Every finding on record at Providence Rehab and Hlthcare Ctratmercyfitzgerald

Based on observations of care and services, clinical record reviews, reviews of policies and procedures and interviews with staff and residents, it was determined that for each resident reviewed with functional limitations with activities of daily living, the facility failed to ensure that a person-centered care plan related to therapeutic exercises and restorative nursing care was developed and implemented for two of seven residents reviewed. (Residents R118 and R88) Findings include:A review of the facility's policy and procedure titled restorative nursing services dated July 2017 revealed that it was the responsibility of the nursing services department to assess and develop a restorative nursing program to promote optimal safety and independence for each resident. The nursing department, physical therapy department and occupational therapy department was responsible for coordinating the restorative nursing program to meet each resident's care needs. The policy indicated that after discharge from rehabilitative care the resident was assessed for restorative nursing care as needed. The restorative nursing program was developed by the resident and his/her family and the interdisciplinary care team to maintain or improve functioning abilities for activities of daily living.Clinical record review for Resident R118 revealed the nurse practitioner's progress notes on January 12 and 13, 2026 that indicated this resident was cognitively intact. Interview with Resident R118 at 10:00 a.m., on January 11, 2026, revealed that the resident was wondering how often he was supposed to receive physical and occupational therapy services. The resident reported that he had not being out of bed into his chair regularly for therapy activities. Observations of Resident R118 at 10:00 a.m., on January 11, 2026, revealed that this resident was in bed with a right foot wound that was wrapped with kerlix and secured with ace wrap. A review of the physician's orders for October 18, 2025, revealed that physical therapy and occupational therapy services were to evaluate and provided rehabilitation services for Resident R118 five times a week. The therapy department (physical and occupation) indicated on October 19, 2025, that Resident R118 was assessed and required therapy to reposition self in bed, move from supine to sit in bed, bilateral lower extremity exercises for strengthening muscles, upper body dressing assistance, toileting and bathing assistance. Clinical record review revealed that there was no person-centered care plan developed and consistently implemented for physical therapy and occupational therapy for Resident R118 for October 18, 2025, through January 2026. The physician had ordered physical and occupational therapy services for Resident R118 five days a week for October 18 through January 2026.Clinical record review revealed that the physical and occupational therapy services of therapeutic exercises and activities, were not consistently documented as provided for Resident R118 five times a week for October 2025 through January 2026. Clinical record documentation for October 2025 revealed a lack of documentation to indicate that physical/occupational therapy services were provided for Resident R118 on October 23, 24, 25, 26 and 31. Clinical record documentation for November 2025 revealed a lack of documentation to indicate that physical /occupational therapy services were provided on November 4, 7, 8, 9, 16, 18, 22, 23, 25, 27 28, 29, 30 and 31. December 2025 revealed a lack of documentation to indicate physical/occupational therapy was provided on December 2, 4, 6, 9, 10, 16, 17, 18, 20, 25, 26, 27 and 28, 2025. Clinical record review revealed a lack of documentation to indicate that physical/occupational therapy was provided for Resident R118 on January 2, 3, 4, 5 and 6, 2026. Interview with the certified occupational therapy assistant, Employee E6 at 1:00 p.m., on January 12, 2026, confirmed the lack of documentation to indicated that physical and occupational therapy services were provided as ordered by the physician for Resident R118 for October 2025 through January 2026. The certified occupational therapist also confirmed that the facility had not developed a person center care plan to meet the physical and occupational therapy needs of Resident R118 from admission through January 12, 2026. Clinical record review for Resident R88 revealed an admission assessment MDS (an assessment of care needs) dated September 28, 2025, that indicated this resident was alert and oriented, had functional limitations of the lower extremity, used a wheelchair and walker as an assistive device. The assessment said that Resident R88 was non ambulatory for 10 feet of walking. The assessment indicated that resident r88 was requiring maximum assist with staff for sit to standing position and was dependent on staff assistance for chair to bed/ bed to chair transfers and toileting. The assessment indicated that this resident had active diagnoses of right femur fracture and difficulty walking. Clinical record review for Resident R88 revealed that this resident was discharged from physical therapy on December 24, 2025. The therapist indicated on December 24, 2025, that this resident required moderate assistance with wheeled walker for 50 feet of ambulation and required t moderate assist of staff with sit to stand transfers with the use of an assistive device. Interview with Resident R88, who was cognitively intact, at 10;30 a.m., on January 12, 2026, revealed that this resident thought that he may need more physical and occupational therapy services. The resident was asking for a program with assistance of staff with transfer from sitting to standing position. The resident was also asking for an exercise program to strengthen the lower extremities for ambulation with the wheeled walker short distances. Observations of Resident R88 at 10;30 a.m., on January 12, 2026, revealed that this resident was in bed with the head of the bed elevated. The resident pointed to a wheelchair in the bed room and said that he could not get into the wheelchair with out staff assistance. Interview with the registered nurse, Employee E5, at 11:30 a.m., on January 12, 2026, confirmed that Resident R88 was not receiving the services of the restorative nursing program since discharged from physical or occupational therapy on December 24, 2025. The registered nurse, Employee E5, also confirmed that the interdisciplinary care team failed to develop and implement a care plan for Resident R88 and his functional impairments with active range of motion care needs.28 PA. Code 211.10(a)(b)(c)(d) Resident care plans28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services28 PA. Code 201.14(a) Responsibility of licensee No Notes

Based on observations, review of clinical records, interview with staff and review of facility policies, it was determined that the facility failed to ensure that residents receive oxygen according to physician's order for one of 24 residents reviewed (Resident R3). Review of facility policy on Oxygen Administration revealed that under section Purpose The purpose of this provide guidelines for safe oxygen administration Preparation #1. Verify that there is a physician's order for this procedure. #2. Review the physician's orders or facility protocol for oxygen administration. Under section Steps in the Procedure #8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters/minute. #10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident R3 clinical record revealed that Resident R3 was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Respiratory Failure, Tracheostomy Status Review of Resident R3 physicians order revealed an order for Humidified Air via Trach Collar with Oxygen at 3liters per minute bleed in every shift ordered 10/2/25. Observation on Resident R3 conducted on January 12, 2026, at 9:19 AM revealed that Resident R3 was on oxygen concentrator at 1.75 liters per minute. Follow up observation on Resident R3 conducted on January 13, 2026, at 12:44 PM revealed that Resident R3 was an oxygen concentrator at 1.75 liters per minute. Interview with Respiratory Therapist Employee E7 confirmed that Resident R3's oxygen rate was at 1.75 liters per minute. Further Employee E7 revealed that Resident R3 should be at 3 liters of oxygen per minute. 28 Pa. Code 211.12(c) Respiratory services

Based on record review and review facility policy was determined the facility failed to ensure that medications were administered to residents according to physician's instructions for one of 24 residents reviewed. (Resident R130)Review of facility policy on Administering medications revealed that under section policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementation #2. the director of nursing services supervises and directs all personal administer medications and or have related functions. #4. medications are administered in accordance with prescriber orders including any required timeframe. #7. Medications are administered within one hour of their prescribed time unless otherwise specified. Review resident R 130s clinical record revealed that resident R130 was admitted to the facility on [DATE], and was discharged on December 18, 2025. Further review of resident R130 clinical record revealed diagnosis of but not limited to Unilateral Primary Osteoarthritis Right Hip, Presence of Right Artificial Hip Joint, Presence of Right Artificial Shoulder Joint, Low Back Pain, Idiopathic Aseptic Necrosis of Right Humerus. Review resident R 130 physicians order revealed orders for the following medications:Doxycycline Hyclate oral capsules 50mg give two capsules by mouth every 12 hours for wound infection for 6 administrations start date December 16, 2025, Crestor tablet 20mg give one tablet by mouth at bedtime start date December 16, 2025, Omeprazole 40mg capsule delayed release give one capsule by mouth in the morning for GERD start date December 17, 2025, Thyroid Oral Tablet 120 MG (Thyroid) Give 1 tablet by mouth in themorning for Hypothyroidism-Start Date-12/17/2025. Review of resident R 130s MAR (medication administration record) revealed that Crestor oral tablet 20mg one tab by mouth, was coded 22 on December 17, 2025, during the 9pm medication administration schedule. Further, Doxycycline oral capsule 50mg two capsules by mouth was coded 22 on December 16, 2025, during the 9:00AM medication administration schedule and was coded 22 on December 17, 2025, during the 9:00 AM medication administration schedule. Further, Thyroid Oral Tablet 120 MG (Thyroid) 1 tablet by mouth in the morning for Hypothyroidism-Start Date-12/17/2025 06:00AM D/C'd 12/17/25 9:07 PM was coded 22 on December 17, 2025. Further review of Resident R130's MAR revealed that 22 was the code for not administered Further review of Resident R 130th MAR revealed that Omeprazole 40MG capsule was not signed off as given on December 17, 2025. Review of Resident R130's progress note dated December 16, 2025, revealed the following: Doxycycline Hyclate Oral Capsule 50 MG Give 2 capsule by mouth every 12 hours for wound infection for 6 Administrations -On order Review of resident and R 130s progress now dates December 17, 2025, time stamped 6:35 revealed the following: Thyroid Oral Tablet 120 MG Give 1 tablet by mouth in the morning for Hypothyroidism- awaiting delivery Review of Resident R130's Progress not dated December 17, 2025, revealed Doxycycline Hyclate oral capsule 50 mg, give two capsules by mouth every 12 hours for wound infection for 6 administration was not available. Further, progress note indicated awaiting pharmacy.28 Pa. Code 211.9(a) Pharmacy services

Based on review of facility policy, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that residents were free from misappropriation of resident property for three of 10 residents reviewed (R1, R2, R3). This deficiency is cited as past non-compliance.Clinical record review revealed that resident R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to hemiplegia and hemiparesis (weakness and paralysis affecting one side of the body), and dementia. Continued review revealed that resident R2 was admitted to the facility on [DATE], with diagnoses including, but not limited to muscle wasting and systemic lupus erythematosus (a chronic auto immune disorder that cause widespread organ and tissue, and causes inflammation that can affect multiple body systems). Continued review revealed that resident R3 was admitted to the facility on [DATE], with diagnoses including, but not limited to muscle wasting, anemia, and lymphedema (a chronic condition that causes abnormal and persistent swelling in your body which is usually seen in the arms and legs but can occur elsewhere). Review of facility documentation revealed the following:On October 20, 2025, the family of resident R1 made the facility aware that the resident's access card, debit card, and credit cards were missing, and that unauthorized purchases had been made on October 18 and 19, 2025. After a police investigation, the perpetrator, employee E3, was identified and apprehended on November 24, 2025. The facility terminated the employee following identification by police. Further review revealed that during the investigation, police recovered SEPTA fare cards from two additional residents, residents R2 and R3, which had been in employee E3's possession. Documents stated that affected residents had been unaware that their cards were missing, and that they suffered no psychological or physical harm from the misappropriation.Review of records for residents R1, R2, and R3, revealed that all three affected residents no longer resided at the facility. Interviews conducted by the facility as part of the investigation revealed no further residents reported missing personal items or finances. All residents interviewed by the facility reported they felt safe. No further perpetrators or incidents were identified by the facility or by police. On January 1, 2026, the Nursing Home Administrator, employee E1, presented documentation indicating that the facility had initiated a plan of correction on November 19, 2025, related to prevention and reporting of misappropriation of resident property. Review of the facility's Plan of Correction documentation revealed the following: 1. Interviews were conducted with residents with a BIMS of 12 or higher on the second floor unit for any concerns with stolen money. All variances were reviewed with Center administration and investigated.2. Immediate Actions/EducationReported to COSAReported to the policeReported to DOHSocial service and psyche services offered and continue to support and car[e] plan psychosocial wellbeingTrauma informed care plan in placeStaff have been educated on abuse, misappropriation of property. Education will be ongoing and completed prior to the start of shift. Completed 96% by 11-21-25. Staff have been educated in mandatory reporting of any suspected misappropriation.3. Ongoing compliance will be monitored by:Audit of five random residents for any care/safety concerns daily for seven days three times a week for two weeks weekly for two weeks biweekly for two weeks then monthly for two months.Term paperwork completed and sent certified to employee's home on [DATE]Report certification submitted to licensing board for certified [CNA].4. All ongoing compliance audits will be presented and reviewed at the QAPI meeting monthly for the next 6 months. An email from employee E2, the Director of Nursing, confirmed that staff had reached 100 percent education on November 22, 2025. The facility alleged a date of compliance with this plan of correction of November 25, 2025.Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policy on prevention and reporting of misappropriation of resident property. Random staff and resident interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(d) Resident rights 28 Pa Code 201.29(j) Resident rights

Based on review of clinical records, interviews with staff, facility documentation and policy, it was determined that the facility failed to implement fall interventions for one of two residents reviewed for falls. (Resident CL1) Findings include: Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including cerebral palsy (group of neurological disorders that affect movement), muscle weakness, need for assistance with personal care, and abnormalities of gait and mobility. Resident CL1 had a Brief Interview for Mental Status score of 15, indicating intact cognitive function. Review of Resident CL1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening), dated April 13, 2025, indicated that the resident had an upper extremity impairment on one side, and lower extremity impairment on both sides. The resident utilized wheelchair for mobility and required substantial/maximal assistance with showers; and extensive assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed.) Review of Resident CL1's current care plan revealed a care plan for falls related to deconditioning, date-initiated January 5, 2025. Interventions included low bed in lowest position at all times, except during care. Continued review of Resident CL1's clinical records revealed a nursing note dated April 28, 2025, which indicated, resident fell at 10:15 p.m. and complained of pain on the head. The resident hit her face on the nightstand. Review of facility fall investigation dated April 28, 2025, revealed that the resident fell at 10:15 p.m. and hit her head on the nightstand. Review of resident statement revealed, I slid off the bed while on my side. Interview with the Director of Nursing, conducted on May 5, 2025, at 10:52 a.m. revealed, the aid was bathing the resident on the air mattress. The resident was on her side, on the bed and lying on the middle of the bed. The Nurse Assistant, Employee E5, noted redness on her bottom and went to the door to ask for some cream and the resident had fallen. Interview with the Nurse Assistant, Employee E5, conducted on May 5, 2025, at 12:10 p.m. revealed that the resident was positioned in the middle of the bed, on her right side facing the door; and the bed was in the average position at the hips when I went up to the door to ask for cream. Further interview confirmed that Employee E5 had not placed the bed in the lowest position and on the back side, prior to leaving the resident unattended. Follow-up interview with the Director of Nursing, conducted on May 5, 2025, at approximately 1:30 p.m. confirmed that the resident's bed should have been lowered before the Nurse aide, Employee E5 walked away from the resident to request the cream because she was no longer providing direct care. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that intravenous (IV) devices were maintained in accordance with professional standards of practice for one of six residents reviewed (Resident R2). Findings include: Review of facility policy, Central Venous Catheter Care and Dressing Changes dated revised March 2022, revealed, The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Continued review revealed, Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised. Further review revealed that central venous access devices should be assessed for signs of complications, including inspection of the site, measurement of the length of the external catheter and measurement of the arm circumference. Review of Resident R2's Admission Assessment, dated April 21, 2025, revealed that the resident was admitted to the facility on [DATE], at 6:30 p.m. and that the resident had a PICC line (Peripherally Inserted Central Line Catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart) in her right upper arm at the time of her admission. Continued review revealed that no measurements, such as the total catheter length, external catheter length or arm circumference, were recorded on the assessment. Interview on April 23, 2025, at 9:45 a.m. Resident R2 stated that she receives antibiotic medication through her PICC line and that the PICC line was inserted at the hospital prior to her admission to the facility. Resident R2 stated that the pump that administers the medication through her PICC line often alarmed and that she was concerned that it was not working properly. Observation, at the time of the interview, revealed that Resident R2's PICC line dressing was dated April 17, 2025, and that the dressing was peeling away from the resident's skin. Review of physician's orders for Resident R2 revealed an order, dated April 21, 2025, to change the transparent dressing of the PICC line on admission and then every seven days. Continued review revealed additional physician orders, dated April 21, 2025, related to Resident R2's PICC line care, including to document the baseline external length of the catheter and check the external length with each dressing change; to document the baseline total length of the catheter; and to document the baseline mid-upper arm circumference and check arm circumference every seven days. Review of Resident R2's Medication Administration Records revealed that there was no documentation of the PICC line external catheter length, no documentation of the resident's upper arm circumference, and no documentation of the baseline total catheter length. Further review of Resident R2's clinical record, including progress notes, evaluations and care plan, revealed that there was no documentation available for review at the time of the survey that the PICC line catheter length or arm circumference were measured at any time since the resident was admitted to the facility. Observation with the Director of Nursing on April 23, 2025, at 6:23 p.m. confirmed that Resident R2's PICC line dressing was dated April 17, 2025, and that the dressing was not changed at any time since the resident was admitted to the facility. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(c)(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policies, review of facility documents, clinical record reviews, and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to allegations of neglect for one of six residents reviewed (Resident R1). Findings include: Review of facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated revised September 2022, revealed, All allegations are thoroughly investigated. Continued review revealed, The individual conducting the investigation as a minimum . interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of Resident R1's care plan, dated initiated April 5, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including orthopedic aftercare following surgical amputation, muscle weakness and need for assistance with personal care. Continued review revealed that the resident had an ADL (Activities of Daily Living) self care performance deficit. Interventions included that the resident required staff assistance with grooming/personal hygiene and that the resident required one person staff assistance with toileting using bedside commode. Review of facility documentation submitted to the Pennsylvania Department of Health on April 9, 2025, at 12:33 p.m. revealed that Resident R1's representative alleged neglect after an incident that occurred on April 8, 2025, during the evening shift, when a nurse aide refused to assist the resident with hygiene after the resident used the toilet. Review of facility documentation, Grievance/Concern Form written by Resident R1, revealed, I needed help getting cleaned up from using the bathroom. The aide said to me you can't help yourself. I said if I could I would. The aide said I'm not cleaning you, you have to help yourself. There is nothing wrong with your upper body or arms. Then I explained my legs are swollen and can't clean myself correctly. The resident then told the aide to leave the room. Review of facility documentation related to the event revealed a written statement by Employee E12, nurse aide, dated April 8, 2025, which stated, I went to the patient's room to provide her care. She asked me to wipe her feces, I simply told her why, then I told her 'Okay could you get up so I can do it.' She said 'no' she doesn't need me anymore and that I leave the room. I went to report the incident to the charge nurse. Interview on April 23, 2025, at 10:04 a.m. Resident R4 confirmed that she was Resident R1's roommate and present in the room at the time of the incident. Resident R4 stated that Resident R1 asked the nurse aide to clean her because she could not reach; the nurse aide asked Resident R1 if there was anything wrong with her arms or hands, Resident R1 replied no, the nurse aide told Resident R1 that she could wash herself, then Resident R1 replied that she was not able to. The nurse aide then left the room and a new nurse aide was assigned who provided care to Resident R1. Interview on April 23, 2025, at 12:22 p.m. with Employee E13, Social Services Director, revealed that she was informed that Resident R1 had reported a care concern and that she spoke with the resident to follow-up on her concerns. Employee E13, Social Services Director, stated that the resident reported that she had an uncomfortable incident with a nurse aide; the resident requested assistance with toileting hygiene and the nurse aide kept telling her to do it herself. The resident reported that she did not feel that she received the care that she needed and that she felt neglected. Interview on April 23, 2025, at 12:38 p.m. with Employee E11, Social Services Assistant, revealed that on the day of the incident, he was informed that Resident R1 had reported a care concern and he went to follow-up with the resident. Employee E11, Social Services Assistant, stated that he went into Resident R1's room, that he tried to figure out what happened, and then he reported the concern to the nursing supervisor for follow-up. Employee E11, Social Services Assistant, stated that he was not requested to provide a written statement of his interview with Resident R1 and confirmed that he did not write a statement. Interview on April 23, 2025, at 1:46 p.m. with Employee E6, licensed nurse, revealed that on the day of the incident she entered Resident R1's room and noticed that the resident was upset. She asked the resident if she was ok, the resident explained that the nurse aide did not want to wipe her bottom. Employee E6, licensed nurse, stated that she reported this to the supervisor who changed the staff assignment for the resident. Interview on April 23, 2025, at 2:47 p.m. Employee E14, licensed nurse supervisor, confirmed that he was the nursing supervisor on duty at the time of the incident. Employee E14, licensed nurse supervisor, stated that Employee E12, nurse aide, informed him that Resident R1 was angry with her and told her to leave the room. Employee E14, licensed nurse supervisor, spoke with the resident, who reported to him that she did not like Employee E12's interaction and approach. Employee E14, licensed nurse supervisor, stated that he assigned Employee E10, nurse aide, to provide care to Resident R1 for the remainder of the shift and that care was provided immediately. Continued interview with Employee E14, licensed nurse supervisor, revealed that he reported the incident to the Director of Nursing and requested written statements from staff at that time. Employee E14, licensed nurse supervisor, stated that he obtained statements from Employee E12, nurse aide; Resident R4 (roommate of Resident R1) and that Resident R1 declined to give a statement at that time. Employee E14, licensed nurse supervisor, stated that he assumed Employee E11, Social Services Assistant, would write a statement because he spoke with the resident at the time of the incident. Employee E14, licensed nurse supervisor, stated that he did not obtain a written statement from Employee E6, licensed nurse, because he did not think that the employee was aware of or involved in the incident. Employee E14, licensed nurse supervisor, also stated that he did not obtain a written statement from Employee E10, nurse aide, because she provided care after the incident occurred. An interview with Employee E10, nurse aide, was attempted during the survey, however, the employee was not available and did not respond to the request for interview. Interview on April 23, 2025, at 3:31 p.m. the Director of Nursing revealed that Resident R1 contacted him with her concerns at the time the incident occurred on April 8, 2025, and that the resident was angry because the nurse aide would not help her with toileting hygiene. The Director of Nursing stated that the next day, on April 9, 2025, at 12:00 p.m. that the resident's representative reported an allegation of neglect to the facility. The Director of Nursing stated that an investigation was initiated immediately when the allegation was received. Continued interview with the Director of Nursing revealed that the facility's investigation process includes obtaining witness statements from residents, staff, visitors and anyone who may have witnessed the event. The Director of Nursing was not able to recall if statements were obtained from Employee E6, licensed nurse, or Employee E10, nurse aide. Interview on April 23, 2025, at 3:57 p.m. the Nursing Home Administrator stated that an investigation to rule out neglect for Resident R1 was immediately initiated as soon as the allegation was received by the facility. The Nursing Home Administrator stated that the facility's investigation process includes obtaining witness statements from the nursing supervisor, nurse aides, licensed nurses, residents, roommates, family and anyone who could have been witness to the event. The Nursing Home Administrator confirmed that statements were not obtained from Employee E11, Social Services Assistant; Employee E6, licensed nurse; or Employee E10, nurse aide, as part of the facility's investigation. The Nursing Home Administrator stated that the above employees should have provided written statements as part of the facility's investigation since they were involved in the resident's care at time of the incident. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c) Nursing services

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to transmission-based precautions and air mattresses, for two of six residents reviewed (Residents R3 and R5). Findings include: Review of facility policy, Enhanced Barrier Precautions dated revised March 2024, revealed, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Continued review revealed, EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . transferring. Review of facility policy, Isolation - Categories of Transmission-Based Precautions dated revised September 2022, revealed, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Continued review revealed, Staff and visitors wear gloves when entering the room . Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of Resident R3's care plan, dated initiated February 20, 2025, revealed that the resident was colonized with the multi-drug resistant organism CRE (Carbapenem-resistant Enterobacterales - a bacterial infection that is difficult to treat) and to use isolation precautions per policy. Review of Resident R3's active physician orders revealed an order dated January 22, 2025, for Enhanced Barrier Precautions. Continued review revealed another physician's order, dated January 23, 2025, for Contact Precautions. Observation on April 23, 2025, at 10:02 a.m. revealed signage posted outside of Resident R3's room indicating that the resident required Enhanced Barrier and Special Contact Precautions. The signage specified that surgical masks, eye protection, gowns and gloves were required while providing care. Interview, at the time of the observation, Employee E5, licensed nurse, stated that PPE (Personal Protective Equipment - such as masks, gowns, gloves and eye protection) were needed when providing care for Resident R3 and were located in the resident's room. Continued observation on April 23, 2025, between 10:05 a.m. and 10:15 a.m. revealed Employee E6, licensed nurse, and Employee E8, nurse aide, entered Resident R3's room and transferred the resident using a hoyer lift from the bed to the wheelchair. The staff stated that they were getting the resident ready to go to dialysis. Both employees were observed only wearing gloves while providing care to Resident R3. Interview on April 23, 2025, at 10:22 a.m. Employee E8, nurse aide, stated that Resident R3 was on isolation precautions due to a surgical incision, that staff were supposed to wear gowns while providing care to the resident and confirmed that only gloves were worn. Review of Resident R5's care plan, dated initiated April 17, 2025, revealed that the resident had impaired skin integrity with interventions including pressure reducing mattress to bed. Review of Resident R5's wound evaluations, dated April 23, 2025, revealed that the resident had pressure wounds on his right gluteus (buttock), sacrum, right dorsum (back of foot), right heel and left heel with recommendations to utilize a mattress with a pump (air mattress). Observation on April 23, 2025, at 10:37 a.m. revealed that an air mattress was laying directly on the floor in front of Resident R5's bed. There were no protective coverings on the mattress to keep it clean or free from dirt and debris. Interview, at the time of the observation, Employee E7, licensed nurse, confirmed that the air mattress was laying directly on the floor and stated that the mattress was being inflated so that it could be switched out with the resident's current mattress. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on facility policy, review of facility documentation, observations, interviews with resident, it was determined that the facility failed to provide a safe, clean, comfortable, homelike environment for two of 12 resident reviewed. (Resident R1 and Resident R2) Findings include: Review of facility policy titled Homelike Environment revised 2021, revealed it is the policy of the facility that residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management will maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include: a clean, sanitary and orderly environment. Review of Resident R1's quarterly Minimum Data Set (MDS-a federal mandated assessment for all residents) dated February 17, 2025 revealed that Resident R1 was admitted to the facility January 9, 2025. This resident required assistance for activities of daility living, total assistance for transfers, support of enteral feeding (tube feeding). The resident also used a urinary catheter. Observation of Resident R1's room on April 1, 2025 at 10:30 a.m. revealed a foul oder, two large bags of laundry at the door. The resident's roommate- Resident R2 observed lying on a bed with no sheets, the floor was soiled with food/crumbs, papers, a wallet, upside down radio, a visible soiled cloth and shoes scattered around. Interview with Resident R1 revealed that he is not happy about being old and having to live here. He stated that the staff was good and requested juice. Interview with Nursing aide, Employee E3 at time of the above observation revealed that Resident R2 constantly keeps his room dirty. The staff continually are cleaning up after him. This employee sorted and organized the resident's clothes out his closet today to make the room neater. Resident R2 refused care and often does not allow staff to touch his belongings. This employee and the staff constantly try to clean his room, but as soon as its id clean, he trashes it again. Review of Residents R2's quarterly Minimum Data Set ( MDS- federal mandated assesment for all residents) dated March 6, 2025 revealed that Resident R2 was admitted [DATE] with a diagnosis of diabetes (failure of the body to produce insulin). The resident was assessed with a BIMS (brief interview of mental status) score of 15, indicating the resident cognition was intact. Further review of Residents R2, clinical record revealed that the resident has occupied the room since June 8, 2024. Review of Resident R2's nursing notes revealed ongoing behavior concerns related to cleanness and unsanitary conditions as follows: December 11, 2024 Resident offered care with shower and shave He is AAOx3 and able to make his needs known. His environment is cluttered with clothes, trash and feces smear toilet tissue and linen. He was offered shower and shave but refused, he stated he already washed. Currently he is in his bed with his private areas exposed, he is given privacy but continues to pull the curtains back. January 8, 2025 Resident found on rounds with brown formed stool on the entire bed. January 15, 2025 Resident found on rounds wiping his rectum of feces with the linen. January 16, 2025 He has poor safety awareness and is at risk for falls r/t cluttered environment. He also continues to keep his pants and underwear down as he masturbates, privacy given, however he prefers to leave privacy curtain open rather than closed. Nursing will continue to educate the resident on unacceptable aspects of his behavior January 18, 2025 Resident's environment very cluttered and smells awful. Resident use his linen to clean himself after defecating. January 19, 2025 propelling himself down the hall with his pants and underwear down by his knees. He has a sheet slightly covering him and dragging behind him with feces smeared on it. Interview with licensed nurse, Employee E4 on April 1, 2025 at 11:55 a.m. revealed that Resident R2 has displayed these behaviors since she began on the second floor since October 2024. Employee E4 stated that this residents is very non complaint with his medications , insulin, and toileting. The staff try to clean his room multiple times a day , sometimes he refuses. Interview with Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 on April 1, 2025 at 1:25 p.m. confirmed that Resident R1 does not get out of bed and is a high risk for infection. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of five residents reviewed (Residents R44, R41 and R72). Findings include: A Binding Arbitration Agreement is a legal process where parties in a dispute agree to have a neutral third party decide their case instead of a judge or jury. The arbitrator's decision is final and the parties usually cannot appeal it. Review of facility policy, Binding Arbitration Agreements dated November 2023, revealed, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Continued review revealed, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement. Further review revealed, After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. Review of Resident R44's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 10, 2024, revealed that the resident was admitted to the facility June 1, 2017, and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and symbolic dysfunction (cognitive language impairment). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 00, which indicated that the resident was severely cognitively impaired. Review of progress notes for Resident R44 revealed a physician evaluation, dated February 22, 2024, at 5:40 a.m. which indicated that the resident was oriented to person only and that the resident was incapable of making decisions. Review of Resident R44's Binding Arbitration Agreement, dated February 22, 2024, revealed that in the space designated for the signature of the resident, it was noted that Resident R44 verbally signed the agreement. In the space designated for the signature of the facility's authorized agent, the agreement was signed by Employee E11, Concierge. Review of Resident R41's Annual MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia and psychotic disorder (loss of contact with reality). Continued review revealed that the resident had a BIMS score of 06, which indicated that the resident was severely cognitively impaired. Review of progress notes for Resident R41 revealed a psychiatry (mental health) evaluation, dated November 28, 2023, which indicated that the resident was oriented to person only with poor thought content, insight and judgement. Review of Resident R41's Binding Arbitration Agreement, dated December 7, 2023, revealed that in the space designated for the signature of the resident, it was noted that Resident R41 verbally signed the agreement. In the space designated for the signature of the facility's authorized agent, the agreement was signed by Employee E11, Concierge. Review of Resident R72's Admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) and cognitive communication deficit (problems with communication due to difficulties with thinking processes). Continued review revealed that the resident had a BIMS score of 00, which indicated that the resident was severely cognitively impaired. Review of progress notes for Resident R72 revealed a nurses note, dated August 9, 2023, at 10:30 p.m. which indicated that the resident was admitted to the facility, that the resident was confused and that he was unable to answer questions logically. Review of Resident R72's Binding Arbitration Agreement, dated August 10, 2023, revealed that in the space designated for the signature of the resident, it was noted that Resident R72 verbally signed the agreement. In the space designated for the signature of the facility's authorized agent, the agreement was signed by Employee E11, Concierge. Interview on January 14, 2025, at 12:48 p.m. Employee E11, Concierge, stated that she asks residents several times if they are able to sign the arbitration agreement and that based on this she uses her personal judgement to determine if residents are capable of signing the agreement. Continued interview revealed that Employee E11, Concierge, does not review residents' clinical records to determine their cognitive status. Employee E11, Concierge, was unaware that Residents R44, R41 and R72 were severely cognitively impaired and was unable to explain the process of determining if severely cognitively impaired residents would have the capacity to understand and sign the arbitration agreement. 28 Pa. Code 201.18(b)(3) Management 28 Pa Code 201.29(a) Resident rights

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to enhanced barrier precautions for one of two residents reviewed for pressure ulcers (Resident R79). Findings include: Review of facility policy, Enhanced Barrier Precautions dated March 2024, revealed that, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Continued review revealed, Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . wound care (any skin opening requiring a dressing). Review of Resident R79's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 20, 2024, revealed that the resident was admitted to the facility September 7, 2023, and had a diagnosis of stage four pressure ulcer of the sacral region (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection). Review of Resident R79's care plan, dated April 29, 2024, revealed that the resident required enhanced barrier precautions, with interventions including the use of gloves and gowns during high-contact care activities, including wound care. Review of physician orders for Resident R79 revealed an order, dated October 3, 2024, to cleanse the sacral wound with 1/4 Dakin's solution (topical antiseptic used to clean wounds), pat dry, apply calcium alginate (soft absorbent wound dressing) to the wound bed and secure with a clean dry dressing. Observation on January 12, 2025, at 12:51 p.m. revealed Employee E8, licensed nurse, and Employee E9, nurse aide, provide wound care to Resident R79's stage four sacral wound. Both employees wore only gloves while providing the wound care. Interview on January 12, 2025, at 1:09 p.m. Employee E8, licensed nurse, confirmed that gowns were not worn while she and the other staff person provided wound care and confirmed that Resident R79 required enhance barrier precautions due to his wound. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that resident rooms were free from offensive odors for one of 34 residents reviewed (Resident R79). Findings include: Review of Resident R79's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 20, 2024, revealed that the resident was admitted to the facility September 7, 2023, and had diagnoses including anoxic brain damage (brain damage caused by lack of oxygen to the brain), pressure ulcer (wound), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and respiratory failure (not enough oxygen passes from your lungs to your blood). Continued review revealed that the resident was severely cognitively impaired, required a feeding tube to meet his nutritional needs and was dependent for all activities of daily living, including bathing, toileting hygiene, and personal hygiene. Observation on January 12, 2025, at 9:41 a.m. revealed a strong odor of urine and bowel movement in the hallway. Continued observation revealed that the odor was coming from Resident R79's room. Upon entering the room, there was also a foul sour odor next to Resident R79's bed. Further observation revealed that there was a large puddle of tube feeding formula on the floor as well as dried spillage on the resident's tube feeding pole and oxygen concentrator (machine that produces concentrated oxygen from the air). Interview on January 12, 2025, at 10:42 a.m. the Director of Nursing confirmed the foul odors and tube feeding spillage in Resident R79's room. The Director of Nursing stated that he would have housekeeping staff clean the room. Continued observation on January 12, 2025, at 12:51 p.m. revealed that the puddle of tube feeding formula had been cleaned from the floor, however, the dried spillage on the feeding pole and oxygen concentrator were still present. Additionally, the room still had a foul sour odor. Further observation and interview on January 12, 2025, at 1:22 p.m. Employee E13, Regional Director of Environmental Services, confirmed that Resident R79's room still had a foul sour odor and soiled medical equipment. Observation on January 13, 2025, at 8:49 a.m. revealed a strong odor of urine and bowel movement in the hallway. Continued observation revealed that the odor was coming from Resident R79's room. Further observation on January 13, 2025, at 12:01 p.m. revealed that there was still a strong odor of bowel movement in Resident R79's room. Observation on January 15, 2025, at 10:26 a.m. revealed a strong odor of urine in Resident R79's room. Employee E8, licensed nurse, confirmed the odor. 28 Pa Code 201.18(d.2)(2.1) Management

Based on review of facility policy, review of clinical records and staff interview, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of a narcotic medication for two of seven residents prescribed narcotic medications reviewed. This deficiency was cited as past non compliance. (Resident R20, Resident R21) Findings include: Review of facility policy on Controlled Substances dated November 2022, revealed that under section Policy Statement: The facility complies with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Under Section Policy Interpretation and Implementation Handling Controlled substances #1, only authorized licensed nursing and or pharmacy personnel have access to Schedule 2 controlled substances maintained on premises. #2. The Director of Nursing Services identifies staff members who are authorized to handle controlled substances. #3 Controlled substances are counted upon delivery. The nurse receiving the medication along with the person delivering the medication must count on the controlled substances together. Both individual sign the designated controlled substance record. #4. If the count is correct, an individual resident control substance record is made for each resident who will be receiving controlled substance. Do not enter more than one prescription per page. This record contains: a. name of the resident, b. name and strength of the medication, c. quantity received, d. number on hand, e. name of the prescriber, f. prescription number, g. name of issuing pharmacy, h. date and time received, i. time of administration, j. method of administration, k. signature of person receiving medication and l. signature of nurse administering medication. Under section Storing Control Substances #1. Control substances are separately locked in permanently affixed compartments except when using single unit packaged drug distribution system in which the quantity stored is minimal and missing. Those can be readily detected. #2. All keys to control substance containers are on a single key ring that is different from any other keys. #3. The charge nurse on duty maintains the keys to controlled substance containers. The Director of Nursing Services maintains a set of backup keys for all medication storage areas, including keys to controlled substance containers. Under a section Dispensing and Reconciling Controlled Substances: #1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between laws diversion and detection follow up. #2. The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following. a. records of personal access and usage, b. medication administration records, c. declining inventory records and d. destruction and waste and returned to pharmacy records. #3 Nursing staff count controlled medications inventory at the end of each shift, using these records to reconcile the inventory count. #4 the nurse coming on duty and the nurse going off duty makes the count together and document and report any discrepancies to the Director of Nursing. Review of Resident R320's clinical record revealed that Resident R320 was admitted to the facility on [DATE], with diagnoses of Malignant neoplasm of Sigmoid Colon, Status post surgery on the Digestive System. Further review of Resident R320's clinical record revealed a physician's order for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for moderate to severe c/o pain for 10 Days-dated 10/7/2024. Review of Resident R321's clinical record revealed that Resident R321 was admitted to the facility on [DATE], with diagnoses of Burn of Unspecified Degree on Left Foot, Chronic Ulcer of Left Foot with Necrosis of Bone, Diabetic Peripheral Angiopathy with Gangrene. Further review of Resident R321's clinical record revealed a physician's order for oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 12 hours as needed for Moderate to Severe Pain- dated 10.10.24 Review of facility investigation record revealed that on October 9, 2024, 8 tablets Oxycodone 5mg tablets was delivered and was received and signed off by Employee E19 unit manager and Licensed nurse, Employee E19. The eight tablets of Oxycodone were placed in the narcotic box and logged into the Narcotic book. On October 10, 2024, licensed nurse, Employee E20 signed out 1 tablet of Oxycodone leaving 7 tablets of Oxycodone in the narcotic box. Narcotic count on October 10, 2024, during change of shift between night shift outgoing licensed nurse Employee E20 and day shift incoming licensed nurse Employee E21 revealed the correct count for Resident R321's Oxycodone 5 mg tabs (7 tablets) Narcotic count on October 10, 2024, during change of shift between day shift outgoing nurse Employee E21 and evening shift incoming nurse Employee E22, revealed the correct count for Resident R321's Oxycodone 5 mg tabs (7 tablets) During the evening shift resident tested positive for covid and was moved to another room during the 3-11 shift. licensed nurse Employee E23 collected med cart keys from Employee E22 and removed the routine meds from the cart and moved to the cart for the wing where Resident R321 was moved to. Further Employee E23 revealed that that she did not remove the Oxycodone from the narcotic box. Narcotic count on October 11, 2024, during change of shift between evening shift shift outgoing licensed nurse Employee E22 and night shift incoming licensed nurse Employee E24, revealed the correct count for Resident R321's Oxycodone 5 mg tabs (7 tablets) On October 11, 2024, during the 11 to 7 shift. Resident R321 requested for an oxycodone pill from licensed nurse Employee E18 . Employee E18 was not able to locate the oxycodone in the medication cart she was assigned to. Employee E18 asked Employee E24 who counted with Employee E22 and confirmed that the count was correct (7), which was when it was discovered that the narcotics and the narcotoc page was missing. Further investigation revealed that the page from the narcotic book containing the accountability record for Resident R321's oxycodone has been ripped off the narcotic book. On October 10, 2024, at 1:01 a.m., 30 oxycodone tablets were delivered for Resident R320. On October 11, 2024, at 2:30pm unit manager Employee E25 and licensed nurse Employee E21 indexed a new narcotic book to replace the narcotic book that was full. Employee E25 and Employee E21 counted Resident R320's Oxycodone 5 mg tablets, and confirmed that there were 30 5 mg tablet of Oxycodone belonging to Resident R320 in the medication cart and transferred all information from the old narcotic book to the new narcotic book On October 11, 2024 at 1600pm (4pm), licensed nurse Employee E21 and licensed nurse Employee E26 counted 30 5 mg Oxycodone tabs. Count was correct. On October 12, 2024, Saturday, at 7:30 am during count in coming licensed nurse Employee E27 and outgoing nurse Employee E18 revealed that the 30 tabs of 5mg Oxycodone tabs were missing. Interview with Director of Nursing (DON) Employee E2 conducted on January 13, 2025 at 1:15pm revealed that the staff did not follow the facility's policy on counting controlled substances. DON revealed that the nurses were only counting the narcotics in the narcotic box and did not reference the narcotic index in the front of the narcotic book where list of narcotics stored in the narcotic box was listed, resulting in not identifying missing narcotics during the shift-to-shift count. Further, DON revealed that he was not able to identify who the perpetrator was because the previous shifts also did not reference the narcotic index before counting the narcotics Review of facility abatement plan revealed that the facility initiated their investigation on the missing narcotic the day it was identified with narcotic audit initiated on October 11, 2024, the day when the missing narcotic was identified. Interview with Assistant Director of Nursing Employee E12 revealed that the facility started educating their licensed staff on October 14, 2024, with 27.3% of staff in-serviced and completed in servicing 92.7% of licensed staff on October 15, 2024. The facility alleged compliance date of October 15, 2024. This deficiency was identified as past non compliance. 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to diabetes management for one of 34 residents reviewed (Resident R80). Findings include: Review of facility policy, Comprehensive Person-Centered Care Plans dated March 2022, revealed, 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. Continued review revealed, The comprehensive, person-centered care plan . reflects currently recognized standards of practice for problem areas and conditions. Review of Resident R80's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated October 11, 2024, revealed that the resident was admitted to the facility February 17, 2024, and had a diagnosis of diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood). Continued review revealed that the resident required insulin injections (medication used to lower blood sugar levels). Review of active physician orders for Resident R80, revealed an order dated April 2, 2024, to check the resident's blood sugar levels before meals and bedtime. Continued review revealed an order dated October 3, 2024, to inject 35 units of Basaglar (long acting) insulin at bedtime. Further review revealed an order, dated April 2, 2024, for Humalog (rapid acting) insulin, inject per sliding scale (variable dosing based on blood sugar level) before meals. Review of Resident R80's care plan, dated April 1, 2024, revealed that no care plan was developed related to diabetes management or dependence on insulin medications. Interview on January 15, 2025, Employee E12, licensed nurse, confirmed that no care plan was developed for Resident R80 related to diabetes and insulin. 28 Pa Code 211.10(c) Resident care policies

Based on observations, interviews with residents and staff and a review of facility documentation and review of clinical records, it was determined that the facility failed to ensure that a safe environment was maintained related to medication being left on a residents over bed table on two occasions for one of 34 residents reviewed (Resident R213). Findings include: Observation during the initial tour of the facility in room [ROOM NUMBER], Bed A on January 12, 2025, at 10:15 a.m. revealed a pill in a 1-ounce dose cup sitting on Resident R213's over-bed table. When asked about the pill Resident 213 indicated that she refused to take it because she believed it would cause her to urinate more and she did not want that. Observation in room [ROOM NUMBER], Bed A on January 13, 2025, at 9:45 a.m. revealed a pill in a 1-ounce dose cup sitting on Resident R213's over-bed table. When Licensed nurse, Employee E7, entered the room she took the pill in the cup and asked Resident R213 why the pill was on the table. The resident said that she does not want to take this pill because she does not need to urinate more that she is now. The nurse quickly left the room and threw the pill in the garbage bag on the side of the med cart. The nurse went and spoke to the unit manager, stating that the resident must have spit the pill out after she left the room because she saw her put all the pills in her mouth. When asked what pill was in the cup, Employee E7 said that it was her potassium chloride, and that she gets this with her diuretic so her potassium level does not get to low and affect her heart. Review of the clinical record for Resident R213 revealed the resident was admitted to the facility on [DATE], with diagnoses of non-ST-elevation myocardial infarction (a type of heart attack that happens when a part of your heart is not getting enough oxygen). Further review revealed that she was getting a 10 meq potassium chloride tablet, Bumex 0.5 mg tablet (a diuretic, used to get rid of extra fluid) and 5 other pills at 9 a.m. each day. An interview was conducted with the Administrator and Director of Nursing on, January 13, 2025, at 2:40 p.m. confirmed that pill should not have been left on Resident 213's over-bed table as it could have been taken by another resident and that this did not provide a safe environment for nursing home residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policies, review of clinical records and interview with staff, it was determined that the facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles for one of twenty-six medications. (Resident R42) Findings include: Review facility Policy on Medication administration revealed that under section Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementation #2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. #9. The individual administering medications verifies the resident ' s identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. #10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of R42's clinical record revealed that Resident R42 was admitted to the facility on July2, 2024 with diagnoses of Acute Sinusitis. Review of Resident R42's physician's orders revealed an order for Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in each nostril one time a day for allergy relief Gently shake, before use prime pump. After use, clean tip and replace the cap -dated 7/2/24. Review of Resident R78's clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnoses of Gastroesophageal Reflux Disease, Centrilobular Emphysema. Review of Resident R78's physician's orders revealed an order for Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in both nostrils every 24 hours as needed for Allergies-ordered 12/9/24 and discontinued 1/6/25 Further review of Resident R78's clinical record revealed that Resident R78 was discharged from the facility on January 6, 2025. Medication administration observation with licensed nurse Employee E7 for Resident R42 conducted on January 13, 2024, at 10:37am revealed that Employee E7 picked up a box labelled Fluticasone 50 mcg with Resident R42's name and room number handwritten on it. Further, Employee E7 proceeded to go to Resident R42's room and administered the nasal spray to Resident R42. Inspection of the Fluticasone nasal spray bottle revealed that a typewritten paper label with Resident R78's name was affixed to the bottle. Interview with the nurse conducted at the time of the observation confirmed that the bottle of fluticasone that she administered to Resident R42 was labelled with Resident R78's name on it. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(1)(2)(5) Nursing services.

Based on observations, review of facility policies, review of clinical records and interview with staff, it was determined that the facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles for one of twenty-six medications. Findings include: Review facility Policy on Medication administration revealed that under section Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementation #2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. #9. The individual administering medications verifies the resident ' s identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. #10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of R42's clinical record revealed that Resident R42 was admitted to the facility on July2, 2024 with diagnoses of but not limited to: Acute Sinusitis. Review of Resident R42s physician's orders revealed an order for Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in each nostril one time a day for allergy relief Gently shake, before use prime pump. After use, clean tip and replace the cap -dated 7/2/24. Review of Resident R78's clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnoses of \Gastroesophageal Reflux Disease, and Centrilobular Emphysema. Review of Resident R78's physician's orders revealed an order for Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in both nostrils every 24 hours as needed for Allergies-ordered 12/9/24 and discontinued 1/6/25 Further review of Resident R78's clinical record revealed that Resident R78 was discharged from the facility on January 6, 2025. Medication administration observation with licensed nurse Employee E7 for Resident R42 conducted on January 13, 2024, at 10:37am revealed that Employee E7 picked up a box labelled Fluticasone 50 mcg with Resident R42's name and room number handwritten on it. Further, Employee E7 proceeded to go to Resident R42's room and administered the nasal spray to Resident R42. Inspection of the Fluticasone nasal spray bottle revealed that a typewritten paper label with Resident R78's name was affixed to the bottle. Interview with the nurse conducted at the time of the observation confirmed that the bottle of fluticasone that she administered to Resident R42 was labelled with Resident R78's name on it. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(1)(2)(5) Nursing services.

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department was conducted on January 12, 2025, at 9:05 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the walk-in freezer revealed two cardboard boxes of bread sitting directly on the floor. Observation in the dish room area revealed standing water on the floor and a clogged floor drain in the middle of the room, and the dietary staff using a shop vacuum to collect the water off the floor which was wet throughout the dish room. Observation of the under-table shelves in the prep area and cooks area revealed visible dirt and, dust and crumbs on the shelves and floor underneath, and the tray slides in the area under the coffee urn were stained with dark brown splashed liquid. Observation of the inside of the convection oven revealed dark black burned on food substances on all surfaces. Observation of the plate heater revealed dirt and crumbs on the inside surfaces where the clean plates are stacked. Interview with the FSD 10:00 a.m. on January 12, 2025, at 9:20 a.m. confirmed the above findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that tube feedings were properly labeled for one of three residents reviewed for tube feedings (Resident R79). Findings include: Review of facility policy, Enteral Nutrition [a form of nutrition that is delivered into the digestive system as a liquid] dated November 2018, revealed Adequate nutritional support through enteral nutrition is provided to residents as ordered. Review of Resident R79's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 20, 2024, revealed that the resident was admitted to the facility September 7, 2023, and had diagnoses including anoxic brain damage (brain damage caused by lack of oxygen to the brain), and dysphagia (difficulty swallowing). Continued review revealed that the resident was severely cognitively impaired and required a feeding tube to meet his nutritional needs. Review of physician orders for Resident R79 revealed an order dated October 21, 2024, for enteral feedings of Peptamen AF (nutritional formula), 375 mL (milliliter) boluses four times per day via feeding tube. Continued review revealed an order, dated September 17, 2024, to change the resident's feeding bag and administration set daily; the order specified to label the bag with the resident's name, date, time and initials. Observation on January 12, 2025, at 9:35 a.m. revealed a bag of tube feeding formula was infusing for Resident R79. The bag was labeled with a date of January 12, 2025. There was no further information on the bag of formula. Interview, at the time of the observation, Employee E8, licensed nurse, stated that the formula was a bolus feeding for Resident R79 and that the formula was Peptamen. Employee E8, licensed nurse, confirmed that the formula bag was not labeled with the resident's name, formula, infusion rate or the time and initials of the person who prepared the feeding. 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for four of six residents reviewed (Residents R2, R3, R4 and R6). Findings include: Clinical record review for Resident R2 revealed a cardiologist note, dated April 16, 2024, at 10:59 p.m. which indicated that the resident was having a change in mental status. The cardiologist consulted with the resident's attending physician and ordered for the resident to be transferred to a local hospital for evaluation. The resident did not return and was ultimately discharged from the facility. Clinical record review for Resident R3 revealed a nurse's note, dated May 1, 2024, at 10:03 a.m. which indicated that the resident had elevated blood pressure, was not opening her eyes or responding to staff. The resident was subsequently transferred to a local hospital for evaluation. Clinical record review for Resident R4 revealed a nurse's note, dated June 2, 2024, at 9:26 a.m. which indicated that the resident had low blood sugar as well as swelling to his face, lip and tongue and was unable to swallow. The physician was notified and ordered for the resident to be transferred to a local hospital for evaluation. Clinical record review for Resident R6 revealed a nurse's note, dated June 3, 3034, at 5:16 p.m. which indicated that the resident was having difficulty breathing, using her accessory muscles and had low oxygen levels. The resident was subsequently transferred to a local hospital for evaluation. The resident did not return and was ultimately discharged from the facility. Further record reviews for Residents R2, R3, R4 and R6 revealed that no documentation was available for review at the time of the survey to indicate that the Office of the State Long-Term Care Ombudsman was notified of the facility-initiated emergency transfers and discharges. Interview on September 23, 2024, at 12:50 p.m. the Director of Nursing confirmed that no documentation was available for review to indicate that the Office of the State Long-Term Care Ombudsman was notified of the facility-initiated emergency transfers and discharges for Residents R2, R3, R4 and R6. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on a review of facility documentation, clinical records and interviews with residents, and staff, it was determined that the facility failed to ensure that two of two residents reviewed were supervised while smoking which resulted in actual harm to Resident R1, whose shirt caught on fire and sustained second degree [CONDITION(S)] on the left side of face, left flank, anterior and posterior left arm and bilateral hand palms. This deficiency was cited as past non-compliance. (Resident R1 & R2) Findings include: A review of the facility Smoking Policy revised May 2017, revealed that the facility would establish and maintain safe smoking practices including unless otherwise designated, smoking articles will be maintained by assigned facility staff. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Chronic Pulmonary Obstructive Disease (a group of lung diseases which damage the lungs making it difficult to breathe) and Plural Effusion (a build-up of fluid in the outer lining of the lungs.) Further review of Resident R1's quarterly Minimum Data Set assessment (MDS-periodic assessment resident's needs) dated July 31, 2020, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment.) score of 11 indicating the resident was moderately cognitively impaired. A review of Resident R1's plan of care revealed a smoking care plan developed January 28, 2020, that indicated that the resident would follow the smoking policy and that he understood that the facility would keep his smoking materials, including cigarettes and lighting material in a locked box, that he would wear a smoking apron and that staff need to light his cigarettes for him. Review of Resident R1's smoking assessment dated [DATE], indicated that Resident R1 had no visual deficit, no dexterity problems, and no limitations of range of motion. The smoking assessment further indicated that the resident was able to light his own cigarettes, able to self extinguish in an ashtray. The resident needed assistance to and from the smoking area and that he was required to wear a smoking apron. A review of Resident R2's clinical records revealed an annual MDS completed on June 26, 2020, with a BIMS score of 15 out of 15, which indicates the resident was cognitively intact. Review of Resident R2's smoking assessment completed August 11, 2020 revealed that the resident was alert and oriented to places, people and time, there was no visual deficits, no problems with dexterity, and no range of motion limitations. The resident required no adaptive equipment. The intervention to the resident's smoking care plan included that the resdient may smoke with supervision. Review of facility documentation revealed on August 21, 2020, at approximately 12:35 p.m., staff heard Resident R1 calling for help. Two nurse aides, two nurses and the unit manager responded to the resident lounge on the first floor where they found Resident R1 sitting on a small table inside the lounge near the door leading out to the smoking area with flames coming from his shirt. The staff were able to put the flames out using their clothing and a fire extinguisher. The unit manager pulled the fire alarm and called 911 (Emergency Medical Services). The paramedics responded and transported the resident to the hospital burn unit. The documentation also revealed that Resident R1 sustained [CONDITION(S)] to his left shoulder, arm, chest, neck and back of his head. Review of facility investigation related to the incident sustained by Resident R1 revealed that the activity assistant, Employee E10, had assisted Resident R1 to the smoking area, located outside the resident lounge on the first floor. She left the smoking area to get another resident a cup of water which is when Resident R1 attempted to light a second cigarette when he dropped the match onto his shirt. Resident R1 was unable to remove the match and his clothing caught on fire and he began yelling for help. Resident R2 was the only other person in the smoking area, and there was an attempt for Resident R2 to help Resident R1. A telephone interview with Employee E10 on August 25, 2020, at approximately 2:43 p.m., confirmed that Resident R1 did not have a smoking apron on at the time of the incident. She stated that she forgot to put the apron on him before bringing him down from his room on the second floor to the smoking area outside the first-floor lounge. A review of a written statement from Employee E10 revealed that she stated that she was outside in the smoking area with Resident R1 and Resident R2 at around 2:35 p.m. when she went into the building to get Resident R2 some water and to check to see if she was being called to do a face-time call which was scheduled for 2:30 p.m. She goes on to say that she took time that she should have been outside because now the residents were left unsupervised. She also wrote that when she responded with the other staff to Resident R1's yelling for help, she froze since it was a shocking moment. And that once the nursing staff put the flames out she went to Resident R1 and that he was saying that his hand was burning. She also said that Resident R2 told them all what had happened. A review of Resident R2's statement revealed that he had asked Employee E10 for water, and that it was after she left that Resident R1 had tried to light a second cigarette, which was already in his hand, and dropped the match. He stated that Resident R1 tried to brush it off, stood up and came toward him saying, Get it off! He said he tried to pat it out and take Resident R1's shirt off, and burned his own fingers. Then Resident R1 went into the building for calling help. Review of the facility investigation dated August 21, 2020, related to the smoking incident involving Resident R2 at approximately 2:30 p.m. confirmed that the tip of four of the resident's right fingers got burned. The resident was transferred to the hospital and returned to the facility with physician's order for [MEDICATION(S)] (topical antimicrobial treatment indicated as an adjunct for the prevention and treatment of wounds). Tiny blisters were assessed to his right 2nd, 3rd, and 4th fingers). A review of Resident R2's clinical records revealed an August 21, 2020, order for [MEDICATION(S)] Cream apply topically three times a day to right 2nd, 3rd and 4th fingers for burn and should continue three times a day for seven days. An interview conducted on August 25, 2020, at approximately 11:45 a.m., with Resident R2 confirmed that he had regularly seen Resident R1 wearing a smoking apron when they were smoking, but that on Friday, August 21, 2020, he was not wearing it. Review of Resident R1's hospital documentation from the burn unit revealed a dermatology consult completed on August 21, 2020, at 3:23 p.m., which indicated that approximately 15% of his total body surface had partial thickness (second degree) [CONDITION(S)] to the left anterior (front) and posterior (back) arm as well as the left flank (side of body) and left-sided face and posterior head. Left arm pain. Resident was admitted to the burn unit for wound care and monitoring. An interview with activity assistant, Employee E5, on August 25, 2020, at approximately 12:05 p.m., revealed that she is one of three activity assistants who regularly take Resident R1 out to smoke. She stated that she would always put the smoking apron, which was hanging on the back of her second-floor office door on a hook, on Resident R1 before taking him down to the first floor smoking area. In a second interview with Employee E5, on August 26, 2020, at about 2:15 p.m. she confirmed that all smoking materials were kept in a locked box kept behind the first-floor nurse station. She also said that she would only ever give Resident R1 one cigarette at a time, and she would usually light it for him, unless he insisted on doing it himself then she would wait there until it was lit and take the matches. This deficiency is cited as past non compliance. On August 21, 2020, the facility initiated a plan of correction to address the substantiated concern of supervision of residents during smoking that included the following: 1) the facility provided first aid to Resident R1 and R2. Both residents were immediately transported to hospital for evaluation and treatment following the smoking incident. 2) The facility suspended smoking at the facility on 8/21/2020. 3) The facility immediately initiated an investigation and suspended Employee E10 on 8/21/2020. 4) A full search was conducted for any smoking paraphernalia kept by any resident at the facility. 5) I f any resident who desired to still smoke was offered alternative to smoking (i.e. [MEDICATION(S)] patches). 6) If paraphernalia was found in a resident room it was returned to the resident's family. 7) The receptionists received inservice training on 8/21/2020 to inspect packages to look for smoking paraphernalia. 8) All facility staff received training on the oversight of residents with smoking paraphernalia on 8/21/2020. 9) All facility staff received training from 8/21/2020 through 8/24/2020 in the facility becoming a smoke free facility. An interview was conducted with the Nursing Home Administrator on August 26, 2020, at approximately 4:00 p.m., confirmed that he understood that the facility failed to provide a safe, supervised smoking environment for Resident R1 and Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.14(c)(d)(1) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, review of hospital records, facility documentation, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure residents were free from staff neglect for one of two residents reviewed, which resulted in actual harm to Resident R1 who was not provided with a smoking apron while smoking. Resident R1 sustained second degree [CONDITION(S)] on the left side of face, left flank, anterior and posterior left arm and bilateral hand palms. This failure was identified as past non-compliance. (Resident R1) Findings include: A review of the facility policy title Abuse and Neglect - Clinical Protocol, dated as revised July, 2017, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the facility Smoking policy, revised May 2017, revealed that the facility would establish and maintain safe smoking practices including unless otherwise designated, smoking articles will be maintained by assigned facility staff. Review of the clinical record for Resident R1 revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of Resident R1's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident's needs) dated July 31, 2020, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment.) score of 11 indicating the resident was moderately cognitively impaired. A review of Resident R1's plan of care revealed a smoking care plan developed January 28, 2020, that indicated that the resident would follow the smoking policy and that he understood that the facility would keep his smoking materials, including cigarettes and lighting material in a locked box, that he would wear a smoking apron and that staff needed to light his cigarettes for him. Further review of the clinical records for Resident R1 revealed a smoking assessment dated [DATE], which indicated that Resident R1 needed assistance to and from the smoking area and that he was required to wear a smoking apron. Review of facility documentation revealed on August 21, 2020, at approximately 12:35 p.m., staff heard Resident R1 calling for help. Two nurse aides, two nurses and the unit manager responded to the resident lounge on the first floor where they found Resident R1 sitting on a small table inside the lounge near the door leading out to the smoking area with flames coming from his shirt. The staff were able to put the flames out using their clothing and a fire extinguisher. The unit manager pulled the fire alarm and called 911 (Emergency Medical Services). The paramedics responded and transported the resident to the hospital burn unit. The documentation also revealed that Resident R1 sustained [CONDITION(S)] to his left shoulder, arm, chest, neck and back of his head. Further review of facility investigation dated August 21, 2020, related to the incident sustained by Resident R1 revealed that the activity assistant, Employee E10, had assisted Resident R1 to the smoking area, located outside the resident lounge on the first floor. She left the smoking area to get another resident a cup of water which is when Resident R1 attempted to light a second cigarette when he dropped the match onto his shirt. Resident R1 was unable to remove the match and his clothing caught on fire and he began yelling for help. Resident R2 was the only other resident in the smoking area, and there was an attempt for Resident R2 to help Resident R1. Resident R1, with flames on his shirt, then went into the building yelling for help when the nursing staff responded. A telephone interview with Employee E10, activity assistant, was conducted on August 25, 2020, at approximately 2:43 p.m. and confirmed that Resident R1 did not have a smoking apron on at the time of the incident. Employee E10, activity assistant, stated that she forgot to put the apron on him before bringing him down from his room on the second floor to the smoking area outside the first-floor lounge. When questioned further about the apron she stated that she had not taken him out to smoke for a while and that she just forgot to get it and put it on him. When asked how the resident got the second cigarette and the matches, she said she did not know. When questioned further she said that she thought that Resident R1 was good at hiding things and that he probably had them hidden in his sock or something like that. A review of Resident R2's clinical records revealed an annual MDS completed on June 26, 2020, with a BIMS score of 15, which indicates the resident was cognitively intact. An interview conducted on August 25, 2020, at approximately 11:45 a.m. with Resident R2 confirmed that he had regularly seen Resident R1 wearing a smoking apron when they were smoking, but that on Friday, August 21, 2020, he was not wearing it. An interview with activity assistant, Employee E5, on August 25, 2020, at approximately 12:05 p.m., revealed that she was one of three activity assistants who regularly take Resident R1 out to smoke. She stated that she would always put the smoking apron, which was observed hanging on the back of her second-floor office door on a hook, on Resident R1 before taking him down to the first floor smoking area. In a second interview with Employee E5, on August 25, 2020, at about 2:15 p.m. she confirmed that all smoking materials were kept in a locked box kept behind the first-floor nurse station. She also said that she would only ever give Resident R1 one cigarette at a time, and she would usually light it for him, unless he insisted on doing it himself then she would wait there until it was lit and take the matches. A review of Resident R1's hospital documentation from the hospital burn unit revealed an evaluation completed on August 21, 2020, at 3:23 p.m. which indicated that approximately 15% of the resident's total body surface had partial thickness (second degree) [CONDITION(S)] to the left anterior (front) and posterior (back) arm as well as the left flank (side of body) and left-sided face and posterior head. The resident was admitted to the burn unit for wound care and monitoring. This deficiency is cited as past non compliance. On August 21, 2020, the facility initiated a plan of correction to address the substantiated concern of supervision of residents during smoking that included the following: 1) the facility provided first aid to Resident R1 and R2. Both residents were immediately transported to hospital for evaluation and treatment following the smoking incident. 2) The facility suspended smoking at the facility on 8/21/2020. 3) The facility immediately initiated an investigation and suspended Employee E10 on 8/21/2020. 4) A full search was conducted for any smoking paraphernalia kept by any resident at the facility. 5) I f any resident who desired to still smoke was offered alternative to smoking (i.e. [MEDICATION(S)] patches). 6) If paraphernalia was found in a resident room it was returned to the resident's family. 7) The receptionists received inservice training on 8/21/2020 to inspect packages to look for smoking paraphernalia. 8) All facility staff received training on the oversight of residents with smoking paraphernalia on 8/21/2020. 9) All facility staff received training from 8/21/2020 through 8/24/2020 in the facility becoming a smoke free facility. The facility failed to protect the rights of residents to be free from neglect by not providing a smoking apron which resulted in actual harm to Resident R1 sustaining second degree [CONDITION(S)] on the left side of face, left flank, anterior and posterior left arm and bilateral hand palms. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.14(c)(d)(1) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical records, facility and hospital documentation and interviews with the staff, it was determined that the facility failed to provide adequate supervision to ensure the safety for two of 30 residents resulting in actual harm (Residents R49 and CL2). Findings include: Review of Resident R49's clinical record revealed physician's orders [REDACTED]. In addition, the physician ordered the staff to administer Hydrochlorothiazide (a water pill) 12.5 milligrams (mg) by mouth every day and Tramadol (a narcotic pain medication to relieve moderate to severe pain) 50 milligrams by mouth at bedtime for osteoarthritis pain. Both medications increase the risk of falls as noted in the plan of care developed July 3, 2014, (Hydrochlorothiazide increases the need to urinate frequently and Tramadol with a sedative (drowsy) effect.) A quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs) completed on November 11, 2015, indicated that Resident R49 was severely cognitively impaired, had total dependence on two staff members for hygiene and bathing, required extensive assist of two staff for transfers and was frequently incontinent of bladder and bowel. A plan of care was developed on July 3, 2014, to address the risk of falls due to an unsteady gait, a history of falls and potential medication side effects. Interventions were included such as a wide bed in the low position, to provide Hipsters (undergarment with extra padding on the hip area), to provide assistance with transfers, to reinforce the need to call for assistance, to administer medications per the physician's orders [REDACTED]. Review of the nursing documentation on January 20, 2016, at 12:00 a.m., indicated that while the nurse was passing medications, she heard the resident calling for help. The resident was found lying on the floor at the top of the bed. The resident was noted to have her gown off, and the gown was still in the bed, and the resident was barefoot. The resident had stated that she was trying to get up to get dressed. A urine specimen for culture and sensitivity was ordered by the physician at that time however there was no evidence that the plan of care for fall prevention had been reviewed and updated after the resident had fallen on January 20, 2016. The nursing documentation also dated January 20, 2016, stated that the resident was an early riser, and that the staff were to monitor the resident due to episodes of time confusion, usually around 2:00 a.m. to 3:00 a.m., and that the resident was to be made aware of the time when awake. A fall assessment dated [DATE], stated that Resident R49 usually thought it was time to get up around 2:00 a.m. to 3:00 a.m. Documentation on January 23, 2016 at 4:43 a.m., stated that at 2:30 a.m. the resident had made an attempt to get out of bed, the resident was made aware of the time, and the resident stated she had some pain on her left side and was medicated for the pain. Review of Resident R49's Medication Administration Record (MAR) dated February 24, 2016, revealed that the resident had received Tramadol 50 milligrams by mouth at 9:00 p.m., bedtime. A nursing note on February 25, 2016, at 7:55 a.m., stated that Resident R49 had been found on the floor at 1:20 a.m., with her head on the side of the dresser. The resident had swelling on the left cheek and eye and there was bleeding from a laceration (a deep cut in the skin) above the eyebrow that measured 4 centimeters by 2 centimeters. An investigation timeline of events completed by the facility on February 25, 2016, noted that nursing rounds were done and Resident R49 was in bed sleeping at 1:00 a.m., and she had not been incontinent. There was no evidence that the resident had been toileted when staff had checked her. The facility's investigation of the resident's fall dated February 25, 2016, revealed that 911 was alerted at 1:35 a.m. The resident was transferred from the facility to the hospital at 1:50 a.m. Review of the hospital documentation dated February 29, 2016, reported that the resident had sustained an acute C3-C4 neck fracture (a fracture in the cervical (neck) region of spine, which may cause functional loss of the ability to breath, cause pain and or tingling). Nursing readmission documentation on March 4, 2016, stated that the resident had returned from the hospital with a neck brace in place, was short of breath and had wheezing, had behavior that was very aggressive and aggravated, had a feeding tube and had bruising under the left eye. The resident was admitted to Hospice care (care for the sick, especially the terminally ill) on March 14, 2016, per the family's request. Observations of the resident on March 28, 2016, during the initial tour of the facility, revealed that the resident was in bed, a Miami J collar (hard padded neck brace) was in place on the resident's neck and that the resident was verbally unresponsive. The Nursing Home Administrator confirmed in an interview on March 31, 2016 at approximately 1:00 p.m., that she was not aware that Resident R49 had previously fallen on January 20, 2016, or that staff had intercepted the resident getting out of bed on January 23, 2016. The facility failed to provide adequate monitoring and supervision for a resident with impaired cognition, identified side effects of medications and a history of falls resulting in actual harm to that resident. Clinical record review of Resident CL2 revealed that the resident was admitted to the facility on [DATE], for rehabilitation and pain management following a right hip replacement. The resident had [DIAGNOSES REDACTED]. The resident was ordered the following medications: [REDACTED]. In addition, the physician ordered Oxycodone Hcl (a narcotic pain reliever- for pain and can cause drowsiness) 5 mg, give two tablets every four hours for severe pain. A quarterly Minimum Data Set assessment completed on December 9, 2015, stated that CL2 had a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. In addition, the resident required the assistance of the staff for transfers, toileting, dressing, eating and bathing and was incontinent of bowel and bladder. A plan of care was developed to address the risk for falls due to impaired balance, poor coordination and potential medication side effects. Interventions in the care plan included to offer toileting before and after meals and twice during the 11 p.m.- 7 a.m. shift and to report the development of pain, and change in mental status, ADL (Activities of Daily Living) function, appetite or neurological status per the facility's After Fall Guidelines. Review of the nursing documentation on December 11, 2015 at 1:03 p.m., stated that the resident fell after returning from therapy. The resident stated that she was trying to pick up a paper from the floor. She was found in a kneeling position with her arms on the bed. The resident was assisted to bed and was assessed. Review of nursing documentation on December 11, 2015 at 7:50 p.m., revealed that the resident was found lying on the floor face down. The nurse reported no injury--neuro checks done (assessment of neurological status) and full range of motion to arms and legs. Review of the nursing documentation on December 12, 2015 at 4:30 a.m., revealed that the resident was found sitting on the floor near her bed. The resident stated that she was trying to get to the bathroom. She stated she did not hit her head. The resident complained of right knee and right hip pain. The resident was assisted to the bathroom, voided and a urine specimen was collected. The resident was assisted back to bed. The physician was notified and ordered an X-ray of the right knee and hip. The radiology report indicated a dislocation (movement of the bone from the normal state) of the right hip arthroplasty (the hip replacement). The resident was transferred to the hospital on December 12, 2015 at 7:30 p.m. The facility failed to provide adequate monitoring and supervision, and failed to update the resident's care plan after two falls less than seven hours apart for a resident with impaired cognition and a history of falls resulting in actual harm to that resident. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 08/26/15 28 Pa Code 201.18(b)(1) Management. Previously cited 08/26/15 28 Pa code 201.18(b)(3) Management. Previously cited 01/23/15, 08/26/15 28 Pa Code 211.12(d)(1) Nursing services. previously cited 08/26/15 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 01/23/15, 08/26/15

br>Based on staff interviews and a review of facility documentation, staff interviews, and observations, it was determined that the facility failed to adequately supervise and provide care to prevent accidents, resulting in actual harm to one resident while receiving care (Resident R1). Findings include: Review of Resident R1's initial nursing evaluation and current care plan revealed that the resident was at high risk for falls due to history of a stroke (lack of oxygenated blood to the brain resulting in loss of certain physiologic functions), dementia (an irreversible degenerative neurological disease characterized by forgetfulness, loss of cognition, and motor coordination) and glaucoma (a disease of the operative functions of the eye). The assessment reflected that the resident required assistance with bed mobility, transferring, dressing and personal hygiene. The assessment also indicated that the resident needed two staff persons for transfers. Review of nursing documentation and facility accident investigation, dated August 20, 2015 @ 11:30 a.m., revealed that Resident R1 fell out of bed while a staff person was attempting to provide incontinence care. It was noted that the care giver provided this care alone and rolled the resident in the bed without securing the resident when attempting to retrieve the equipment needed that was behind the staff person. This resulted in the resident falling from the bed and resulted in an immediate transfer to the hospital. The resident was admitted to the intensive care unit and the resident required intubated (a procedure in which a breathing tube is passed into the patient in order to protect the airway and provide for adequate respirations). On August 26, 2015 at 1:00 p.m. while attempting to interview the resident, upon entering her room, the resident was observed in bed, sleeping soundly, with her bed in the highest position, no fall precautions in place and no staff present. Additionally, a review of the resident care plan, initiated December 2, 2012 and a target date of December 4, 2015, revealed no additional interventions as a result of the resident fall of August 20, 2015 and subsequent hospitalization . A review of the facility's investigative report and an interview with the Director of Nursing on August 26, 2015 at 11:45 a.m. confirmed that the staff member was administering care at the time of the fall and the resident had fallen from the bed. The facility failed to ensure the safety of the resident during continence care and turning, which resulted in actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, facility documentation and facility staff interviews, it was determined that the facility failed to provide adequate assessments and ongoing monitoring of skin integrity, for one of two residents with multiple medical complications, which resulted in actual harm (Resident Cl 1). Findings include: The facility policy titled, "Skin Practice Guide," dated 2013, indicates risk factors for the development of skin alterations as incontinence, diabetes, [MEDICAL CONDITION] and immobility. Those identified with these risk factors should have complete head to toe evaluations and a Braden scale (an assessment tool to measure the risk for skin breakdown) should be completed. Interventions for those residents at risk include, routine skin evaluations, patient specific care plan to include prevention and management interventions. Care plan interventions may include, skin evaluations, support surface selections, positioning and mobility, pain management and incontinence management. Review of the clinical record for Resident Cl 1 revealed that the resident was readmitted to the facility in May 2014, with [DIAGNOSES REDACTED]. In addition, the resident was on contact precautions for a [DIAGNOSES REDACTED] infection ([MEDICAL CONDITION] - an internal bacteria that causes chronic diarrhea). A review of the quarterly Minimum Data Set assessment (MDS-a resident assessment tool) dated June 8, 2014, indicated that the resident was identified with moderate cognitive impairments, required extensive assistance from staff for transfers (moving from area to another), dressing, personal hygiene and bathing. The MDS further indicated that the resident required a Foley catheter (a tube passed into the bladder for the drainage of urine) for [MEDICAL CONDITION] and was incontinent of bowel. A review of the physician's orders [REDACTED]. A review of the nursing skin alteration records, dated June 21, 2014 through August 1, 2014, revealed that the nursing staff did not complete Resident Cl 1's skin assessments every Wednesday as ordered, despite having the risk factors outlined in the facility policy. An interview with Employee E2, the Director of Nursing, on August 28, 2014, at 11:30 a.m., confirmed that the nursing assistants did not perform skin checks on bathing days (Wednesday and Saturday) as the resident refused bathing. A further interview with Employee E2, revealed that no additional interventions were initiated in the current plan of care to address the resident's pattern of refusals with skin assessments and personal hygiene. There was no documentation that a mattress had been provided to relieve pressure to the area as indicated in the facility policy. A telephone interview with the resident's daughter on August 28, 2014, at 2:00 p.m., revealed that the facility had not provided the resident with a specialty mattress prior to the identification of the newly identified sacral skin impairment. The daughter stated in an interview that she witnessed the facility change the mattress on the bed to a specialty mattress on August 1, 2014, after the identification of the new wound. A review of Resident Cl 1's nursing documentation for July 2014, indicated that the resident had discomfort on July 6, 9, 18 and 28, 2014, without receiving pain medication. Nursing documentation dated July 30, 2014, revealed that the resident expressed, "back side pain" in the presence of the daughter and was administered an [MEDICATION NAME] at that time. There was no documented evidence, when it was requested, that a pain assessment had been completed. There was no facility policy available on pain assessments, when this was requested. Nursing documentation dated August 1, 2014, at 4:07 p.m., indicated that the nursing staff identified two new skin alterations above the resident's sacrum (the bone at the base of the spine). The physician's progress notes dated August 2, 2014, at 1:06 p.m., revealed that the resident had, "a large erythemic (reddened) tender, fluctulent (compressible) swelling to the sacrum with expressible purulence (pus)." Further review of the physican's progress notes indicated that the resident required surgical intervention and intravenous antibiotics to treat the newly identified sacral abscess (pus filled cavity). The physican's orders dated August 2, 2014, indicated that the resident was to be transferred to the hospital for further evaluation and treatment of [REDACTED]. Nursing documentation dated August 5, 2014, at 5:47 p.m., indicated that the resident's wound had been positive for osteo[DIAGNOSES REDACTED] and that the wound culture was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus, a contagious and antibiotic-resistant staph bacteria that leads to potentially dangerous infection). The plan of care dated April 2, 2014, did not identify the sacral area as a problem or initiate the development of interventions for the treatment and care of this area. Observation of a photograph taken at the hospital by the attending physician and sent to the Nursing Home Administrator, which was included in the facility documentation related to the resident's newly identified skin alteration, confirms the presence of an open sacral wound as indicated by the attending physican's notes on August 2, 2014. The facility failed to ensure that this resident, who was identified with multiple medical conditions, was adequately assessed and monitored to prevent the development of new pressure ulcers which resulted in actual harm to this resident. 28 Pa Code: 201.18(b)(1) Management 28 Pa Code: 211.12(d)(1)(5) Nursing services. Previously cited 2/27/14, 10/29/13 and 3/28/13.

Based on observation, review of clinical records, facility policy and facility documentation, and interviews with staff, it was determined that the facility failed to reassess a resident for pain resulting in actual harm, obtain physician orders [REDACTED]. Findings include: Review of Resident R71's clinical record revealed that the resident was admitted to the facility on [DATE], following an inpatient hospital stay for dehydration,[MEDICAL CONDITION] (blood stream infection), and multiple decubitus ulcers (pressure sores) with osteo[DIAGNOSES REDACTED] (bone infection) present in the sacral and ischial ulcers. A "Patient History and Physical", completed on November 26, 2013, indicated that Resident R71 had been transferred to the facility for treatment of [REDACTED]. Further review of the "Patient History and Physical" dated November 26, 2013, indicated that at the time of the exam, the resident was noted with nine pressure ulcers. The pressure ulcers were documented in the following areas: left wrist, left armpit, left thigh, penis, calcaneus, left ischium, sacrum and right ischium. The left wrist, left armpit, left thigh, left ischial, sacral and right ischial ulcers were noted to be Stage IV (ulcer involving loss of skin layers, exposing muscle and bone) ulcers. In addition, the patient was noted to be cachectic (extremely malnourished and emaciated) with chronic pain related to the presence of multiple stage IV pressure ulcers. It was also noted in the "Patient History and Physical" that prior to admission, the resident's pain had been treated with [MEDICATION NAME] (narcotic [MEDICATION NAME]-medication used to relieve pain), [MEDICATION NAME] (opiod [MEDICATION NAME]) and [MEDICATION NAME] (opiod [MEDICATION NAME]). A review of Resident R71's Initial Minimum Data Set (MDS-assessment tool) dated November 29, 2013, indicated that the resident was cognitively (ability to think, learn and reason) impaired, unable to walk and requires extensive physical assistance from two or more staff members for dressing, eating, personal hygiene and bathing. The resident is also noted with impaired range of motion to both the upper (shoulders, arms and hands) and lower (legs, knees and feet) extremities bilaterally (both sides of the body). Further review of the initial MDS revealed that the resident had been receiving pain medication on both a scheduled and as needed basis in the last five days prior to the resident's admission to the facility. The initial MDS also reflected that the resident had identified care needs in the area of pain. A review of current physician's order [REDACTED]. Further review of the physician's order [REDACTED]. A subsequent "Patient History and Physical", dated December 20, 2014, indicated that the resident had been observed while receiving dressing changes and that the resident was noted to "Intermittently scream in pain". A Review of Systems noted also dated December 20, 2013, further noted that "Patient screaming in pain." Interview with Employee E8, registered nurse, on February 26, 2014, at 11:10 a.m., immediately prior to the start of wound treatment, revealed that the employee was familiar with the resident and has previously completed wound care on the resident. Further interview with Employee E8 revealed that Resident R71 does have pain on occasion and does experience pain during wound treatment. Employee E8 indicated that the resident had received a scheduled pain medication at 9:00 a.m. and also had been medicated with Tylenol 650 mgs at 10:00 a.m., prior to the start of the treatment. Employee E8 also stated that the resident could be remedicated after the procedure if the resident's pain persisted. Treatment observation to Resident R71 on February 26, 2014, at 11:15 a.m., revealed Employee E8, registered nurse and Employee E9, licensed nurse, providing wound care to multiple wounds on the resident's lower back. As staff began to remove the adhesive dressing from the residents' wound, the resident began to moan. When Employee E8, applied Dakin's solution to the first wound, the resident started to express pain. Employee E8, continued with the wound treatment. When Employee E8 applied Dakin's solution to the second wound the resident again called out in pain in a louder voice. Employee E9 asked the resident if the wound treatment burned the resident responded "yes". Employees E8 continued the wound treatment as the resident again began to moan and express pain loudly. Observation of the resident, at that time, noted the resident to be grimacing. Employees E8 continued the wound treatment as the resident continued to groan and verbalize pain repeatedly. Neither Employee E8 nor E9 offered the resident any additional interventions to relieve the resident's pain. Review of the comprehensive plan of care for resident R71, dated November 26, 2013, and continuing to present, revealed the resident had been identified as at risk for pain. Interview with Employee E2, director of nursing, on February 26, 2014, at 11:50 a.m., revealed that all residents should be assessed and monitored for pain during wound treatments. Further interview with Employee E2, confirmed that if a resident experiences pain during the treatment staff should stop the treatment and assess the resident's pain level. The facility failed to ensure that Resident R71 was assessed and monitored for pain during a wound treatment resulting in actual harm to that resident. Review of Resident R13's clinical record indicated the resident had been admitted from the hospital to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of the Discharge Information from the hospital, dated February 19, 2014, indicated that Resident R13 was scheduled for [MEDICAL CONDITION] therapy on February 20, 2014, at 11: a.m. Review of nursing notes dated February 20, 2014, at 5:20 p.m. noted that Resident R13 was out of the facility for [MEDICAL CONDITION] therapy. The Director of Nursing stated in an interview on February 26, 2014, at approximately 1:30 p.m. that the resident had been going to out-patient [MEDICAL CONDITION] therapy daily and that a physician order [REDACTED]. There was no evidence available at the time of the survey that a physician order [REDACTED]. Review of the clinical record for Resident R60 revealed current physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. The order further clarified that the [MEDICATION NAME] was to be administered as needed (prn) for a hemoglobin level (red blood cell/carries oxygen to tissues) less that 10 mg/dl. (milligrams per deciliter), for a systolic (maximum) blood pressure less than 170 mmHg (millimeters of Mercury), and diastolic (minimum) blood pressure less than 100 mmHg. Review of another physician's orders [REDACTED]. Review of a laboratory report dated February 14, 2014 revealed Resident R60's documented hemoglobin level was 9.6 mg/dl. Review of nursing documentation dated February 20, 2014, indicated Resident R60's [MEDICATION NAME] was not available at the facility, and was reordered from the facility's pharmacy. Review of the Medication Administration Record, [REDACTED]. Further review of the clinical record revealed no documentation of clarification with the physician of what route of administration the [MEDICATION NAME] should be administered every 21 days, if there were any parameters the staff should follow prior to administration of the [MEDICATION NAME] scheduled every 21 days, and no clarification regarding how frequently the "as needed" dose was to be administered to Resident R60. Interview with the Director of Nursing, on February 26, 2014, at 9:30 a.m., confirmed the facility did not have an established policy regarding [MEDICATION NAME] administration, and confirmed there was no clarification of physician's orders [REDACTED]. 483.25 Quality of Care. Previously cited state deficiency 10/29/13 and 3/28/13. 28 PA Code: 211.12(d)(1)(5) Nursing services. Previously cited 10/29/13 and 3/28/13. 28 PA Code: 211.12(d)(2) Nursing services. Previously cited 3/28/13. 28 PA Code: 211.12(d)(3) Nursing services.