Every finding on record at Quality Life Services - Mercer

Based on observation, review of facility policy and documents, and staff interviews it was determined that the facility failed to maintain sanitary conditions related to utensil storage and failed to monitor operating temperatures of the dish machine in the main kitchen.Findings include:A current facility policy entitled Cleaning Dishes/Dish Machine indicated that dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation; and during the unloading process, visually inspect all items for cleanliness, if dishes are not clean repeat prep and wash steps.Review of the facility document entitled High Temperature Dish Machine Log Form provided by the facility on 8/10/26, revealed missing documentation of the operating temperatures of the dish machine for 11 of 28 meals.8/03/26, lunch and supper8/05/26, breakfast, lunch and supper8/08/26, breakfast, and lunch8/09/26, breakfast, lunch, and supper8/10/26, breakfastObservation on 8/10/26, at 10:20 a.m. revealed two butter knives with a yellow substance and three butter knives with visible smearing in the plastic utensil bin on the tray line in the main kitchen.During an interview at that time, the Food Service Manager confirmed that the high temperature dish machine log form lacked evidence that staff monitored the operating temperature of the dish machine before the above meals, and that the butter knives were not clean. 28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(2.1) Management28 Pa. Code 211.6 (f) Dietary Services28 Pa. Code 211.10(d) Resident care policies

Based on review of clinical records and staff interviews, it was determined the facility failed to provide personal care in accordance with the comprehensive person-centered care plan for one of 16 residents reviewed (Resident R7). Findings include:Review of a current facility policy entitled Activities of Daily Living revealed that residents will be provided equipment and instruction for mouth care, shaving, make-up and hair care. Resident R7's clinical record revealed an admission date of 8/25/26, with diagnoses that included memory deficit, arthritis and right sided weakness. Resident R7 was identified with cognitive impairment. Resident R7's Care Plan dated 5/25/26, revealed will will have all my physical, medical and psychological needs met during the duration of my stay in this home. Observation on 6/17/2026 at approximately 1:40 p.m. revealed Resident R7 to not be shaven and had long fingernails with dirt underneath the nails. During an interview on 6/17/26, at 2:40 p.m. the Director of Nursing confirmed that Resident R7 had not been shaven and had long fingernails with dirt under them. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of a facility policy, observations and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators on the nursing unit (resident refrigerator utilized for food brought in from the community). Findings include: A facility policy entitled Food Brought in From Outside Sources dated 1/26, revealed the purpose of this policy is to ensure the nursing homes have procedures in place for the safe and sanitary storage, handling and consumption of food including food and fluids purchased through third party vendors and brought in by family members and other visitors. Observation on 6/15/26, at 1:20 p.m. revealed a refrigerator with freezer in the residents' dining room with six individual ice packs for resident care stored amongst resident food items in the freezer. Interviews at the time of the observation with the Dietary Manager and Dietitian confirmed that the ice packs for resident care stored along with the residents' food were unsanitary and are not permitted to be stored with the residents' food. Interview with the Nursing Home Administrator (NHA) on 6/15/26, at 3:10 p.m. confirmed that resident care items, such as ice packs, are not permitted to be stored with resident food to ensure all food items have safe and sanitary storage. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to follow physician orders for one of two residents reviewed (Closed Record Resident CR2). Findings include: A facility policy entitled, Physician Orders, dated 4/16/25, revealed Policy - Physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so. Purpose - to ensure that the residents receive all medications and treatments that are ordered by the physician in a timely manner. Resident CR2's clinical record revealed an admission date of 6/11/25, with diagnoses that included femur fracture of right leg (fracture of the largest leg bone), metabolic encephalopathy (a condition where brain function is disrupted due to chemical imbalances in the body such as illnesses), diabetes mellitus type two (a chronic health condition when blood sugar is uncontrolled and high), and atrial fibrillation (an irregular and often rapid heart rate that causes poor blood flow). Review of Resident CR2's Medication Administration Record (MAR) revealed a physician's order with start date of 6/11/25, for Xultophy Subcutaneous Solution Pen-Injector 100-3.6 Unit-MG/ML [milligrams/milliliter] (Insulin Degludec Llraglutide)- Inject 5 unit subcutaneously at bedtime for diabetes mellitus type two. Hold date from 6/11/25 to 6/12/25, D/C [discontinue] date 6/17/25. Resident CR2's MAR further revealed for the month of June 2025 that his/her Xultophy insulin was not administered per physician's order on 6/13/25, 6/14/25, 6/15/25, and 6/16/25. During an interview on 7/31/25, at 11:20 a.m. the Director of Nursing confirmed the Xultophy insulin noted above was not administered per physician's order for Resident CR2 during the month of June 2025, due to pharmacy not providing medication. 28 Pa. Code 211.9(d)(f)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of one residents observed with pressure ulcers (Resident R1). Findings include:A facility policy entitled, Wound Dressing Change, dated 7/08/25, revealed the purpose is to prevent contamination of the wound bed. Procedure steps indicated #10 Explain the procedure and provide privacy. Position the area to be treated while maintaining privacy #11 Cleanse your hands #12 Open dressings to be used without touching the dressing. Keep the dressing and/or gauze within the open packet and place it directly on top of the barrier. Open as many gauze packets as necessary to perform the treatment #13 Open the syringe (for cleaning) and keep it within the open packet. Place it directly on top of the barrier. #14 Open the sterile container #15 Place a plastic bag for soiled dressing supplies within easy reach #16 Open the solution to be used and pour it into an individual container. Do not contaminate the dressings with bottle or tubs in anyway. #17 Apply the ordered medication/ointment to the open dressing #18 Expose the area to be treated and protect privacy. 18.1 Apply clean gloves and remove the soiled dressing 18.2 Place the dressing and gloves into a plastic bag and seal #19 Cleanse your hands. Apply clean gloves #20 Cleanse wound using commercial wound cleanser #21 If using NSS, carefully flush the wound with NSS by projecting over the wound. #22 Wipe any excess fluid from the surrounding skin using a dry gauze wipe #23 Measure wound using disposable wound measuring guide, if indicated #24 Dispose of used supplies in the plastic bag. Remove the soiled gloves and place them in a plastic bag #25 Cleanse your hands. Apply clean gloves #25 Apply treatment medication as ordered using a cotton tipped applicator, sterile tongue blade or gauze pad onto which the medication has been applied. Do not touch the exposed area in any way. #27 Apply clean dressing, touching only the edges of the dressing #28 Secure the dressing with tape. Press edges in place #29 Write the date, time and nurse's initials on the tape and then apply it to the top of the dressing. #30 Remove gloves and place them in a plastic bag #31 Cleanse your hands. Resident R1's clinical record revealed an admission date of 5/20/25, with diagnoses including cellulitis of left lower limb (a bacterial infection that causes redness, pain, and warmth), anxiety, osteoarthritis of knee (occurs when flexible tissue at the ends of the bones wear down in the knee), and diabetes mellitus (a chronic health condition where there is not enough insulin produced to control blood sugar levels). During an observation of wound care on 7/29/25, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E1 proceeded with gloved hands to cleanse Resident R1's coccyx wound area and apply a new dressing without the benefit of washing hands after the removal of the old dressing. During an interview on 7/29/25, at 1:10 pm. LPN Employee E1 confirmed that he/she did not wash hands during the wound dressing change of R1's coccyx pressure ulcer, potentially cross contaminating the new dressing and the wound. During an interview with the Director of Nursing on 7/29/25, at 1:20 p.m. he/she confirmed that hand hygiene should be performed numerous times with a wound dressing change, including before and after the removal of the old dressing, and application of the new dressing to ensure proper infection control measures are taken to prevent cross contamination and infection. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility infection control program and staff interview, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control. Findings include: Review of the facility infection control program revealed there was no evidence of staff with specialized training to function as the IP and fulfill the responsibility for the Infection Prevention and Control Program. During an interview on 6/18/25, at approximately 10:00 a.m the Director of Nursing (DON) disclosed that as of 6/02/25, the IP no longer worked at the facility and that the DON had been covering the position since the IP left and as of 6/18/25, had not successfully completed the required specialized IP training. During an interview on 6/18/25, at approximately 11:25 a.m. the DON confirmed that there were no staff overseeing the infection control program who worked at least part time at the facility. 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to ensure evidence for provision of documentation of pressure ulcers for two of eight residents identified for pressure ulcers (Residents R1 and R2). Findings include: A facility policy entitled, Skin integrity and wound management with a policy and procedure review date of September 2, 2021, revealed, Perform skin inspection on admission and weekly by a licensed nurse. Document in PCC [Point Click Care]. Perform wound assessment and complete proper forms upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included obesity, reduced mobility, weakness, abnormalities of gait and mobility, and radiculopathy of the lumbar region (compressed nerve root of the lower back causing pain and numbness). Review of Resident R1's progress notes revealed that Resident R1 had developed a facility acquired Stage 2 (partial-thickness loss of skin) pressure ulcer on coccyx from 3/02/24. During an interview on 1/22/25, at approximately 1:15 p.m., Resident R1 stated that the facility does not regularly measure the pressure wound on his/her coccyx but does perform treatments. Review of Resident R1's progress notes revealed that documentation of weekly skin assessments for description and measurements were documented weekly until 5/22/24, then were documented 8/08/24, 12/18/24, 1/23/25, and 1/24/25. Review of Resident R1's clinical record revealed no evidence of weekly pressure ulcer documentation. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included urinary tract infection, pressure ulcer of the sacral region, type 2 diabetes (long term condition in which the pancreas does not make enough insulin and the body cannot control blood sugar), and underweight. Review of Resident R2's progress notes revealed that Resident R2 was admitted to the facility with a Stage 4 (full thickness loss of skin and bone exposure) pressure ulcer on right sacrum. Review of Resident R2's progress notes revealed that an initial skin assessment and documentation of weekly skin assessments for description and measurements were not documented until 1/23/25. Review of Resident R2's clinical record revealed no evidence of weekly pressure ulcer documentation/assessments. During an interview on 1/24/25, at 2:30 p.m. the Regional Nurse confirmed that there was no evidence of documentation of weekly pressure ulcer assessments completed in Resident R1 and R2's clinical records. 28 Pa. Code 211.5(f)(iv)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy and clinical records and facility documentation, and resident and staff interviews, it was determined that the facility failed to provide assistance with personal hygiene and showers for three of four residents reviewed (Residents R3, R4, and R5). Findings include: Review of facility policy entitled Showers with a revision date of March of 2020, revealed, A shower is provided for residents who are able to participate. Showers are given according to a pre-determined schedule and as needed. Observation of skin for redness, irritation, or irregularities is conducted during shower. Assist resident into shower and onto shower chair (resident may stand to shower if able). Remain with the resident. Assist resident with showering as needed. Document bath and personal care in Point Click Care. Resident R3's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 12/27/24, indicated that Resident R3 required substantial/maximal assistance from staff for bathing. During an interview on 1/22/25, at 1:30 p.m. Resident R3 stated that he/she is not getting bathed and hasn't had a shower in 2-3 weeks. Review of Resident R3's physician orders revealed that he/she was to get a shower every Monday and Thursday afternoon and as needed. Shower/bath documentation under tasks section of the clinical record, for the last 30 days, revealed that Resident R3 only received one bed bath, and zero showers in the shower room over 30 days. During an interview on 1/22/25, at 1:40 p.m. Resident R4 reported that he/she does not get showered/ bathed routinely and that he/she has not received a shower/bath in two weeks. Review of Resident R4's physician orders revealed that he/she was to get a shower every Wednesday and Saturday afternoon and as needed. Resident R4's most recent quarterly MDS dated [DATE], indicated that he/she required dependent assistance from staff for bathing. Shower/bath sheets revealed that Resident R4 hadn't received a shower in the past 30 days. Resident R5's MDS dated [DATE], indicated that Resident R5 required substantial/maximal assistance from staff for bathing. During an interview on 1/22/25, at 1:50 p.m. Resident R5 stated that he/she has not received a shower regularly and cannot remember when his/her last shower was. Review of Resident R5's physician orders revealed that he/she was to get a shower every Wednesday and Saturday on day shift and as needed. Shower/bath documentation in tasks for the last 30 days, revealed that Resident R5 only received one shower on 1/05/25, in the shower room and had been given Bed baths documented five times over 30 days. During an interview on 1/22/25, at 3:30 p.m. the Nursing Home Administrator and Regional Nurse confirmed that there was no evidence to determine that Residents R3, R4, and R5 were given a shower per their shower schedule on scheduled shower/bath days and the residents should be assisted by staff into the shower room unless he/she refuses. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policies, clinical records and facility documentation, and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Resident Protection from Abuse, Neglect or Exploitation, dated 1/16/23, revealed abuse- the willful infliction of injury .with resulting physical harm or pain or mental anguish .Willful means the individual acted deliberately, not that the individual intended to inflict injury or harm. Review of the Mechanical Lift: Use of policy, dated 1/16/23, revealed the purpose of the lift is to provide a safe, comfortable transfer between two surfaces for residents who have diminished functional abilities and to preform lift: 6.1: with one person on each side of the bed roll the resident toward you onto his/her side, 6.2 Have the person on the other side of the bed place the sling under the resident's buttocks . Review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses of dementia, high blood pressure and unsteadiness on the feet. Review of Resident R1's Annual Minimum Data Set (MDS- an assessment tool used to facilitate the management of care), assessment dated [DATE], revealed that Resident R1 required extensive two-person assist with transfers. Review of Resident R1's ADL (Activities of Daily Living) Self Performance Deficit ADL care plan, originally dated 8/03/18, and revised on 4/27/21, revealed transfer with assist of 2 staff members and transferring sling. Review of a physician's order dated 7/22/22, revealed an order transfer with Hoyer (type of mechanical lift) and assist of two. Review of information submitted by the facility, dated 6/01/23, revealed that Nurse Aid (NA) Employee E1 was getting Resident R1 out of bed and into a chair using a full body lift. Resident R1 sustained a knot with an abrasion on the top left side of the forehead. NA Employee E1 stated they were not aware how the injury occurred and was not aware of the injury until it was pointed out by Licensed Practical Nurse (LPN) Employee E2. NA Employee E1 stated that Resident R1 was combative with care, grabbing the lift, screaming, biting and kicking. The documentation revealed that NA Employee E1 was suspended pending an investigation, the physician was notified and message was left for family. Review of Resident R1's clinical record revealed a nursing note written by the Assistant Director of Nursing on 6/01/23, at 7:43 a.m. revealed Resident was noted to have a large hematoma on the forehead.Hematoma was noted to be 1 centimeter by 0.8 centimeters. A scant amount of blood was noted in the center of hematoma. Neuro checks [neurological assessments regarding any head injury] initiated and are within normal limits at this time. The clinical record also identified that the physician was notified with neuro checks to continue and no need for x-ray per physician. Review of a statement written by NA Employee E1 revealed that on 6/01/23, I got Resident R1 up with a Hoyer. NA Employee E1 stated that someone asked if he/she noticed a knot on Resident R1's head, which NA Employee E1 stated no. Another nurse reminded NA Employee E1 that help was needed with Resident R1. Review of a statement written by LPN Employee E2 revealed that when NA Employee E1 was asked if they had help with Resident R1's transfer, NA Employee E1 stated they did not have help. NA Employee E1 stated to LPN Employee E2 I could not find anyone, we are short staffed. Facility documentation dated 6/07/23, revealed that NA Employee E1 transferred Resident R1 without assistance of another staff person as required. The facility neglected to utilize the appropriate transfer for a resident as ordered by the physician and care planned. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 210.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records and facility documentation and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm of a laceration to the head that required staples for one of four residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Resident Protection From Abuse, Neglect or Exploitation, dated 1/16/23, revealed abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident R1's clinical record revealed an admitted [DATE], that included diagnoses of dementia, diabetes and fracture of the pelvis. A review of Resident R1's Quarterly Minimum Data Set (MDS- an assessment used to facilitate the management of care and needs), dated 1/31/23, revealed that Resident R1 was confused and required extensive two person assist with transfers. A review of the task care plan for Resident R1 revealed on 12/13/22, Resident R1 was to utilize a front wheeled walker with two assist and physician's order summary indicated under Activities/Mobility: Resident R1 was a transfer with assist of two staff members. Review of a nursing note written on 3/02/23, revealed that Registered Nurse Employee E7 was notified by Nurse Aide (NA) Employee E6 that they needed help. Resident R1 was laying on their left side with their feet towards the door and head towards the end of the bed. The lift was near the resident's bed. Observed by the RN was a laceration on the resident's head with a medium amount of blood in the resident's hair and on the floor. The physician was contacted and Resident R1 was sent to the hospital. Review of a nursing note, dated 3/03/23, revealed that Resident R1 returned to the facility with a laceration repair done on the left back side of the scalp with three stitches in place. A review of NA Employee E6's statement, dated 3/02/23, revealed that NA Employee E6 indicated he/she was preparing Resident R1 for bed. Resident R1 was attempting to get into bed without assistance so NA Employee E6 got Resident R1 to sit in her chair and NA Employee E6 got a Sit to Stand lift. NA Employee E6 positioned Resident R1 to be lifted, placed Resident R1's hands on the handles and started the lift. Resident R1 let go of the handles and slide down between the lift and the bed. Resident R1 hit their head on the metal railing on the bed. NA Employee E6's statement further indicated that this was not the first time to use a Sit to Stand lift on Resident R1. Review of information submitted by the facility, dated 3/03/23, revealed that NA Employee E6 was transferring Resident R1 from their wheelchair to bed with a Sit to Stand lift. The resident let go of the handles and slid down between the bed and the lift, with Resident R1 hitting their head on the bed. The NA Employee E6 immediately unhooked the resident and laid the resident on the floor and got the nurse. Resident R1 was noted to have a laceration to the back of the head, the physician was notified and Resident R1 was sent to the hospital. Resident R1 returned to the facility with three sutures to the back of the head. The report revealed that Resident R1's transfer order was an assist of two with a wheeled walker and NA Employee E6 stated the reason he/she used the Sit to Stand lift was that the resident was having difficulty standing. The report stated that a NA cannot use a lift without an order and two staff members are to be present for lift use. During an interview on 4/5/23, at 11:17 a.m. the Director of Nursing (DON) confirmed that Resident R1 was a two person transfer with a wheeled walker. The DON also confirmed NA Employee E6 transferred the resident without the assistance of another staff member and also transferred the resident without a physician's order to use the Sit to Stand lift. The facility neglected to utilize the appropriate transfer for a resident as care planned which caused actual harm of a laceration requiring medical treatment and staples to Resident R1's head. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for three of three residents reviewed (Residents R1, R2, and Closed Record CR3). Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, Alzheimer's disease, and dysphagia (difficulty swallowing). Review of Resident R1's clinical record revealed a Pressure Ulcer Wound Tool dated 11/16/22, indicated wound to the right hip that was first found / occurred on 11/14/22. The Pressure Ulcer Wound Tool dated 11/23/22, revealed wound to the right buttocks that was first found / occurred on 11/8/22. The clinical record lacked documentation of the right hip area before or after 11/16/22, and of the right buttocks area before 11/23/22. During an interview on 12/29/22, at 1:24 p.m. the Assistant Director of Nursing (ADON) confirmed that Resident R1 never had an area to his / her right hip and the 11/16/22 Pressure Ulcer Wound Tool should have reflected right buttocks with found / occurred date as 11/8/22. ADON confirmed staff were not accurately documenting the location or first date found / occurred for Resident R1. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, diabetes, and dementia. Review of Resident R2's clinical record revealed a Non-Pressure Wound Tool dated 9/2/22, and 9/9/22, indicated a blister to the right buttocks and lacked a first found / occurred date. A Pressure Ulcer Wound Tool dated 9/15/22, and 9/22/22, indicated an area to the right buttocks and lacked a first found / occurred date. A Pressure Ulcer Wound Tool dated 9/30/22, indicated wound to the left buttocks that was first found / occurred on 8/30/22. A Pressure Ulcer Wound Tool dated 11/17/22, indicated a wound to the right hip that was first found / occurred on 8/30/22. The clinical record lacked documentation of the left hip wound before or after 9/30/22, and of the right hip before or after 11/17/22. During an interview on 12/29/22, at 1:27 p.m. the ADON confirmed that Resident R2 had a wound develop to his/her right buttocks on 8/30/22, and all Non-Pressure Wound Tool and Pressure Ulcer Wound Tool assessments completed should have reflected the found / occurred date as being 8/30/22. ADON also confirmed that Resident R2 never had an area to his/her left buttocks or right hip. ADON confirmed staff were not accurately documenting the location or first found / occurred for Resident R2. Review of Resident CR3's clinical record revealed an admitted [DATE], with diagnoses that included dementia, dysphagia, and high blood pressure. Review of Resident CR3's clinical record revealed a Pressure Ulcer Wound Tool dated 9/9/22, indicated a wound to the left upper and left lower left buttocks with a first found / occurred on 9/9/22. A Pressure Ulcer Wound Tool dated 9/15/22, and 9/22/22, indicated a wound to the left upper and left lower buttocks and lacked a first found / occurred date. A Pressure Ulcer Wound Tool dated 9/30/22, indicated a wound to the left upper buttocks with a first found / occurred on 9/21/22, and the left lower buttocks with a first found / occurred on 10/21/22. A Pressure Ulcer Wound Tool dated 10/7/22, 10/27/22, and 11/16/22, indicated a wound to the left upper buttocks and left lower buttocks with a first found / occurred of 9/11/22. A Pressure Ulcer Wound Tool dated 11/23/22, indicated a wound to the left hip with a first found / occurred on 9/11/22. A Pressure Ulcer Wound Tool dated 11/30/22, and 12/7/22, indicated a wound to the right buttocks with a first found /occurred on 9/11/22. A Pressure Ulcer Wound Tool dated 12/16/22, indicate a wound to the sacrum with a first found / occurred on 9/14/22. The clinical record lacked documentation of the left hip wound before or after 11/23/22, of the right buttocks before 11/30/22, and of the sacrum before 12/16/22. Review of Resident CR3's treatment record indicated that from 11/9/22, through 12/18/22, wound care was ordered and completed for a left hip wound. The Pressure Ulcer Wound Tool only mentions the left hip on 11/23/22, and not before or after this date. During an interview on 12/29/22, at 1:32 p.m. the ADON confirmed the following: Resident CR3 had wounds develop to his/her left upper and lower buttocks on 9/9/22, that merged to one larger area on 11/16/22 and all Pressure Ulcer Wound Tool assessments for the left buttocks should have reflected found / occurred date as being 9/9/22, Resident CR3 never had an area to his/her left hip or sacrum and those areas should have been documented as the left buttocks, on 11/30/22, and 12/7/22, the right buttocks should have been documented as the left buttocks, and the physician orders for treatment to the left hip, should have indicated the left buttocks instead. The ADON confirmed staff were not accurately documenting the location or first found / occurred for Resident CR3. 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for three of three residents with pressure ulcers reviewed (Residents R1, R2, and Closed Record CR3). Findings include: Review of current facility policy entitled, Skin Integrity and Wound Management dated 2/9/22, indicated Perform wound assessment and complete proper forms upon initial identification of altered skin integrity, weekly, and with any deterioration of wound. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, Alzheimer's disease, and dysphagia (difficulty swallowing). Review of Resident R1's clinical record revealed a progress note dated 11/8/22, that indicated wound care for coccyx to be done daily. A clinical record assessment entitled Pressure Ulcer Wound Tool dated 11/16/22, revealed a wound to the coccyx was first found / occurred on 11/8/22, wound to the left buttocks that was first found / occurred on 11/8/22, and a wound to the right buttocks that was first found / occurred on 11/8/22. The clinical record lacked an initial assessment of the coccyx, left buttocks, and right buttocks wound on 11/8/22, when found by staff. During an interview on 12/29/22, at 1:24 p.m. the Assistant Director of Nursing (ADON) confirmed that Resident R1's wounds and pressure ulcer measurements / assessments were not completed upon initial finding of the areas. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, diabetes, and dementia. Review of Resident R2's clinical record revealed a blister to the right buttocks developed on 8/30/22, with the first measurements / assessments being completed on 9/2/22. Further review revealed a Pressure Ulcer Wound Tool being completed for a right buttocks wound on 10/7/22, and then not again until 10/27/22, a period of 20 days and then not again until 11/17/22, a period of 21 days. During an interview on 12/29/22, at 1:27 p.m. the ADON confirmed that Resident R2's wounds and pressure ulcer measurements / assessments were not completed upon initial findings of the area or as frequently as required from 10/7/22, through 11/17/22. Review of Resident CR3's clinical record revealed an admitted [DATE], with diagnoses that included dementia, dysphagia, and high blood pressure. Review of Resident CR3's clinical record revealed a pressure area to the left buttocks developed on 9/9/22. A Pressure Ulcer Wound Tool was completed on 10/7/22, and then not again until 10/27/22, a period of 20 days and then not again until 11/16/22, a period of 20 days. During an interview on 12/29/22, at 1:32 p.m. the ADON confirmed that Resident CR3's wounds and pressure ulcer measurements / assessments were not completed as frequently as required from 10/7/22, through 11/17/22. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy, employee personnel records and staff interviews, it was determined that the facility failed to demonstrate that potential new employees are fully screened to ensure eligibility for employment in a long term care facility for one of five newly hired employees (Employee E5). Findings include: Review of a facility policy entitled Background Checks, last reviewed on 1/20/22, directed that a Federal Criminal History Background Checks be completed for employees that lived out of state in the previous two years prior to employment. Review of the employment record for Registered Nurse (RN), Employee E5, documented a hire date of 6/16/22, and revealed out of state residence within the past two years. There was no evidence that a Federal Criminal History Background Check was conducted as required. During an interview on 9/2/22, at 10:35 a.m. the Nursing Home Administrator confirmed that a Federal Criminal History Background Check was not conducted for RN Employee E5 prior to employment. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.19 Personnel policies and procedures

Based on observations and staff interview, it was determined that the facility failed to maintain equipment in proper condition to maintain a safe and sanitary environment for one of one hallways leading to the kitchen. Findings include: Observations on 10/4/21, at 8:51 a.m. in the short hallway leading into and out of the kitchen revealed that the windows were open and that the one window screen had approximately a one inch by one inch hole in it with the potential for bugs and flies to enter the hallway adjacent to the kitchen area. In addition, other window screens in this area had smaller open areas creating the potential to get larger and let bugs and flies into the kitchen area. During an interview on 10/4/21, at 9:00 a.m. the Environmental Services Director confirmed the above information. 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility records and staff interviews, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control. Findings include: During the entrance conference interview on 10/4/21, the Nursing Home Administrator (NHA) revealed that the facility past Director of Nursing (DON) was the designated IP and since his/her departure from the facility, the corporate nurse had been overseeing the infection control program and duties. Review of facility records indicated that the DON who was the designated IP left the faciity on [DATE]. During an interview on 10/7/21, at 8:33 a.m. the NHA confirmed that the corporate nurse who had been overseeing the infection control program and duties for the past 66 days had not yet completed the required specialized training / education. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed during catheter care for one of 14 residents reviewed (Resident R91). Findings include: Review of the Catheter: Care of Indwelling Urinary policy, dated 1/28/21, identified for staff to use downward strokes from the pubic area to the rectal area and when cleaning the catheter tube, wash away from the insertion site. Observation on 10/5/21, at 2:15 p.m. revealed that Nurse Aide (NA) Employee E2 identified that Resident R91's catheter was leaking and requested Licensed Practical Nurse (LPN) Employee E1 to check it. LPN Employee E1 noticed that the catheter tubing leading to the foley bag was disconnected. He/she connected the tubing without first cleansing the tubing with alcohol. During an interview on 10/5/21 at 2:20 p.m., LPN Employee E1 confirmed the above information. Observation on 10/5/21, at 2:25 p.m. revealed that NA Employee E2 was performing catheter care on Resident R91 and did not wash from the pubic area to rectal area. In addition, he/she cleansed the catheter tube towards the pubic area instead of away from the pubic area. During an interview on 10/5/21, at 2:35 p.m., NA Employee E2 confirmed the above information. During an interview on 10/6/21, at 8:30 a.m. the Director of Nursing confirmed that alcohol should have been used before connecting the catheter tubing and that catheter care included washing the pubic area and cleansing the catheter tube away from the pubic area. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility policy, observations and staff interview, it was determined that the facility failed to update/revise the care plan for one of sixteen residents (Resident R23). Findings include: The facility policy related to resident care plans, dated 1/06/20, indicated that care plans are working tools that are reviewed and revised at specific intervals and when there are changes in the resident's status. The policy indicated that when there are changes, the care plan is updated to include updated goals, new approaches/interventions and appropriate time frames. Resident R23's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Observations on 9/22/20, at 1:00 p.m., on 9/23/20, at 3:00 p.m., and on 9/24/20, at 11:15 a.m., revealed Resident R23 seated in a bedside chair with [MEDICATION NAME] (elastic dressing for swelling and support) on both hands/arms. Resident R23's fingers on both hands were swollen. Progress Notes dated 8/11/20, indicated that Resident R23 developed swelling of the hands and arms, extending up to the elbows, with the right arm more swollen than the left. Notes from a telemedicine (a medical exam conducted via an electronic device) visit conducted later the same day, revealed that Resident R23 had 4+ (severe) [MEDICAL CONDITION] of the right arm and 3+ (moderate) [MEDICAL CONDITION] of the left. New orders for lab work and an order for [REDACTED]. Progress Notes dated 8/14/20, indicated Resident R23's hands and arms were still swollen, but less, and that [MEDICATION NAME] were now in place as Resident R23 was not able to raise and/or straighten his/her arms. Resident R23's care plan related to chronic (long standing) kidney disease and fluid balance, lacked the new interventions to elevate Resident R23's arms and utilize [MEDICATION NAME]. During an interview on 9/24/20, at 1:45 p.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that Resident R23's care plan was not updated to reflect interventions instituted to address the [MEDICAL CONDITION] of the upper extremities. 28 PA Code 211.10(a) Resident care policies 28 PA Code 211.11(e) Resident care plan

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of 16 residents (Resident R23). Findings include: The facility policy related to restorative nursing (interventions to promote a resident's ability to function at their highest level), dated 1/06/20, indicated that restorative programs, including splinting and bracing, are to be documented in the medical record. Observations on 9/22/20, at 1:00 p.m., on 9/23/20, at 3:00 p.m., and on 9/24/20, at 11:15 a.m., revealed Resident R23 seated in a bedside chair with [MEDICATION NAME] (elastic dressing for swelling and support) and palm guards (positioning devices for the hand to prevent or treat contractures) on both hands. Resident R23 was wearing socks and his/her feet were plantar flexed (pointed downward). Prafo boots (a positioning device for the foot to prevent/treat foot drop) were present on the bedside stand. Resident R23's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R23's current physician orders [REDACTED]. The clinical record lacked documentation to reflect the consistent use of the palm guards on each shift per physician order. Documentation reflected the palm guards were in place on only two days (8/22/20 and 8/25/20) since ordered on [DATE]. During an interview on 9/24/20, at 11:50 a.m., Licensed Practical Nurse (LPN) Employee E2 indicated Resident R23's [MEDICATION NAME] were instituted in early August 2020, following a verbal order from the Certified Registered Nurse Practitioner. LPN Employee E2 confirmed that the verbal order wasn't entered in the clinical record. LPN Employee E2 further stated he/she wasn't sure why there were Prafo boots in Resident 23's room. During an interview on 9/24/20, at 11:55 a.m. Rehabilitation Employee E3 indicated that on 8/10/20, the therapy department recommended that Resident R23 wear Prafo boots at all times, with removal only for personal hygiene. During an interview on 9/25/20, at 11:55 a.m., the Director of Nursing confirmed that Resident R23's clinical record was not complete and accurate, lacking written orders/recommendations for Prafo boots and [MEDICATION NAME] and lacking daily documentation of palm guard use. 28 PA Code 211.5(f) Clinical records 28 PA Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, Minimum Data Sets (MDS-periodic assessment of resident care needs), Resident Assessment Instrument (RAI) Version 3.0 Manual, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of 16 residents (Resident R11). Findings include: Review of the RAI manual, dated 10/19, revealed that a significant change (decline or improvement) in condition assessment would be done if there was a change in two or more areas of the MDS including but not limited to decision making ability, mood change, change in frequency or severity of behavioral symptoms, decline in activities of daily living (ADL) incontinence patterns and unplanned weight loss. Resident R11's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R11's quarterly MDS, dated [DATE], revealed the following: Section D0100 or D0200 had no issues identified during the Resident Mood Review Section G0110 A1- limited assist with one person physical assist for bed mobility Section G0110 B1- supervision with one person physical assist for transfer Section G0110C1-independent walking in the room Section G0110D1-independent walking in the corridor Section G0110E1-independent with locomotion on the unit Section G0110F1, independent with locomotion off the unit Section G0110G1-limited assist with one person physical assist for dressing Section G0110H1-supervision with one person physical assist eating Section G0110I1-limited assist with one person physical assist for toilet use Section G0110J1-limited assist with one person physical assist for personal hygiene Section H0400-always continent of bowel Section K0300-no weight loss Resident R11's quarterly MDS dated [DATE], revealed the following change/decline in areas: Section D0100 or D0200 identified Resident R11 was feeling tired or with less energy Section G0110 A1- extensive assist with two person physical assist for bed mobility Section G0110 B1- extensive assist with two person physical assist for transfer Section G0110C1-extensive assist with one person physical assist walking in the room Section G0110D1-extensive assist with one person physical assist walking in the room Section G0110E1-extensive assist with one person physical assist walking in the room Section G0110F1, extensive assist with one person physical assist walking in the room Section G0110G1-extensive assist with one person physical assist for dressing Section G0110H1-extensive assist with one person physical assist eating Section G0110I1-extensive assist with two person physical assist for toilet use Section G0110J1-extensive assist with one person physical assist for personal hygiene Section H0400-incontinent of bowel Section K0300- weight loss Resident R11's MDS dated [DATE], identified changes in more than two of the identified criteria to initiate a significant change in condition MDS including a decline in mood, activities of daily living, bowel incontinence and weight loss. During an interview on 9/24/20, at 12:24 p.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that Resident R11 had changes in more than two areas identified from the 6/04/20 MDS to the 8/03/20 MDS and a significant change in condition MDS should have been initiated. 28 PA Code 201.14(a) Responsibility of licensee 28 PA Code 211.5(f) Clinical Records

Based on observations, review of facility policies and staff interviews, it was determined that the facility failed to maintain a sanitary environment in the main kitchen. Findings include: The Cleaning Dishes policy, dated 1/14/19, indicated to allow dishes to dry. invert dishes in a single layer to air dry. The Hand Washing policy, dated 1/14/19, revealed to wash hands after handling soiled equipment or utensils. Observations on 2/25/19, at 12:30 p.m. revealed the following: The kitchen floor was sticky in front of the ice machine area and there was a gap between the tile on the floor and the linoleum floor in the same area. A black buildup and debris was observed in the gap (the gap appeared as a one half inch seam the whole way around the gray tile). There were several blackened raised areas noted on the floor in the main kitchen. Additional observations of this floor area occurred on 2/26/19, at 8:31 a.m. The ice machine had an area of black substance noted on a protruding white plastic piece inside the ice machine. The Certified Dietary Manager (CDM) Employee E3 confirmed the observations of the kitchen floor and the ice machine at the time of the observations on 2/25/19, at 12:30 p.m Observation on 2/26/19, at 8:31 a.m. revealed two large service pans nested wet as they were in the drying phase of the cleaning process. At the time of the observation, the CDM Employee E3 confirmed the pans were nested wet and not positioned properly to dry effectively. Observation of dining service on 2/25/19, at 12:38 p.m. revealed a nurse aide enter the dining area with a fork in their hand asking where to place the fork due to a resident had dropped it on the floor in their room. The nurse aide placed the soiled fork on a four shelf cart and proceeded to obtain clean utensils to take to the resident without first washing or sanitizing their hands. During an interview on 2/28/19, at 11:20 a.m. the Director of Nursing confirmed that the staff should have washed/sanitized their hands prior to obtaining the clean utensils. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. code 201.18(b)(1) Management 28 Pa. Code 211.6(f) Dietary services