl and was administered 2 units of Lispro; on August 2, 2025, at 7:30 a.m. the resident had a blood sugar of 93 mg/dl and was administered 2 units of Lispro; on August 2, 2025, at 4:30 p.m. the resident had a blood sugar of 97 mg/dl and was administered 2 units of Lispro; on August 3, 2025, at 11:30 a.m. the resident had a blood sugar of 104 mg/dl and was administered 2 units of Lispro; on August 6, 2025, at 9:00 p.m. the resident had a blood sugar of 101 mg/dl and was administered 2 units of Lispro; on August 11, 2025, at 7:30 a.m. the resident had a blood sugar of 98 mg/dl and was administered 2 units of Lispro; on August 2, 2025, at 11:30 a.m. the resident had a blood sugar of 106 mg/dl and was administered 2 units of Lispro; on August 12, 2025, at 7:30 a.m. the resident had a blood sugar of 109 mg/dl and was administered 2 units of Lispro; on August 18, 2025, at 7:30 a.m. the resident had a blood sugar of 98 mg/dl and was administered 2 units of Lispro; on August 18, 2025, at 11:30 a.m. the resident had a blood sugar of 92 mg/dl and was administered 2 units of Lispro; on August 22, 2025, at 7:30 a.m. the resident had a blood sugar of 98 mg/dl and was administered 2 units of Lispro. Interview with the Director of Nursing on August 26, 2025, at 12:48 p.m. confirmed that Resident 6's insulin was not administered as physician ordered for the dates listed above. A facility policy related to consultations and appointments, dated March 12, 2025, indicated that upon return from a consultation, the nurse will review the consult documentation and ensure any new orders or recommendations are promptly communicated to the attending physician for approval and implementation. If no consult documentation is returned, the nurse will call the consulting physician to follow up. A significant change MDS assessment for Resident 25, dated June 2, 2025, revealed that the resident was cognitively intact, was independent with care needs, received radiation and had a diagnosis of prostate cancer. A consult note for Resident 25, from the radiation oncologist/urologist, dated July 22, 2025, revealed that the resident had moderate to severe dysuria (painful urination). A urinalysis (a test that examines a urine sample to detect and monitor various health conditions, including urinary tract infections) was done and showed evidence of an infection. A culture (a laboratory test that determines if bacteria or other microorganisms are present in a urine sample) was pending and the physician indicated that he would like the resident to start Bactrim double strength (DS) (an antibiotic) twice daily for 10 days and when the culture results come back, if it was resistant to Bactrim DS, he would change to antibiotic to one that shows sensitivity (identifies bacteria or yeast causing a urinary tract infection (UTI) and which drugs work best to treat the infection). A physician’s note for Resident 25, dated July 30, 2025, at 3:14 p.m. revealed that the resident endorsed dysuria and was seen for follow up status post urology recommendations. He indicated that the resident had a urine sample obtained from urology on July 22, 2025, and that urology prescribed Bactrim for 10 days. He indicated that the resident was to get his first dose the evening of July 30, 2025. There was no documented evidence that the facility obtained Resident 25’s radiology oncology/urology recommendations on July 22, 2025, for Bactrim DS related to a urinary tract infection. Interview with the Director of Nursing on August 25, 2025, at 11:48 a.m. confirmed that Resident 25’s consult note from July 22, 2025, was not sent to the facility until July 30, 2025. She indicated that typically there are no communication sheets sent back with the resident unless there are changes. She indicated that they must have forgotten to send the consult sheet indicating the recommendation for the antibiotic. She indicated that they did not consider the resident’s appointments with radiology/urology consult appointments as it was scheduled routinely for a time period of six weeks. She indicated that typically, for consult appointments, they would call the physician for updates if no communication was returned post appointment. The facility policy for administration procedures for all medications, dated March 12, 2025, indicated that medications will be administered in a safe and effective manner. Staff are to at a minimum, review the five rights of medication administration at each step of medication administration. Prior to removing the medication package/container from the cart/drawer, check for vital signs or other tests to be done during or prior to medication administration. When preparing to administer medication, staff are to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to the medication administration and notify the physician and/or prescriber of held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test result for vital signs resulting in medication being held. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30 , dated June 28, 2025, revealed that the resident was cognitively impaired, received scheduled pain medication, received an opioid (a controlled pain medication), and had diagnoses that included dysphagia following a cerebral infarction (difficulty swallowing after having a stroke). Physician's orders for Resident 30 dated July 15, 2025, included for the resident to receive 25 milligrams (mg) of metoprolol tartrate (used to treat high blood pressure) twice a day and to hold the medication if the resident's blood pressure (BP) was less than 130 over 80. Review of the Medication Administration Record (MAR) for Resident 30, dated August 2025, indicated that 25 mg of metoprolol tartrate was administered to the resident on August 1 at 5:00 p.m. when the resident's BP was 151/60, August 2 at 9:00 a.m. when the resident's BP was 142/70, August 2 at 5:00 p.m. when the resident's BP was 145/78, August 3 at 9:00 a.m. when the resident's BP was 145/61, August 4 at 9:00 a.m. when the resident's BP was 132/78, August 5 at 9:00 a.m. when the resident's BP was 119/66, August 5 at 5:00 p.m. when the resident's BP was 120/60, August 7 at 9:00 a.m. when the resident's BP was 133/74, August 8 at 9:00 a.m. when the resident's BP was 144/66, August 9 at 9:00 a.m. when the resident's BP was 136/69, August 9 at 5:00 p.m. when the resident's BP was 125/68, August 10 at 5:00 p.m. when the resident's BP was 126/74, August 11 at 9:00 a.m. when the resident's BP was 134/78, August 11 at 5:00 p.m. when the resident's BP was 131/64, August 12 at 5:00 p.m. when the resident’s BP was 131/64, August 13 at 9:00 a.m. when the resident’s BP was 147/64, August 113 at5:00 p.m. when the resident’s BP was 149/57, August 14 at 5:00 p.m. when the resident’s BP was 155/61, August 15 at 5:00 p.m. when the resident’s BP was 136/77, August 18 at 9:00 a.m. when the resident's BP was 122/66, August 19 at 5:00 p.m. when the resident's BP was 132/71, August 20 at 5:00 p.m. when the resident's BP was 126/77, August 21 at 5:00 p.m. when the resident's BP was 143/64, August 23 at 9:00 a.m. when the resident's BP was 128/78, and August 24 at 5:00 p.m. when the resident's BP was 124/70. Interview with the Director of Nursing June 4, 2025, at 12:48 p.m. confirmed that Resident 30 was administered metoprolol tartrate when it should have been held per physician's orders for a BP less than 130 over 80 on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 65 residents reviewed (Residents 13 and 144).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 23, 2025, revealed that the resident was cognitively intact, required assistance with care needs including bathing and toileting hygiene, had an indwelling catheter and was incontinent frequently of bowel. A care plan for Resident 13, dated April 21, 2025, indicated that the resident had a history of refusal of medications, showers and treatments.Physician's orders for Resident 13, dated June 9, 2025, revealed that the resident was scheduled to receive a shower on Wednesdays and Saturdays on the 3-11 shift.A review of the nurse aide bathing report and Treatment Administration Record (TAR) for Resident 13 from April 2025, through August 24, 2025, revealed that there was no documented evidence that the resident received a shower as scheduled and there was no documented evidence that the resident refused his showers, requiring a bed bath be given.Interview with the Director of Nursing on August 25, 2025, at 4:36 p.m. confirmed that there was no documented evidence that Resident 13 received and/or refused showers from April 2025, through August 24, 2025, as per the resident's schedule and physician's orders.A quarterly MDS assessment for Resident 144, dated August 10, 2025, revealed that the resident was admitted to the facility on February, 5, 2025, was cognitively intact, required assistance with care needs including bathing and toileting, was frequently incontinent of bowel and bladder, and had a diagnosis of cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain).An interview with Resident 144 on August 23, 2025, at 10:45 a.m. indicated that she had not received a shower since she was admitted to the facility. She indicated that she would like a shower but was never offered one.Physician's orders for Resident 144, dated April 1, 2025, revealed that the resident was scheduled to receive a shower on Wednesdays and Saturdays on the 7-3 shift with indications to document refusals.A review of the nurse aide bathing report and TAR for Resident 144 from February 2025, through August 24, 2025, revealed that there was no documented evidence that the resident received a shower as scheduled and there was no documented evidence that the resident refused her showers, requiring a bed bath be given.Interview with the Director of Nursing on August 25, 2025, at 4:36 p.m. confirmed that there was no documented evidence that Resident 144 received and/or refused showers from February 2025, through August 24, 2025, as per the resident's schedule and physician's orders.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 65 residents reviewed (Resident 5 and 30). Findings include: A facility policy regarding medication administration, dated March 12, 2025, indicated that after administering the medication, document administration on the Medication Administration Record (MAR) and the controlled substance sign out record, if necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 15, 2025, indicated that the resident was cognitively intact, required assistance with care needs, had pain and was taking an opioid medication (medications with the potential to be abused used to treat pain). Physician's orders for Resident 5, dated May 22, 2025, included an order for the resident to receive 5 milligrams (mg) of Oxycodone HCL (a narcotic pain medication) every four hours as needed for severe pain 7-10 on a pain scale for 14 days. Physician's orders for Resident 5, dated June 5, 2025, included an order for the resident to receive 5 mg of Oxycodone HCL every four hours as needed for severe pain 7-10 on a pain scale observe for respiratory depression, sedation and constipation. Physician's orders for Resident 5, dated July 11, 2025, included an order for the resident to receive 5 mg of Oxycodone HCL every six hours as needed for severe pain 7-10 on a pain scale. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 5, dated May 2025 through August 2025, revealed that a 5 mg tablet of Oxycodone HCL was signed out on May 16 at 3:10p.m., May 22 at 1:00 p.m., May 23 at 12:45 p.m., May 25 at 9:30 a.m., May 30 at 10:15 a.m., June 5 at 2:36 p.m., June 9 at 9:4- a.m., June 18 at 9:00 p.m., June 19 at 9:00 p.m., June 22 at 9:55 a.m., July 2 at 8:00 p.m., July 3 at 9:00 p.m., July 28 at 1:50 a.m., July 29 at 11:00 a.m., August 3 at 3:15 p.m., August 5 at 9:45 a.m., August 18 at 1:00 p.m. and 6:45 p.m., and August 24 at 7:03 p.m. However, there was no documented evidence in Resident 5's clinical record, including the MAR, that the signed-out doses of Oxycodone HCL were administered to the resident on the above-mentioned dates and times. Interview with the Assistant Director of Nursing on August 26, 2025, at 4:42 p.m. confirmed that there was no documented evidence in Resident 5’s clinical record to indicate that the signed-out doses of Oxycodone HCL were administered to the resident on the above-mentioned dates and times. The facility's policy regarding controlled substances, dated March 12, 2025, indicated that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications. Wasting of controlled medication is done in the presence of the nurse and a witness who also signs the disposition sheet. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30 , dated June 28, 2025, revealed that the resident was cognitively impaired, received scheduled pain medication, received an opioid (a controlled pain medication), and had diagnoses that included dysphagia following a cerebral infarction (difficulty swallowing after having a stroke). Physician's orders for Resident 30, dated June 27, 2025, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain. The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 30, both dated July and August 2025, revealed that a Fentanyl patch was applied to the resident on July 3, 6. 9, 10, 12, 15, 18, 21, 24, 27, and 30, and August 2, 5, and 8, 2025. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates. Interview with the Director of Nursing on August 26, 2025, at 4:13 p.m. revealed that she was not aware that removing and destroying a Fentanyl patch required two nurse signatures and that there were not two witness signatures for the destruction of Resident 30’s Fentanyl patches on the above mentioned dates. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 9 of 65 residents reviewed (Residents 2, 3, 32, 35, 87, 99, 119, 122, 200). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date, and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days. A comprehensive MDS assessment for Resident 2 revealed that the ARD was May 13, 2025. The MDS assessment was dated as completed on May 28, 2023, which was two days late.A comprehensive MDS assessment for Resident 3 revealed that the ARD was July 13, 2025. The MDS assessment was dated as completed on July 28, 2023, which was two days late.A comprehensive MDS assessment for Resident 32 revealed that the ARD was August 6, 2025. The MDS assessment was dated as completed on August 20, 2023, which was one day late.A comprehensive MDS assessment for Resident 35 revealed that the ARD was May 13, 2025. The MDS assessment was dated as completed on May 27, 2023, which was one day late.A comprehensive MDS assessment for Resident 87 revealed that the ARD was August 1, 2025. The MDS assessment was dated as completed on August 15, 2023, which was one day late.A comprehensive MDS assessment for Resident 99 revealed that the ARD was April 30, 2025. The MDS assessment was dated as completed on May 16, 2023, which was three days late.A comprehensive MDS assessment for Resident 119 revealed that the ARD was May 1, 2025. The MDS assessment was dated as completed on May 16, 2023, which was two days late.A comprehensive MDS assessment for Resident 122 revealed that the ARD was May 14, 2025. There was no MDS completed in the prior 366 days.A comprehensive MDS assessment for Resident 200 revealed that the ARD was May 2, 2025. The MDS assessment was dated as completed on May 16, 2023, which was one day late.Interview with the Registered Nurse Assessment Coordinator Consultant (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 26, 2025 at 3:44 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 65 residents reviewed (Residents 9, 10, 34, and 111).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0450D (antipsychotic medication review) was to be checked (1) yes, if a physician documented a GDR (gradual dose reduction-process involves slowly tapering a patient's medication to see if their symptoms can be managed with a lower dose or if the drug can be discontinued entirely) as clinically contraindicated. Physician's orders for Resident 9 dated May 21, 2025, included for the Resident to receive 0.5 milligrams (mg) of Risperdal (an antipsychotic medication) two times a day. Review of psychiatric consults for Resident 9 dated June 11, 2025, and July 16, 2025, indicated that a GDR was not indicated due to the resident having a chronic psychiatric illness and was stable on the current medication regimen. A quarterly MDS assessment for Resident 9 dated August 8, 2025, was coded 0 (no) for Section N0450D indicating that a physician did not document that a GDR of the resident’s antipsychotic medication was contraindicated. An interview with the regional Registered Nurse Assessment Coordinator on August 26, 2025, at 3:19 p.m. confirmed that there was documentation that a GDR was contraindicated for Resident 9, and her quarterly MDS assessments dated August 8, 2025, was coded incorrectly. Section N0415H was to be coded if the resident received an opioid (pain medication) medication during the seven-day assessment period and Section N0451K was to be coded if the resident received an anti-convulsant during the seven-day assessment period. Physician's orders for Resident 10, dated May 28, 2025, included orders for the resident to receive 50 mg Tramadol (opioid) at bedtime for pain management. Review of the resident's MAR for June 2025 revealed that the resident received Tramadol from June 1 through 30, 2025. However, a quarterly MDS assessment for Resident 10, dated June 12, 2025, revealed that Sections N0415H was not coded, indicating that the resident did not receive an opioid medication during the assessment period. Physician's orders for Resident 34, dated December 4, 2024 and October 6, 2023, included orders for the resident to receive 50 mg Tramadol twice a day for leg pain and 25 mg of Lamotrigine (anticonvulsant medication) twice a day for mood stabilization. Review of the resident's MAR for May 2025 revealed that the resident received Tramadol and Lamotrigine from May 1 through 31, 2025. However, a quarterly MDS assessment for Resident 34, dated May 16, 2025, revealed that Sections N0415H and N0415K were not coded, indicating that the resident did not receive an opioid or anticonvulsant medication during the assessment period. The RAI User's Manual, dated October 2024, revealed that if the pneumococcal (pneumonia) vaccine was not received, Section O0250C (pneumococcal vaccine) was to be coded with the reason the pneumonia vaccine was not received. The section was to be coded with a (1) if the resident was not in the facility; (2) if the received outside the facility; (3) if the resident was not eligible (medical contraindication); (4) offered and declined; (5) not offered; (6) inability to obtain influenza vaccine due to a declared shortage; and (9) none of the above. A quarterly MDS assessment for Resident 14, dated July 9, 2025 revealed that Section O0250C was coded with not offered. However, an influenza consent/declination form, dated September 25, 2024, revealed that Resident 14 was offered the influenza vaccine and declined. An interview with the Regional Registered Nurse Assessment Coordinator on August 26, 2025 at 3:19 p.m. confirmed that Resident 10, 14, 34, and 111's MDS assessments were coded incorrectly. The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, revealed that Section N was to be coded for medications received in the last seven days. Section N0415B was to be coded if the resident received an antianxiety medication in the previous seven days. Section N0451H was to be coded if the resident received an opioid (narcotic) medication in the previous seven days. Physician's orders for Resident 111, dated May 21, 2025, included an order for the resident to receive 0.5 milligrams (mg) Lorazepam (anti-anxiety medication) twice a day, and an order dated February 26, 2025 for the resident to receive 5 mg oxycodone (opioid) every six hours as needed for pain which was administered on June 1, 2025. A quarterly MDS assessment for Resident 111, dated June 4, 2025, revealed that Section N0415B was coded indicating that the resident had not received an anti-anxiety medication and Section N0415H was coded indicating that the resident had no received an opioid medication. An interview with the regional Registered Nurse Assessment Coordinator on August 26, 2025 at 3:19 p.m. confirmed that Resident 111's MDS was coded incorrectly. 28 Pa. Code 211.5(f) Medical records.

Based on review of policies, clinical records and investigative reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from any physical restraints not required to treat the resident's medical symptoms for two of 65 residents reviewed (Residents 111, 172). Findings include:The facility's policy on restraints, dated March 12, 2025, indicated that each resident would be free of restraints.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated June 4, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and utilized a wheelchair for mobility. The resident's care plan, dated June 2, 2022, revealed that the resident was at risk for falls and should be placed in a highly populated area to be monitored and not left alone in his room. A quarterly MDS for Resident 172, dated June 12, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and utilized a wheelchair for mobility. Observations on August 24, 2025, at 9:46 a.m. revealed that Licensed Practical Nurse E3 pushed Resident 172 in his wheelchair to a table in the dining room and then engaged the wheelchair brakes. Resident 111 was seated at the same table with her wheelchair brakes engaged. Residents 111 and 172 were observed at that time to be attempting to push away from the table or move away but were unable to do so because their chairs were locked in place. There was no programming going on at that time.Observations on August 24, 2025, at 10:51 a.m. revealed that Residents 111 and 172 were still seated at the table with their wheelchair locks engaged. Resident 111 was trying to push her chair away from the table. Resident 172 was attempting to pull the tablecloth and table and then push the table away. He was unable to push himself away from the table because his chair was locked in place.Interview with Licensed Practical Nurse E3 on August 24, 2025 at 9:50 a.m. revealed that staff lock residents' wheelchairs in place in the dining room because they are at risk for falling. She stated that the residents would try to get up from their chairs and fall if they were not locked in place.Interview with the Director of Nursing on August 24, 2025 at 1:09 p.m. revealed that she did not believe it was a restraint to put the residents at the table and lock their chairs, even though it restricted their movements, because they were at risk of falling. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.8(a) Use of restraints.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that encoding/transmitting Minimum Data Set assessments were completed within the required time frame for 5 of 65 residents reviewed (Residents 15, 77, 147, 199, 200). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for entry and death in facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the event date (A1600 for an entry record; A2000 for a Death in Facility tracking record)A discharge MDS assessment for Resident 15 had an ARD of May 4, 2025, but it was not completed (Section Z0500B) until May 19, 2025.An entry MDS assessment for Resident 77 had an ARD of June 1, 2025, but it was not completed (Section Z0500B) until June 25, 2025.A discharge MDS assessment for Resident 147 had an ARD of April 15, 2025, but it was not completed (Section Z0500B) until June 6, 2025.An entry MDS assessment for Resident 199 had an ARD of May 22, 2025, but it was not completed (Section Z0500B) until June 6, 2025.An entry MDS assessment for Resident 200 had an ARD of June 7, 2025, but it was not completed (Section Z0500B) until June 29, 2025.Interview with the Registered Nurse Assessment Coordinator Consultant (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 26, 2025 at 3:44 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 2 of 65 residents reviewed (Residents 25, 174). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 25 had an ARD of August 2, 2025, but it was not completed (Section Z0500B) until August 19, 2025.A quarterly MDS assessment for Resident 174 had an ARD of May 8, 2025, but it was not completed (Section Z0500B) until May 26, 2025.Interview with the Registered Nurse Assessment Coordinator Consultant (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 26, 2025 at 3:44 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 65 residents reviewed (Resident 13) who had an indwelling urinary catheter.Findings include:The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated March 12, 2025, revealed that catheter drainage bags were to be kept off the floor.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated July 9, 2025, revealed that the resident was cognitively impaired, incontinent of bladder, and had urinary tract infections.Physician's orders for Resident 11, dated August 19, 2025, included an order for the resident to have an indwelling urinary catheter due to a pressure ulcer.Observations of Resident 14 on August 26, 2025, at 2:27 p.m. revealed the resident was laying in bed and her catheter collection bag was in direct contact with the floor. Interview with Licensed Practical Nurse XX ([NAME]) at that time confirmed that the catheter bag should not be in contact with the floor.Interview with the Assistant Director of Nursing on August 26, 2025, at 4:38 p.m. confirmed that Resident 14's catheter bag should be off the floor.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 65 residents reviewed (Residents 5 and 13).Findings include:The facility's policy regarding care plans, dated March 12, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen based on relevant clinical data and decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in condition, when the desired outcome has not been met, when the resident has been readmitted from the hospital and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 15, 2025, and completed July 22, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had a stage three pressure ulcer (pressure wound involving the fat layers beneath the skin), and did not receive intravenous (administration of fluids and/or medications directly into a person's vein) medications. A care plan for the resident, dated May 29, 25, indicated that the resident had a stage three pressure ulcer. A care plan for the resident, dated June 16, 2025, indicated that the resident was on intravenous fluids for a fluid deficit. A care plan for the resident, dated June 19, 2025, indicated that the resident had a midline intravenous catheter (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications). A care plan for the resident, dated July 2, 2025, indicated that the resident had a stage three pressure ulcer. A care plan for the resident, dated July 14, 2025, indicated that the resident was taking oral vancomycin (an antibiotic) related to sepsis (the body's extreme response to infection) and that staff were to maintain contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment).Review of Resident 5's clinical record, including review of the resident's Medication Administration Record (MAR) and physician's orders, revealed no documented evidence that the resident had an active stage three pressure ulcer, was receiving intravenous fluids, had a midline intravenous catheter, was taking oral vancomycin and no documented evidence that the resident was on contact precautions.Interview with the Director of Nursing on August 24, 2025, at 1:07 p.m. confirmed that Resident 5's care plans should have been updated to reflect that the resident did not have an active stage three pressure ulcer, was no longer receiving intravenous fluids, did not have a midline intravenous catheter, was no longer taking oral vancomycin and was not actively on contact precautions.A quarterly MDS assessment for Resident 13, dated May 23, 2025, and completed on May 28, 2025, revealed that the resident was cognitively intact, required assistance with care needs, received an antibiotic and had a diagnosis that included hepatic encephalopathy (loss of brain function when the liver is unable to remove toxins from the blood). A care plan for the resident, dated May 19, 2025, indicated that the resident was receiving intravenous antibiotic medications related to sepsis and extended spectrum beta-lactamase (ESBL) infection (a resistant bacterial infection that can be spread through contact) and was on contact precautions.Review of Resident 13's clinical record, including review of the resident's Medication Administration Record (MAR) and physician's orders, revealed no documented evidence that the resident was receiving an intravenous antibiotic for sepsis/ESBL infection and there was no documented evidence that the resident was on contact precautions.Interview with the Director of Nursing on August 25, 2025, at 4:26 p.m. confirmed that Resident 13's care plans should have been updated to reflect that the resident was no longer receiving intravenous antibiotic for sepsis/ESBL infection and no longer required contact precautions.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 65 residents reviewed (Resident 13). Findings include:The facility's policy regarding care plans, dated March 12, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are chosen based on relevant clinical data and decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in condition, when the desired outcome has not been met, when the resident has been readmitted from the hospital and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 23, 2025, revealed that the resident was cognitively intact, required assistance with care needs, received an antibiotic and had a diagnosis that included hepatic encephalopathy (loss of brain function when the liver is unable to remove toxins from the blood).Physician's orders for Resident 13, dated June 10, 2025, included an order for the resident to receive 550 milligrams (mg) of Rifaximin (an antibiotic) twice daily for hepatic encephalopathy.There was no documented evidence that a care plan was developed to address Resident 13's hepatic encephalopathy and his need for long term antibiotic use for treatment of his hepatic encephalopathy.Interview with the Director of Nursing on August 25, 2025, at 4:26 p.m. confirmed that Resident 13 did not have a care plan to address his hepatic encephalopathy and his need for long term antibiotic use for treatment of his hepatic encephalopathy.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview it was determined the facility failed to monitor and provide interventions to prevent the worsening of a newly discovered pressure ulcer for one of 5 residents reviewed resulting in actual harm to Resident 67. Findings Include: Review of Resident 67's Braden Scale Assessment (Assessment used to determine a residents risk for developing a pressure ulcer) dated November 14, 2021, revealed the resdient was at risk for developing pressure ulcers. Review of Resident 67's care plan revealed a care plan initiated November 14, 2021, for at risk for pressure ulcer developement related to immobility. Review of Resident 67's head to toe skin assessment dated [DATE], revealed a new open area on the coccyx (small triangular bone at the base of the spine) measuring 2.5 centimeters (cm) long and 1.5 cm wide and an open area on the left buttock measuring 2 cm long and 1 cm wide. Further review of the clinical record revealed this is the first mention of the wound in the record. Review of Resident 67's progress notes revealed a nursing entry dated December 23, 2021, at 6:57 a.m. stating resident has small opening at sacrum. wound nurse evaluation needed. Resident was provided barrier cream during incontinence episode and repositioned this shift. Further review of Resident 67's progress notes revealed a nursing entry dated December 23, 2021, at 1:34 p.m. indicating resident will be evaluated by the medical doctor on Monday (December 27, 2021). Review of Resident 67's clinical record failed to reveal any documented evidence the resident was evaluated by the doctor for the wounds on the sacrum and buttock on December 27, 2021. Review of Resident 67's Wound Evaluation and Management Summary, dated December 28, 2021 revealed a necrotic (dead tissue) unstageable pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) to the sacrum measuring 5.2 cm long, 0.2 cm wide, and 0.1 cm deep with a moderate amount of serous exudate (liquid comprised largely of a watery fluid of electrolytes and sugars) and 70% slough (necrotic tissue that needs to be removed from the wound for healing to take place). The wound dressing treatment plan was a primary dressing of an alginate calcium (highly absorptive dressings made of soft, non-woven fibers derived from brown seaweed or kelp) and a secondary dressing of a gauze island with border (an absorptive dressing consisting of three layers: low adherent layer protects the wound surface, absorbent gauze layer absorbs exudate, and a non-woven adhesive tape holds the dressing in place). Review of Resident 67's Medication and Treatment Administration (MAR) record for December 2021 revealed the resident did not receive treatments when the wound was discovered on December 22, 2021 until December 30, 2021; when the new dressing recommended by the wound physician on December 28, 2021 was initiated. Interview with the Nursing Home Administrator and the Director of Nursing on September 1, 2022, at 1:15 p.m. revealed the facility has been under new management since June 1, 2022, and had no access to the previous owners policies and procedures. Further interview with the Nursing Home Administrator and the Director of Nursing confirmed there was a delay in providing appropriate documentation and wound care for the wound discovered on December 22, 2021, resulting in the wound deteriorating and a delay in the recommendations made by the wound nurse being put into place to promote healing of the wound resulting in actual harm to Resident 67. CFR 483.25 (b)(1) (i)(ii) previous cited on 7/27/21 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services Previously cited on 12/20/21; 7/30/21; 5/5/21; 1/19/21 and 09/09/20

Based on facility policy and procedure review, staff and resident interview, facility documentation review, and clinical record review it was determined the facility failed to ensure that one of 32 residents was free from neglect during care resulting in actual harm causing a skin tear requiring emergency room visit and suture repair. This deficiency is cited as past noncompliance. (Resident 134) Findings Include: Review of facility policy and procedure titled Abuse and Neglect, revised July 2017, revealed a definition of neglect as the failure of the facility, it's 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 Resident 134's care plan revealed a care plan for ADL (Activities of Daily Living- term used to collectively describe fundamental skills required to independently care for oneself) self-care performance deficit related to [CONDITION(S)] (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Interventions listed under section titled Focus, include patient is a stand lift for safety, initiated on June 11, 2017, and requires a Hoyer lift PRN (as needed) initiated on June 5, 2017. All interventions on the care plan have a revision date of June 2, 2022. Review of Resident 134's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated June 16, 2022, revealed Resident 134 required the extensive assistance of two staff members for transfers. Interview with Resident 134 on August 30, 2022, at approximately 9:30 a.m. revealed resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 134's Progress Notes revealed a nursing entry dated July 19, 2022, at 11:48 p.m. stating As CNA [nurse aide] was putting resident to bed, resident's right foot got caught under the bed and as a result resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 911 was called and [resident] was taken to the ER. Review of facility investigation into the injury revealed a witness statement from non licensed Employee E5 stating I was getting her ready for bed and I was transferring her from the wheelchair to bed and her foot slid under the bed and cut her leg open on the metal part underneath the bed. Further review of the witness statements revealed there was no other staff member with Resident 134 and nurse aide Employee E5 at the time of the fall. Subsequent interview with Resident 134 on September 2, 2022, at approximately 9:30 a.m. confirmed the resident was being transferred from the wheelchair without using a lift and only the assistance from non licensed, Employee E5. Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2022, at 10:30 a.m. confirmed Resident 134 was not transferred using the appropriate level of assistance resulting in actual harm to Resident 134. Further review of the facility investigation of the injury revealed the facility substantiated the allegation of neglect for not following the care plan interventions of a stand lift to be used when transferring Resident 134. The facility suspended Nursing Employee E5 until the conclusion of the investigation and re-educated nursing staff on finding the resident care information and resident transfer status. The facility also educated all their staff on this procedure and audited all resident who were mechanical lift transfers for care plan correctness. These interventions were completed on July 24, 2022, resulting in a past non-compliance situation of neglectful resulting in harm to Resident 134. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited on 12/20/21; 7/30/21; 5/5/21; 1/19/21 and 09/09/20 Based on facility policy and procedure review, staff and resident interview, facility documentation review, and clinical record review it was determined the facility failed to ensure that one of 32 residents was free from neglect during care resulting in actual harm causing a skin tear requiring emergency room visit and suture repair. This deficiency is cited as past noncompliance. (Resident 134) Findings Include: Review of facility policy and procedure titled Abuse and Neglect, revised July 2017, revealed a definition of neglect as the failure of the facility, it's 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 Resident 134's care plan revealed a care plan for ADL (Activities of Daily Living- term used to collectively describe fundamental skills required to independently care for oneself) self-care performance deficit related to [CONDITION(S)] (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Interventions listed under section titled Focus, include patient is a stand lift for safety, initiated on June 11, 2017, and requires a Hoyer lift PRN (as needed) initiated on June 5, 2017. All interventions on the care plan have a revision date of June 2, 2022. Review of Resident 134's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated June 16, 2022, revealed Resident 134 required the extensive assistance of two staff members for transfers. Interview with Resident 134 on August 30, 2022, at approximately 9:30 a.m. revealed resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 134's Progress Notes revealed a nursing entry dated July 19, 2022, at 11:48 p.m. stating As CNA [nurse aide] was putting resident to bed, resident's right foot got caught under the bed and as a result resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 911 was called and [resident] was taken to the ER. Review of facility investigation into the injury revealed a witness statement from non licensed Employee E5 stating I was getting her ready for bed and I was transferring her from the wheelchair to bed and her foot slid under the bed and cut her leg open on the metal part underneath the bed. Further review of the witness statements revealed there was no other staff member with Resident 134 and nurse aide Employee E5 at the time of the fall. Subsequent interview with Resident 134 on September 2, 2022, at approximately 9:30 a.m. confirmed the resident was being transferred from the wheelchair without using a lift and only the assistance from non licensed, Employee E5. Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2022, at 10:30 a.m. confirmed Resident 134 was not transferred using the appropriate level of assistance resulting in actual harm to Resident 134. Further review of the facility investigation of the injury revealed the facility substantiated the allegation of neglect for not following the care plan interventions of a stand lift to be used when transferring Resident 134. The facility suspended Nursing Employee E5 until the conclusion of the investigation and re-educated nursing staff on finding the resident care information and resident transfer status. The facility also educated all their staff on this procedure and audited all resident who were mechanical lift transfers for care plan correctness. These interventions were completed on July 24, 2022, resulting in a past non-compliance situation of neglectful resulting in harm to Resident 134. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited on 12/20/21; 7/30/21; 5/5/21; 1/19/21 and 09/09/20

Based on policy and clinical record review, interview, and observation, it was determined that the facility failed to timely identify a pressure ulcer for one of six residents reviewed (Resident 116) which resulted in actual harm to Resident 116 who developed an unstageable pressure ulcer to the left heel which caused the resident pain and required debridement. Findings include: Review of facility policy, Skin Management, last revised July 2017 revealed that the Braden Scale for Predicting Pressure Ulcer Risk should be completed quarterly. The policy also revealed that weekly skin checks will be completed in the resident's record. Interview with Resident 116 on July 27, 2021 at 9:54 a.m. revealed the resident had a wound on the left heel that was painful at times. Review of Resident 116's clinical record revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 116's care plan identified the resident as being at risk for pressure ulcers with an intervention added October 29, 2019, to complete a full body check weekly and document. Review of Resident 116's significant change Minimum Data Set (MDS - periodic assessment of resident care needs) dated June 25, 2021, revealed the resident required extensive assist of one staff person for bed mobility and personal hygiene and was totally dependent on one staff person for bathing. The MDS indicated that the resident was an extensive assist for two staff person transfers and toilet usage. The MDS further indicated that the resident was at risk for skin breakdown. The MDS assesment also indicated that the resident was frequently incontinent of urine and bowel. Review of Resident 116's weekly Head to Toe Skin check dated June 6, 2021, revealed the resident's skin was intact at the time of the assessment. Review of Resident 116's progress notes revealed a nursing note dated June 22, 2021, which stated, During shower, resident was found with unstageable [(full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound)] wound on the left heel that measures 5 cm (centimeters) x 4 cm. Review of Resident 116's assessments revealed there were no skin checks documented between June 6, 2021 and June 22, 2021, the day the unstageable wound on the left heel was discovered. Review of Resident 116's Braden Assessments revealed the last Braden Assessment documented prior to the development of the unstageable wound was conducted on July 2, 2020, and identified the resident as not being at risk for skin breakdown. Review of Resident 116's wound consult dated July 7, 2021, revealed that the wound was debrided (the removal of dead or infected skin tissue to help a wound heal) by the wound doctor. Following debridement, the wound was classified as a stage 3 pressure ulcer (full thickness skin loss exposing subcutaneous tissue) by the wound doctor on July 19, 2021. Review of Resident 116's progress notes revealed a restorative note dated July 3, 2021 indicating, resident has stated that [resident] is no longer interested in excercising or any restorative activites. Resident was receiving restorative programs to increase bed mobility and range of motion. Further review of Resident 116's progress notes revealed a physician (provider) note dated July 27, 2021 indicating, [resident] is encouraged to get OOB (out of bed) to chair, reports pain in L (left) heel, being managed by wound Dr. Observation of Resident 116's wound on July 30, 2021, at 10:12 a.m. with licensed nurse Employee E13 revealed the wound was now 1.8 cm x 1 cm x 0.1 cm. Employee E13 and the resident both stated that the wound was doing much better than it was before. Resident 116 again indicated that the wound caused pain at times. The facility's failure to do quarterly Braden assessments and weekly skin assessments on Resident 116, resulted in a delay in identifying an unstageable pressure ulcer to the resident's left heel. This facility deficient practice was discussed with the Nursing Home Administrator and Director of Nursing on July 30, 2021, at 1:42 p.m. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 1/19/2021, 11/22/2019, 10/16/2019, 8/2/2019 28 Pa. Code 201.18(b)(1)(3)(e)(1) ManagementPreviously cited 1/19/2021, 11/22/2019, 10/16/2019 28 Pa. Code 211.5(f) Clinical recordsPreviously cited 5/5/2021, 12/30/2019, 11/22/2019, 9/3/2019, 8/2/2019 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing servicesPreviously cited 5/5/2021, 1/19/2021, 9/9/2020, 6/1/2020, 12/30/2019, 11/22/2019, 10/16/2019, 9/3/2019, 8/2/2019

Based on review of the facility policy, clinical records, facility documentation, hospital records, resident and staff interviews, it was determined that the facility failed to follow a physician's order, administer medications per physician, thoroughly assess and notify the attending physician timely of a resident's change in condition, for four (Resident 112, 124, 134, and 137) of 30 residents reviewed. The failure to thoroughly assess and subsequently notify attending physician of the change in condition resulted in actual harm to Resident 134, requiring hospitalization in an Intensive Care Unit (specialized care unit within a hospital that provides extensive care treatment). Findings include: Review of Resident 134's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 134's physician's progress note dated June 30, 2021, revealed, Resident R134 was alert and oriented to time, person, and place, with a normal mood. The respiratory assessment revealed that the resident had no significant symptoms, denied cough, shortness of breath, wheezing, and orthopnea (Shortness of breath when lying flat). Review of Resident 134's nursing progress note dated July 5, 2021, at 5:11 p.m., revealed that Resident 134 was weaned off supplemental oxygen. pulse oximeter (measures the percentage of oxygen saturation) result was 94% on room air (normal Spo2 level is 95% and above. People with [CONDITION(S)]- 90 and above). Review of Resident 134's progress note dated July 6, 2021, at 5:59 p.m., revealed that [Resident 134] was being weaned off supplemental oxygen, Spo2 was 96%, no shortness of breath was observed. Review of Resident 134's physician orders dated June 29, 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 134's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 134's clinical record failed to reveal documentation regarding the reason the [MEDICATION(S)] puff was administered to the resident on July 17, 2021, at 10:15 p.m. Further review of the clinical record failed to reveal a thorough respiratory assessment was completed before and after the administration of the [MEDICATION(S)] puff. Review of Resident 134's clinical record failed to reveal notification to the physician regarding the resident's change in condition until the morning of July 18, 2021. Further review of Resident 134's nursing progress notes dated July 18, 2021, at 6:30 a.m., revealed Called to resident's room to assess acute change in mental status. Progress note indicated that Resident R134 was difficult to arouse, vital signs at 108/62, pulse rate 114, 90% Spo2 with four liters of supplemental oxygen. The resident was initially not responding to verbal stimuli, required physical stimulation, lethargic, crackles sound (A sound heard on the lung field that has fluid in the small airway) when lung was auscultated. Breathing was labored. MD was notified, ordered to transfer to the hospital. The resident was transferred out of the facility via 911. A review of the facility documentation titled, Supervisor's Report, revealed that at 6:30 a.m., resident had signs and symptoms of Shortness of breath, crackles, [CONDITION(S)] (low blood pressure), and [CONDITION(S)] (increased heart rate), hospitalized via 911. A review of the SBAR note (Situation, Background, Assessment, and Recommendation- A technique that can be used to facilitate prompt and appropriate communication with healthcare professionals), dated July 18, 2021, at 7:30 a.m., revealed that at 5:45 a.m., Resident R134's vital signs were: Blood pressure-108/62, pulse rate-114 BPM, Spo2-90% with oxygen via nasal cannula. A review of the same note revealed that the resident had shortness of breath and was non-responsive. The physician was notified of the condition at 5:50 a.m. Review of Resident 134's progress notes dated July 18, 2021, at 7:24 a.m., revealed that the facility called the hospital and to provide care instructions to the emergency room nurse. The facility was informed that the resident was being stabilized and was placed on a [CONDITION(S)] (Bilevel Positive Airway Pressure- A method of breathing support). Review of Resident 134's hospital records, revealed an Emergency Medicine Note, dated July 18, 2021, at 7:57 a.m., indicating, [Resident R134] presented to emergency room (ER) with a change in mental status and respiratory issues. The emergency medicine note further revealed, that from the history obtained from the nursing staff from the facility, for two days, [Resident 134] had not been [herself/himself]. The resident had decreased oral intake, sleeping most of the time, and not responding much other than moaning to painful stimuli. The same note revealed that as per the facility staff, [Resident 134] was observed: 'over the last day or so, the patient had increased difficulty breathing with BP (blood pressure) trending down'. The resident does not wear oxygen at baseline and was on four liters with 90% Spo2 at the facility. The resident was noted today with gurgling noises to the left lung and called 911 to bring the patient in. the patient was a full a code. In the ER (emergency room ), the patient was afebrile, in [CONDITION(S)] (Increased pulse rate), mild tachypneic with Spo2 of 90% on six liters (oxygen), and BP of 107/61. The patient is minimally responsive, intermittently moans to painful stimuli, opens eyes but otherwise follows no command. Continued review of hospital records including document titled Clinical Impressions which revealed the following: Hypoxic respiratory failure (Means not having enough oxygen in the blood but levels of [MEDICATION(S)] are close to normal) on high flow, [CONDITION(S)] (a life-threatening condition, infection in the bloodstream), and Acute Renal Failure (A condition in which the kidneys suddenly can't filter waste from the blood). Further review of hospital records, CXR (chest x-ray) did on July 18, 2021, revealed right greater than left basilar consolidations are nonspecific and may reflect subsegmental atelectasis (Loss of small lung volume). Evolving Pneumonia (Infection in the lung) is not excluded, and clinical correlation is advised. Additional review of hospital records including Assessment and Plan, dated July 18, 2021, revealed Acute Metabolic [CONDITION(S)] (A condition in which the brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Severe [CONDITION(S)]-possibly Pneumonia, Acute Respiratory Failure with [CONDITION(S)]. Plan of care includes ICU (Intensive Care Unit) level of care, a broad-spectrum antibiotic to cover pneumonia. An interview with the Director of Nursing (DON) was conducted on July 30, 2021, at 11:00 a.m. The DON confirmed that there was no documented evidence that Resident 134's respiratory condition was thoroughly assessed before and after administration of the medication ([MEDICATION(S)]) ordered to be given as needed for wheezing episodes. The DON also confirmed that there was no documented evidence that the physician was notified of the resident's change in condition nor when the administered PRN [MEDICATION(S)] (on July 17, 2021, at 10: 15 p.m.) was ineffective. The facility failed to thoroughly assess Resident 134's change in condition and timely notify the physician which resulted in actual harm of resident of hospital admission with care and treatment required within an intensive care unit. Review of Resdient 112's bowel record for the month of April 2021 revealed the resident had no documented bowel movement from the 3 p.m.-11 p.m. on April 1, 2021 until the 7 a.m.- 3 p.m. shift on April 10, 2021. Review of Resident 112's physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 112's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing and Nursing Home Administrator on July 30, 2021 at 12:30 p.m. confirmed the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 124's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 124's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated June 27, 2021, revealed that the resident was cognitively intact. A review of Resident 124's Physician's order dated June 21, 2021, revealed an order to check blood sugar before breakfast one time a day every Monday, Wednesday, and Friday for blood sugar monitoring. A review of Resident 124's June and July 2021, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the same MARs revealed no documentation of the result of the blood sugars taken. An interview with Resident 124 on June 30, 2021, at 9:15 a.m., confirmed that her/his blood sugar was only monitored two times a week. An interview with the Director of Nursing on June 30, 2021, at 1:00 p.m., confirmed that the blood sugar monitoring order for Resident 124 was not followed. The facility failed to follow the physician's order to check Resident 124's blood sugar three times a week. Review of the facility's policy labeled Weight Management System, July 2017, states weigh residents on admission then weekly for three weeks then monthly or with the physician order. Monthly weights are reviewed and reweights requested. Residents with a weight variance are reweighed within 48 hours. Determine residents with significant weight change or weight loss. Notify the Physician, Resident and Resident Representative. Review of Resident 137's clinical record revealed weights taken on February 2, 2021 of 267.2 pounds and again on March 4, 2021, of 293.4 pounds a weight gain of 26.2 pounds. Further review of the clinical record revealed a reweight on March 5, 2021 of 293.0 pounds, verifying a weight gain of 26 pounds. A nursing noted dated March 9, 2021 states that the physician was notified of bilateral (both sides) lower leg with pitting [CONDITION(S)] (swelling caused by excess fluid. When swollen skin remains indented after being pressed, this is called pitting [CONDITION(S)]), pain/warm to touch, small blisters noted on the lower extremity, no signs of infection at this time. Review of Resident 137's clinical record failed to reveal documentation of physician notification regarding the 26 pound weight gain. An interview conducted with the Nursing Home Administrator and the Director of Nursing on July 30, 2021 at 1:00 p.m. confirmed that the physician was not notified of the 26-pound weight gain. 28 Pa. Code 201.18(b)(1) Management Previously cited 1/19/21, 11/22/19 28 Pa. Code 211.5(f) Clinical records Previously cited 5/5/21, 12/30/19, 11/22,19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/5/21, 1/19/21, 9/9/21, 6/1/20, 12/30/19, 11/22/19 28 Pa. Code 211.12(c)(d)(3)Nursing services

Based on observation, resident and staff interview, and clinical records review, it was determined that the facility failed to administer physician ordered routine pain medication for one (Resident 354) of six residents reviewed. The failure to administer routine pain medications (12:00 a.m., and 6:00 a.m.) resulted in actual harm in Resident 354 who experienced a generalized severe body pain of 10/10. Findings include: Review of Resident 354's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 354's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care), dated July 23, 2021, revealed that the resident was cognitively intact with no documented behavior. The same MDS revealed that the resident required extensive two-person assistance with bed mobility. Review of Resident 354's clinical record revealed, the resident was admitted to the facility on [DATE], from the hospital after surgery of the left femur fracture sustained in a fall at home. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 28, 2021, at 10:30 a.m., Resident 354 was observed sitting in a wheelchair touching her/his left leg. An interview with Resident 354 was conducted, she/he stated, I was in so much pain last night and woke up this morning in much more pain. The resident indicated, Last night at around midnight, the nurse told me that I don't have medications because there was no prescription for my [MEDICATION(S)]. The resident also stated, The nurse told me that there's no reason to call the physician because he was sleeping. The resident informed the nurse that her pain level was 8/10. The nurse administered a PRN (as ordered) Acetaminophen 325 mg two tablets ordered for a pain level of 3-4 to Resident 354 despite having a complaint of an 8/10 pain level. The resident stated that she was so tired that she ended up falling asleep with a pain level of 6/10 after taking the Acetaminophen. Further in the interview, the resident continued, I woke up at around 8:00 a.m. with severe pain all over my body, every nerve was painful, I was crying. When asked what the pain level was from 1-10, the resident answered, It was 10. Further interview with the resident revealed that she/he did not get her/his [MEDICATION(S)] because she/he was asleep but found a a white pill on top of the wheelchair cushion and an empty medicine cup on the floor. The resident was unsure how the pill ended up in her/his wheelchair but thought that the nurse might have left the medicine in a cup on the bedside table and accidentally fell while she was asleep. The resident stated, The doctor came and saw me crying. As per the resident, she/he informed the physician that she/he did not get her/his pain medication ([MEDICATION(S)]) because it did not have prescription. Resident 354 then reported, the doctor informed resident that the nurse was mistaken and that she/he should have received her pain medication at midnight. A nurse came after the doctor left and administered [MEDICATION(S)] to the resident. An interview with Employee E6 on July 28, 2021, at 11:00 a.m., confirmed, a white pill was found in the resident's room and was given to the physician. Employee E6 indicated the white pill was identified as a [MEDICATION(S)] 7.5/325 mg tablet. The employee stated, the physician told her/him to administer PRN [MEDICATION(S)] to Resident 354. Review of July 2021, MAR (Medication Administration Record) revealed that a PRN [MEDICATION(S)] was administered to Resident 354 on July 18, 2021, at 8:20 a.m. Review of the facility's documentation, the physician's statement, dated July 28, 2021, revealed that a white pill was given to the physician by Resident 354. The pill was identified and confirmed as [MEDICATION(S)] 7.5/325 mg by the physician based on the number on the pill and comparison from the other [MEDICATION(S)] 7.5/325 mg and medication book. An interview with licensed nurse Employee E4 on July 30, 2021, at 10:00 a.m., confirmed that she/he was the night nurse of Resident 354 on July 27, 2021. Employee E4 stated that Resident 354's [MEDICATION(S)] scheduled for 12:00 a.m., was not available, the nursing supervisor was made aware and Employee E4 was informed that the prescription was already faxed to the pharmacy. Employee E4 stated that she/ he called the pharmacy and the physician but did not get an answer. Employee E4 administered PRN Acetaminophen 325 mg two tablets. Employee E4 stated that the [MEDICATION(S)] was delivered afterward (unsure of the time) and was given to the resident at 6:30 a.m. Employee E4 narrated that the resident was asleep but was woken up for the medication administration. The resident sat at the edge of the bed and said, Why are you watching me? Employee E4 stated that she walked out of the resident's room without checking if the pain medication was swallowed by the resident. The employee also confirmed that she/he did not come back to the resident's room after giving the medication. An interview with Resident 354 on July 30, 2021, at 10:15 a.m., revealed that she/he did not wake up at 6:30 a.m., the resident confirmed that she/he woke up at 8:00 a.m. on July 28, 2021. A review of the facility documentation, physician statement, and pharmacy statement revealed, the facility contacted the physician on July 26, 2021, at 2:20 p.m. requesting a refill of the [MEDICATION(S)], an E-script (digital version of a prescription) was sent to the pharmacy. The E-scripts were received by the pharmacy and the medication was sent on midnight route and was delivered to the facility approximately 3:15 a.m., on July 28, 2021. An interview with licensed nurse Employee E5, in the presence of the Assistant Director of Nursing (ADON), was conducted on July 30, 2021, at 10:20 a.m. Employee E5 stated that the controlled medication is reordered electronically. A follow-up call from the pharmacy is done if the medication reordered was not delivered at the expected time. The above information was conveyed to the Director of Nursing on July 30, 2021, at 11:00 a.m. The facility failed to administer Resident 354's scheduled pain medication which resulted in actual harm, by experiencing severe generalized body pain. 28 Pa. Code 201.18(b)(1) Management Previously cited 1/19/21, 11/22/19 28 Pa. Code 211.5(f) Clinical records Previously cited 5/5/21, 12/30/19, 11/22,19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/5/21, 1/19/21, 9/9/21, 6/1/20, 12/30/19, 11/22/19 28 Pa. Code 211.12(c)(d)(3)Nursing service

Based on review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to provide supervision to Resident R1 and to ensure the proper function of the resident's wander guard devices which resulted in actual harm to Resident R1 who eloped form the facility, sustained a fall and a sinus fracture. The facility failed to ensure that Resident R3 was free of accidents during transportation via wheelchair which resulted in Resident R3 falling from the wheelchair requiring transfer to the hospital via Emergency Medical Services and [DIAGNOSES REDACTED]. (Resident R1 and Resident R3) Findings include: Review of facility policy, Elopement Management, revised (MONTH) (YEAR) revealed that upon admission and readmission, residents will be assessed for elopement risk. Residents assessed on admission with risk for elopement will have interventions implemented to promote safety and preventative measures implemented to mitigate elopement risk. If a signaling device is determined to be an appropriate safety device, the facility is to check placement and function of the signaling device routinely. The Maintenance Director or designee will complete preventive maintenance. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on (MONTH) 13, (YEAR). An elopement risk assessment completed (MONTH) 14, (YEAR), revealed a score of 12, indicating that the resident was at risk for elopement. Review of physician's orders [REDACTED]. Review of Resident R1's admission MDS assessment (periodic assessment of resident needs) dated (MONTH) 20, (YEAR), included [DIAGNOSES REDACTED]. The assessment also indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment and exhibited wandering behaviors on one to three days of the seven day look-back period. Review of physical therapy evaluation and plan of treatment completed (MONTH) 9, 2019, indicated that the resident was able to ambulate 510 feet during a six minute walk test and that the resident presents with good activity tolerance, with minimal balance deficits, she is at her baseline from her last discharge. As her functional test scores indicates minimal risk of falls she doesn't require skilled physical therapy services at this time. Review of Resident R1's quarterly MDS assessment dated (MONTH) 22, 2019, revealed a BIMS score of 12, indicating moderate cognitive impairment, and no wandering. The assessment indicated that the resident required supervision for walking in the resident's room, corridor, and on the unit. Balance during walking was not steady, but able to stabilize without human assistance. Review of Resident R1's nursing progress note of (MONTH) 2, 2019, revealed resident left the unit around 1820 (6:20 p.m). Was informed by staff she had left the unit via an unidentified elevator. Began search of the entire building with all available staff. Was then informed by our Director of Nursing (DON) that she had been located out side and was being transported by ambulance to a local hospital. Additional progress note of (MONTH) 2, 2019, indicated that the DON was notified at 6:45 p.m. that the resident may be out of the building. The DON then received a phone call that the resident was on the ground outside the building. The resident had sustained a hematoma to her forehead from the fall. The resident had a wander guard on the right upper extremity which was removed and tested by the DON upon returning to the building. The wander guard was functioning and the alarm sounded. Review of hospital emergency department (ED) note of (MONTH) 2, 2019, revealed resident was brought in by Emergency Medical Services (EMS) for head injury and fall. Patient wandered away from the dining hall today at the nursing home, tripped, hit her head on concrete as well as sustained some abrasions to her right palm. The Hospital Emergency Department discharge note of (MONTH) 2, 2019, revealed minor nondisplaced sinus fracture, will treat with [MEDICATION NAME] C (antibiotic) and follow up with ear nose and throat discharged home with antibiotics. Review of physician's consult of (MONTH) 5, 2019, revealed minor left frontal sinus fracture and recommended observation, [MEDICATION NAME] orally (antibiotic) and to avoid trauma/pressure to forehead for two weeks. Review of Resident R1's (MONTH) 2019 Treatment Administration Record (TAR) revealed no documentation that the wander guard had been checked for function from (MONTH) 1-4, 2019. Review of facility documentation revealed that another resident had observed Resident R1 getting on the elevator on 2 Main. The other resident called the receptionist to alert her that Resident R1 was on the elevator. An elopement drill was initiated. The DON was notified that Resident R1 was found outside the building on the ground. The resident had sustained a hematoma to the forehead and 911 (Emergency Medical Services) had been called. Interview with Resident R2 on (MONTH) 9, 2019, at 10:55 a.m. indicated that she was playing cards in the aviary by the elevator on 2 Main nursing unit. Resident R2 heard Resident R1 state she was going home and saw Resident R1 get on the elevator. Resident R2 stated that no alarm sounded at that time. Resident R2 called the receptionist on the ground floor to alert her that Resident R1 was on the elevator. The receptionist indicated that Resident R1 was not there. Resident R2 stated that the phone call was made at 6:41 p.m. Interview with the Nursing Home Administrator (NHA) on (MONTH) 9, 2019, at 11:05 a.m. revealed that the elevator by the receptionist desk does not have a wander guard alarm, however, there is an alarm on the door to the outside. The alarm did not sound on the door when Resident R1 exited. The NHA revealed that the resident exited the front door, went down the driveway, and up the sidewalk towards the business office building where she was found. Interview with facility business staff, Employee E3 on (MONTH) 9, 2019, at 11:35 a.m. revealed that he was leaving the business office building around 6:45 p.m. when he saw a resident on the ground. Employee E3 indicated that bystanders had stopped to assist the resident and he checked her name band. Employee E3 called the receptionist to alert her and the DON arrived on scene. Interview with maintence staff, Employee E4 on (MONTH) 9, 2019, at 11:55 a.m. revealed that residents from 2 Main can access the elevators even if wearing a wanderguard. Employee E4 indicated that all exits to outside have wanderguard alarms, including the lobby entrance. The sensitivity on all alarms was increased to better detect residents wearing wander guards. Interview with the DON on (MONTH) 9, 2019, at 12:10 p.m. revealed that the elopement drill worked in this situation, but the equipment was deficient. All staff were re-inserviced on elopements after the incident. Interview with Physical Therapy Director, Employee E8 on (MONTH) 10, 2019, at 10:35 a.m. revealed that Resident R1 had been reassessed on (MONTH) 9, 2019, and it was determined that resident could ambulate independently and was able to ambulate 500 feet without difficulty. Therapy Director estimated that Resident R1 had ambulated approximately 400 from the front door to the location of the fall. The facility failed to supervised Resident R1 and failed to ensure proper function of the resident's wander guard device which resulted in actual harm to Resident R1 who eloped form the facility, sustained a fall, required transfer to the hospital via Emergency Medical Services and [DIAGNOSES REDACTED]. Review of Resident R3's annual MDS assessment dated (MONTH) 12, 2019, revealed a BIMS score of 15, indicating that the resident was cognitively intact. The assessment also indicated that the resident required extensive assistance of one person for locomotion on the unit and used a wheelchair for mobility. Review of progress note of (MONTH) 2, 2019, revealed that at approximately 5:45 p.m. Resident R3 had fallen from the wheelchair in the dining room. Resident was able to state that she was being wheeled into the dining room for dinner when she fell forward out of the wheelchair. Resident R3 was assessed with [REDACTED]. Emergency Medical Services (911) was called. Review of progress note of (MONTH) 3, 2019, revealed that the resident was admitted to the hospital with [REDACTED]. Review of hospital after visit summary dated (MONTH) 8, 2019, revealed [DIAGNOSES REDACTED]. Review of written statement of licensed staff Employee E6 obtained on (MONTH) 2, 2019, revealed that Resident R3 stated she was being wheeled into the dining room by Employee E7 (nursing assistant) and she was pushing her too fast. Review of facility submitted information indicated that Resident R3 asked Employee E7 to slow down, but Employee E7 continued to push Resident R3 to the dining room table, at which time Employee E7 stopped abruptly and the resident fell forward out of her chair. Interview with the Physical Therapy Director on (MONTH) 10, 2019, at 10:40 a.m. revealed that Resident R3 required a bariatric wheelchair and was in the appropriate wheelchair at the time of the incident. Interview with the DON on (MONTH) 10, 2019, at 9:15 a.m. revealed that the resident was not interviewed because she was sent directly to the hospital. Additional interview at 1:45 p.m. revealed that the facility determined that non licensed staff, Employee E7 was responsible for the accident and terminated Employee E7. The facility failed to ensure that Resident R3 was free of accidents during transportation via wheelchair which resulted in Resident R2 falling from the wheelchair and requiring transfer to the hospital via Emergency Medical Services. Resident R3 sustained a cervical fractured as a result of the fall requiring surgery. 483.25(d)(2) Free of Accident Hazards/supervision/devices Previously cited 10/5/18 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 10/5/18 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 211.10(d) Resident care policies Previously cited 10/5/18 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 10/5/18

Based on a review of facility policy and procedure, observations, clinical record review, and staff interview it was determined that the facility failed to assure that residents at risk for the development of pressure ulcers were monitored for skin breakdown, and failed to assure that all interventions ordered were implemented to prevent skin breakdown for three out of 30 residents, resulting in actual harm to two residents (Residents G10; Q5 and Q7). Findings include: Review of the facility policy and procedure for wound identification (not dated), indicated that the staff were to identify the suspected stage of the wound, and describe the wound noting measurements, length, depth, drainage, odor, color of wound bed and surrounding tissue. This policy further documented that staff are to do weekly skin checks and document them on the weekly skin sheets as well as write a detailed progress note. Review of the facility policy and procedure for skin checks (not dated), indicated that skin checks would be preformed weekly according to shower/bath schedules. The policy further stated that the nurse will measure and stage any wounds found and that a detailed nursing note must be completed for each skin check noting any wounds, Documentation must also be completed on the weekly skin check sheets. Review of Resident G10 ' s face sheet revealed an admitted [DATE]. Review of Resident G10's of admission Minimum Data Set Assessment (MDS- assessment of resident care needs and status) revealed that the resident had no pressure ulcer. Review of the admission Braden scale dated May 17, 2013 revealed a score of 18 indicating the resident was at risk for pressure sore development. Review of facility's documentation dated July 4 and July 10, 2013 revealed that licensed nurse, Employee E14 indicated that they were notified by a CNA (certified Nursing Assistant) Employee E15 that the resident had a wound on the left heel but the licensed nurse only assessed the the outer aspect of the resident's heel which had a skin tear and did not assess the inner aspect of the resident's ankle on July 4, 2013. The facility at the time (July 4, 2013) obtained an order for [REDACTED]. dated July 4, 2013 revealed an order to cleanse left heel skin tear with normal saline apply oil [MEDICATION NAME] 4x4 and kling (dressing) change daily. Review of Resident G10's weekly skin documentation dated July 8, 2013 related the resident had an unstageable left heel wound (full thickness tissue loss covered where the base of the wound is covered by slough and or eschar (tan brown or black dead tissue in the wound) The July 10, 2013 wound assessment listed a deep tissue injury of the left heel ( a pressure related injury to the subcutaneous tissue under intact skin, purple in color) measuring 4 cm (centimeter) x 3.5 cm x 0.1 cm deep and had a small amount of sanguineous (bloody) drainage. The peri-wound ( area surrounding the wound) was described as indurated (hardened or thickened tissue). Dietary consult was completed on July 11, 2013 recommended for arganaid 1 packet two times a day , pro applesauce at breakfast and pro-pudding at lunch. Review of Resident G10's wound assessment documentation dated July 18, 2013 revealed that the wound was unstageable covered with 100% eschar (dead tissue). Review of wound documentation dated October 23, 2013 revealed that the wound was a stage 3 measured 1.2 centimeters length x 2 centimeters width and 0.5 centimeters depth with 30 % slough(dead tissue and 70 % granulation. Observation of Resident G10's wound with licensed nursing Employee E 16 and interview immediately after the observation on October 25, 2013 at 1:55 p.m. with nursing Employee E16 indicated that the wound still had some slough (dead tissue) and some depth to it. The facility failed to timely identify ensure accurate assessment and ensure timely care services resulting in actual harm to Resident G10 with the development of a pressure ulcer. A review of Resident Q5's June 2013 physician orders indicated that the resident had [DIAGNOSES REDACTED]. Further review of the June 2013 physician orders indicated that the resident had physician orders to have skin checks performed twice a week. Review of a Braden assessment ( assessment that identifies a residents risk for skin breakdown) completed on June 25, 2013 indicated that the resident was at high risk for skin breakdown. A review of Resident Q5's July 2013 physician orders indicated an order dated June 26, 2013 that the resident was to have a prevalon boot (fabric boot that covers the foot and heel to prevent skin breakdown) to the left foot to relieve pressure. A nursing note dated July 5, 2013 indicated that the resident's son was called regarding the development of an ulcer to the left heel, but gave no detailed description of the wound. Interview with Employee E5, a licensed nurse, on October 29, 2013 at 1:20 p.m. confirmed that there were no available nursing notes or skin checks for this resident during the months of June and July 2013. Licensed nurse, Employee E5 further confirmed that there was no nursing note documenting the initial wound. However, Employee E5, reported that the wound measurements were documented on a separate facility investigation report. Review of a facility investigation report dated July 4, 2013 indicated that while at therapy the Therapist noted that Resident Q5 had skin breakdown to the left heel and that the area that was dark and contained a fluid filled blister that measured 2 centimeters by 3 centimeters. Then July 4, 2013 incident report further documented that Prevalon boots were again ordered and placed on the resident. Interview with Employee E5, a licensed nurse on October 29, 2013 at 2:00 p.m. indicated that the the employee could not account for why Prevalon boots were again ordered July 4, 2014 for Resident Q5, when the boots where already ordered June 26,2013 and should have been in place. Review of Resident Q5's the Wound Roster dated October 17, 2013 indicated that the wound was measured at that time to be 1.9 length by 1 centimeter width and .3 centimeter depth and is classified as a Stage III ulcer (a skin ulcer that becomes crater like in nature and involves damage to the underlying tissue of the skin). Observation of Resident Q5's wound on October 29, 2013 at 2:20 p.m. indicated that the area was noted to be clean with minimal serous drainage but that it looked to measure about 1.5 centimeters in length by 1 centimeter in width with an approximate depth of .5 centimeters. The facilities failure to assure that Resident Q5's skin checks were completed as ordered, and that the Prevelon boot was in place as ordered caused actual harm to Resident Q5 in the form of a Stage III pressure ulcer to the residents left heel. Review of Resident Q7's annual assessment, dated March 31, 2013, revealed [DIAGNOSES REDACTED]. The annual assessment also indicated that the resident was extensive assist of two staff for bed mobility and transfer, and an extensive assist of one staff for dressing, eating, hygiene and bathing. Review of the resident's care plan at this time revealed skin impairment interventions which included skin checks twice a week. Review of the resident's May 2013 nursing assessment revealed a Braden (tool used to determine risk factors for pressure sore development) score of 17 which indicates the resident was not at risk. However, a review of podiatry notes from April 23, 2013 through June 25, 2013 revealed that the resident had signs of [MEDICAL CONDITION] (narrowing of the arteries in the legs, limiting blood flow) and/or peripheral venous disease (blockage of the veins from the feet which carry blood to the heart) leading to arterial and/or [MEDICAL CONDITION] ([MEDICAL CONDITION] which is a slow and progressive circulation disorder) to the feet therefore placing the patient at medical risk of a poor outcome. Interview with licensed nurse Employee E12 on October 28, 2013 at approximately 1:30 p.m. confirmed that there was a breakdown in communication from the podiatrist which is why the [DIAGNOSES REDACTED]. Review of Resident Q7's June 2013 physician orders revealed the same [DIAGNOSES REDACTED]. Further review of the physician orders revealed an order for [REDACTED]. Interview with licensed nurse, Employee E5 on October 28, 2013 at approximately 11:30 a.m. revealed that Employee E5 could not explain why there was no evidence of skin checks on June 11 and 18, 2013 for Resident Q7. There was no evidence that skin checks were completed according to the care plan interventions or according to the physician orders. Review of a podiatry note, signed on June 25, 2013 at 5:27 p.m., for an examination completed on that date, revealed a wound description for the left great toe for a deep tissue injury which measured 1.7 centimeters length and 0.8 centimeters width. Review of the nursing note for June 26, 2013 revealed the discovery of an unstageable wound to the resident's left great toe. Review of the wound care flow sheet for June 26, 2013 revealed an unstageable wound to the left great toe which measured 1.7 centimeters length and 0.8 centimeters width with 100% eschar (dead tissue, black in color, in the wound bed). The facility failed to complete skin checks as ordered and care planned. 28 Pa. Code: 201.18(b)(1) Management Previously cited 11/14/2012; 10/21/2011 28 Pa. Code: 201.18(e)(1) Management Previously cited 11/14/2012; 10/21/2011 28 Pa. Code: 211.5(f) Clinical records Previously cited 11/14/2012; 10/21/2011 28 Pa. Code: 211.10(c) Resident care policies Previously cited 11/14/2012; 10/21/2011 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 11/14/2012; 10/21/2011

Based on review of the facility policies/procedures, review of clinical records, observations and interviews with staff, it was determined that the facility failed to timely identify and provide treatment for [REDACTED]. Findings include: Review of the current facility Wound Care Policy revised January 2009, indicated that wound evaluations will be performed on admission, weekly and on discovery. The evaluation was a formal process in which the wound characteristics, underlying conditions and contributory medical history are identified. The components of the wound evaluation included: location, measurements, appearance, drainage, odor, presence of undermining/tunneling, healing, stage, pain and [MEDICAL CONDITION]. The evaluation was to be utilized to determine the treatment approach. Review of the Medical Nutrition Therapy Policies for Pressure Ulcers/Wounds, dated October 2009, revealed that residents with pressure ulcers/wounds would receive appropriate nutrition intervention to promote healing. The procedure included referring all residents who were identified with skin breakdown to the Registered Dietitian for evaluation and treatment. Review of Resident K14's October 2011, physician's orders [REDACTED]. Review of the quarterly Minimum Data Set Assessment (MDS- a periodic assessment of care needs) completed on April 26, 2011, identified the resident required extensive assistance of two staff persons for bed mobility, transferring and ambulation. Review of Resident K14's nursing re-admission assessment dated [DATE], revealed that the resident was readmitted to the facility from the hospital and was assessed with [REDACTED]. There was no other description noted of the area to include measurements, drainage, and/or odor of the pressure ulcer, as indicated in the facilities Wound Care Policy. Review of the Braden Scale assessment dated [DATE], revealed a score of 16, which indicated that the resident was at a risk for developing pressure ulcers. Review of the physician transfer orders dated July 19, 2011, revealed no orders for treatment or wound assessment to the sacrum pressure ulcer. Review of the physician orders [REDACTED]. Review of Resident K14's wound assessment completed on July 21, 2011, by the facility wound consultant revealed that the sacral wound deteriorated from a Stage II to an unstageable pressure ulcer measuring 2.3 cm. by 1.2 cm. with 100% slough (dead tissue that has been shed or discarded). Interview with the Director of Nursing (DON), on October 18, 2011 at 10:00 a.m., confirmed that the licensed nursing staff failed to obtain a physician order [REDACTED]. The facility failed to evaluate Resident K14's pressure ulcer upon readmission to the facility, and failed to obtained treatment orders for the resident's sacral pressure ulcer, resulting in actual harm to Resident K14 with further deterioration of the resident's sacral pressure ulcer. Review of Resident O14's June 2011, physician orders [REDACTED]. Review of the hospital transfer nursing information dated June 6, 2011, revealed that Resident O14 was transferred to the facility from the hospital on June 6, 2011, and required assistance with bed mobility and transferring. Review of the facility Braden Scale assessment dated [DATE], revealed that the resident scored 16, which indicated that the resident was at risk for pressure ulcer development. Review of the nursing readmission assessment, dated June 6, 2011, noted that the resident was assessed with [REDACTED]. There was no other description noted of the right heel pressure ulcer to include measurements, drainage, and odor, as indicated in the facilities Wound Care Policy. A physician's orders [REDACTED]. Review of the June 2011, Treatment Administration Record (TAR) revealed blank areas indicating that the above treatment was not administered to the resident from June 6, 2011 to June 9, 2011. The order was discontinued on June 9, 2011, when another treatment was ordered by the physician. Review of the facility wound consultant assessment, dated June 8, 2011, revealed that Resident O14 was assessed with [REDACTED]. by 0 .7 cm. Observation conducted of resident O14's right heel on October 19, 2011, at 12:15 p.m., revealed an open area on the resident's right heel with pink granulation tissue (fibrous connective tissue in a healing wound). Interview with the DON on October 19, 2011, at 11:50 a.m., confirmed that there was no initial description of Resident O14's pressure ulcer to the right heel on the June 6, 2011, admission record and that there was no evidence of treatment to the pressure ulcer that occurred until June 8, 2011, when the pressure ulcer was assessed as unstageable. 28 Pa. Code: 201.18(b)(1) Management Previously cited 10/13/2009 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited 11/01/2010, 07/29/2010, 10/13/2009 28 Pa. Code: 211.10(c) Resident care policies Previously cited 03/21/2011, 11/01/2010 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services Previously cited 11/01/2010, 02/03/2010 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 03/21/2011, 11/01/2010, 07/29/2010, 02/03/2010, 10/13/2009