Every finding on record at Quality Life Services - Westmont

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital eight of 22 residents reviewed (Residents 3, 4, 5, 7, 17, 18, 32, 41). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated January 30, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all daily care needs, and had a diagnosis that included respiratory syncytial virus (RSV) pneumonia.Nursing notes for Resident 3, dated January 5, 2026, at 5:37 a.m., revealed that the resident was admitted to the local hospital with the diagnosis of deep vein thrombosis (DVT) (a clot in a vein).Nursing notes for Resident 3, dated January 23, 2026, at 12:35 p.m., revealed that the resident was coughing with her meal, unable to tolerate nectar thick liquids and respirations were even unlabored. Physician's orders for the resident to be sent to the local hospital for worsening respiratory conditions. The resident was admitted with diagnosis of RSV.There was no documented evidence for Resident 3 that a written notification of transfer was provided to the resident's responsible party on the dates listed above.A significant change MDS assessment for Resident 4, dated February 17, 20206, indicated that the resident was cognitively impaired, required maximum assistance from staff for her daily care needs and had diagnoses that included, chronic kidney disease.A nursing noted for Resident 4 dated September 11, 2025 at 12:19 p.m. revealed that the registered nurse was called the residents room where Resident 4 was minimally responsive. Resident had right upper thigh wound and the site had yellow drainage. Resident 4 was transported to the hospital where she was admitted with a diagnosis of infection of left hip wound.A nursing note for Resident 4 dated January 11, 2026 at 12:09 p.m. revealed that Resident 4 was lethargic and unable to maintain oxygen saturation. Resident 4 was transported to the hospital where she was admitted with a diagnosis of RSV.Review of Resident 4's clinical record revealed that there was no documented evidence that a written notification of transfer was provided to the resident's responsible party on the above mentioned dates. A quarterly MDS assessment for Resident 5, dated January 19, 2026, indicated that the resident was cognitively impaired, dependent on staff for his daily care needs and had diagnoses that included, arthritis and pain. A nursing note for Resident 5 dated September 20, 2025 at 12:19 p.m. revealed that the resident had intractable pain unrelieved with bedrest and ordered pain medication. Resident 5 was transported to the hospital where he was admitted with a diagnosis of urinary tract infection.A nursing note for Resident 5 dated January 12, 2026 at 8:45 p.m. revealed that the resident was crying out in pain when attempting to reposition in bed unrelieved with ordered pain medication. Resident 5 was transported to the hospital where he was admitted with a diagnosis of urinary tract infection.Review of Resident 5's clinical record revealed that there was no documented evidence that a written notification of transfer was provided to the resident's responsible party on the above mentioned dates. A quarterly MDS assessment for Resident 7, dated December 12, 2025, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs and had diagnoses that included, Parkinson's disease (a progressive neurodegenerative brain disorder affecting movement and central nervous system function).A nursing note for Resident 7, dated June 13, 2025 at 8:07 p.m. revealed that the resident had a change in mental status. Resident 5 was transported to the hospital where he was admitted with a diagnosis of change in mental status.A nursing note for Resident 7, dated August 22, 2025, at 7:34 a.m. revealed that the resident was having chest pain and asking for help. Resident 7 was transported to the hospital where he was admitted with a diagnosis of chronic congestive heart failure.A nursing note for Resident 7, dated October 29, 2025, at 7:25 a.m. revealed that the resident had a changes in behavioral status. Resident 7 was transported to the hospital where he was admitted with a diagnosis of metabolic encephalopathy (a syndrome of temporary or permanent brain dysfunction not caused by direct brain injury).A nursing note for Resident 7, dated November 28, 2025, at 12:17 p.m. revealed the resident had significant pain unrelieved with ordered pain medication. Resident 7 was transported to the hospital where he was admitted with a diagnosis of hydrocephalus (a medical condition involving the abnormal accumulation of cerebrospinal fluid within the brain's ventricles).A nursing note for Resident 7, dated December 7, 2025, at 9:36 a.m. revealed the resident had lethargy and weakness of the right side. Resident 7 was transported to the hospital where he was admitted with a diagnosis of generalized weakness.A nursing note for Resident 7, dated December 20, 2025, at 3:22 p.m. revealed that the the resident had a increased lethargy with marked weakness. Resident 7 was transported to the hospital where he was admitted with a diagnosis of acute cystitis (a sudden infection causing inflammation in the bladder).Review of Resident 7's clinical record revealed that there was no documented evidence that a written notification of transfer was provided to the resident's responsible party on the above mentioned dates. A quarterly MDS assessment for Resident 17, dated February 24, 2026, revealed that the resident was severely cognitively impaired, required assistance from staff for daily care needs, and had medical diagnoses that included kidney failure and Parkinson's disease. A nursing note for Resident 17 dated February 16, 2026, at 5:55 p.m. revealed that the resident was unable to hold her arms up, her hand grips were unequal, had a recent decrease in intake of food and fluids, had a headache and was somewhat lethargic. The physician was notified and ordered the resident to be sent to Conemaugh Hospital for evaluation. The resident was admitted with diagnosis of dehydration. There was no documented evidence for Resident 17 that a written notification of transfer was provided to the resident's responsible party.An admission MDS assessment for Resident 18, dated January 22, 2026, revealed that the resident is cognitively intact, requires assistance from staff for daily care needs, and has medical diagnosis that includes heart failure and high blood pressure. A nursing note for Resident 18 dated February 28, 2026, revealed that the resident was being evaluated for weakness and physician's orders were to send to local hospital. The resident was admitted with diagnosis of urinary tract infection and ambulatory dysfunction.There was no documented evidence for Resident 18 that a written notification of transfer was provided to the resident's responsible party.A quarterly MDS assessment for Resident 32, dated February 20, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had medical diagnoses that included heart failure and hypertension (high blood pressure).Nursing notes for Resident 32, dated November 2, at 5:00 a.m. and November 7, 2025, at 1:36 a.m. revealed that the resident complained of having shortness of breath and chest pain. Physician's orders were obtained each day to transfer the resident to the hospital for further evaluation and treatment.There was no documented evidence for Resident 32 that a written notification of transfer was provided to the resident's representative.An admission MDS assessment for Resident 41, dated January 5, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnosis that included cellulitis of right lower limb (an infection in the limb).A nursing note for Resident 41, dated January 15, 2026, at 8:27 p.m., revealed that the residents femoral popliteal bypass surgical incision (a surgical procedure that creates a new pathway for blood flow around a blocked artery in the leg) was hard, large and tender. Physician's orders were to send to the local hospital and the resident was admitted .There was no documented evidence for Resident 41 that a written notification of transfer was provided to the resident's responsible party.Interview with the Nursing Home Administrator on March 11, 2026, at 8:30 a.m. confirmed that for Resident's 3, 4, 5, 7, 17, 18, 32, 41 there was no evidence that a written notice of transfer was provided to the responsible parties. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for one of 22 residents reviewed (Resident 18).Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 18, dated January 22, 2026, revealed that the resident is cognitively intact, requires assistance from staff for daily care needs, and has medical diagnosis that includes heart failure and high blood pressure. Physician's orders for Resident 18 dated January 20, 2026, included an order for the resident to receive 12.5 milligrams of Carvedilol two times a day and to hold if systolic blood pressure is less than 100 mmHg; if heart rate is less than 60 beats per minute; and call physician if systolic blood pressure is greater than 170 mmHg. A review of Resident 18's Medication Administration Record (MAR's)for January and February 2026 indicated that the residents blood pressure on January 23 was 186/73 mmHg, on January 30 was 176/76 mmHg, on January 31 was 176/76 mmHg, on February 1 was 180/70 mmHg, on February 10 was 181/67 mmHg. There was no evidence that the physician was notified on the above dates that the residents systolic blood pressure was greater than 170 mmHg. On February 2, 2026, the resident's blood pressure was 162/78 mmHg and heart rate was 54 beats per minute. However, according to the MAR, staff administered carvedilol on February 2, 2026, when the medication should have been held. Interview with Nursing Home Administrator on March 11, 2026, at 9: 27 a.m. confirmed that the physician should have been notified of elevated systolic blood pressures on the days mentioned above and that the medication should have been held for heart rate less than 60 beats per minute and it was not. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to label one bottle of eye drops with the opened date, in one of two medication carts reviewed (B cart), failed to label two vials of tuber sol (a solution injected into the body to detect tuberculosis) with the opened date, in one of one medication room refrigerator reviewed, and failed to discard expired medical supplies in one of one medication rooms reviewed. Findings include:The facility's policy regarding medication labeling and storage, dated [DATE], revealed that multi-dose medications that have been opened or accessed are to be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open medication.Observations of the B medication cart on [DATE], at 09:24 a.m. revealed one bottle of Latanoprost Ophthalmic Solution .005 percent eye drops that were opened and not dated with the date they were opened.Observations in the medication room refrigerator on [DATE], at 09:27 a.m. revealed two open vials of tuber sol that were opened and not dated with the date they were opened.Observations in the medication room on [DATE], at 9:35 a.m. revealed that there were nine Huber needles (special needles used to access Medi ports, which are small medical devices implanted under the skin), that expired in November of 2024 and August of 2025, twenty-one intravenous starter kits that expired in January of 2023, February of 2024 and [DATE], and four, 22 gauge intravenous catheters (medical supplies used in the vein to provide fluids or medication), that expired in September of 2025.Interview with Licensed Practical Nurse 1 on [DATE]. 2025, at 9:45, confirmed that the bottle of eye drops and the two vials of tuber sol were not properly labeled with an expiration date, and that expired medical supplies should not be in circulation in the medication room.Interview with the Nursing Home Administrator on [DATE], at 10:08 a.m. confirmed that the multi-dose medications should have been labeled with an expiration date, and that that expired medical supplies should not be in the medication room.42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 22 residents reviewed (Resident 25).Findings include:The facility's policy regarding medication administration, dated November 11, 2025, indicated that staff were to ensure that medications were administered as prescribed in accordance with nursing principles and practice while maximizing independence and choice by utilizing resident centered care policies.Observations during medication administration on March 11, 2026, at 6:47 a.m. revealed that Licensed Practical Nurse 1 prepared to administer medications to Resident 25 and obtained Fish Oil and Senna/Docusate from stock medication bottles (medication used for multiple residents). The nurse touched the capsules of Fish Oil and Senna/Docusate with her bare hands and placed the capsules into the cup of medications. She then picked up a pill that had fallen on the top of the medication cart, picked it up with her bare hands, and placed it into the cup of medications. She then administered the medications to Resident 25.Interview with Licensed Practical Nurse 1 on March 11, 2025, at 6:29 a.m. confirmed that she should not have touched the medication with her bare hands.Interview with the Director of Nursing on March 11, 2026, at 8:00 a.m. confirmed that staff were not to touch residents' medications with their bare hands.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders to provide medications as ordered by the physician for two of 26 residents reviewed (Residents 24, 25) and failing to obtain a physician's order for fortified foods and health shakes for one of 26 residents reviewed (Resident 14). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated January 15, 2025, revealed that the resident was cognitively impaired and required maximum assistance from staff for her daily care needs. Physician's orders for Resident 24, dated December 28, 2024, included an order for the resident to receive 25 milligrams (mg) of Metoprolol (high blood pressure medication) daily and to hold the medication if the systolic (top number) blood pressure was less than 120 millimeters of mercury (mmHg) or the diastolic (bottom number) was less than 70 mmHg. However, the resident's Medication Administration Record (MAR) for January 2024 and February 2024 revealed that the resident was administered 25 mg Metoprolol on the following dates when her pressure was below the hold parameters: January 3 blood pressure was 118/70 mmHg; January 4 blood pressure was 110/70 mmHg; January 5 blood pressure was 102/72 mmHg; January 10 blood pressure was 110/76 mmHg; January 14 blood pressure was 116/90 mmHg; January 15 blood pressure was 104/68 mmHg; January 17 blood pressure was 110/80 mmHg; January 18 blood pressure was 114/80 mmHg; January 20 blood pressure was 118/80 mmHg; January 22 blood pressure was 112/82 mmHg; January 26 blood pressure was 118/64 mmHg; January 28 blood pressure was 112/72 mmHg; January 30 blood pressure was 114/83 mmHg; January 31 blood pressure was 110/75 mmHg; February 3 blood pressure was 110/78 mmHg; February 5 blood pressure was 108/82 mmHg; February 6 blood pressure was 102/74 mmHg; February 11 blood pressure was 126/76 mmHg; February 16 blood pressure was 104/80 mmHg; February 20 blood pressure was 106/80 mmHg. Interview with the Nursing Home Administrator on February 20, 2025, at 2:31 p.m. confirmed that Resident 24's Metoprolol was administered on the above dates when it should have been held. An admission MDS assessment for Resident 25, dated January 17, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included hypertension (elevated blood pressure). A care plan for the resident, dated January 13, 2025, revealed that the resident has hypertension, and when administering anti-hypertensive medications staff was to monitor for their effectiveness and any possible side effects such as orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position) and increased heart rate. Physician's orders for Resident 25, dated January 14, 2025, included an order for the resident to receive one five mg tablet of Amlodipine (used to treat high blood pressure) in the morning and staff was to hold the medication for a systolic blood pressure of less than 110 mmHg. Resident 25's MARs for January and February 2025 revealed that staff administered the one five mg tablet of Amlodipine upon arising on January 31, 2025, for a blood pressure reading of 98/60 mmHg and upon arising on February 5, 2025, for a blood pressure reading of 102/54 mmHg. Physician's orders for Resident 25, dated January 13, 2025, included an order for the resident to receive one 100 mg tablet of Atenolol (used to treat high blood pressure) two times per day and staff was to hold the medication for a systolic blood pressure of less than 110 mmHg or a heart rate less than 55 beats per minute (BPM). Resident 25's MARs for January and February 2025 revealed that staff administered the one 100 mg tablet of Atenolol upon arising on January 31, 2025, for a blood pressure reading of 98/60 mmHg; upon arising on February 5, 2025, for a blood pressure reading of 102/54 mmHg; at natural sleep time on January 25, 2025, for a blood pressure reading of 104/64 mmHg; and on February 9, 2025, for a blood pressure reading of 105/58 mmHg. However, review of the resident's clinical record, including the MARs, revealed no documented evidence that staff obtained the resident's heart rate prior to the natural sleep time administration of the one 100 mg tablet of Atenolol to determine if the medication should have been administered. Physician's orders for Resident 25, dated January 15, 2025, included an order for the resident to receive one 50 mg tablet of Hydralazine (used to treat high blood pressure) three times a day and staff was to hold the medication for a systolic blood pressure of less than 110 mmHg or a heart rate less than 55 BPM. Resident 25's MARs for January and February 2025 revealed that staff administered the one 50 mg tablet of Hydralazine upon arising on January 22, 2025, for a blood pressure reading of 109/46 mmHg; on February 5, 2025, for a blood pressure reading of 102/54 mmHg; before supper on January 25, 2025, for a blood pressure reading of 108/60 mmHg; on January 27, 2025, for a blood pressure reading of 90/50 mmHg; on February 8, 2025, for a blood pressure reading of 102/62 mmHg; at natural time of sleep on January 25, 2025, for a blood pressure reading of 104/64 mmHg; and on February 9, 2025, for a blood pressure reading of 105/58 mmHg. However, review of the resident's clinical record, including the MARs, revealed no documented evidence that staff obtained the resident's heart rate prior to the before supper and the natural sleep time administrations of the one 50 mg tablet of Hydralazine to determine if the medication should have been administered. Interview with Nursing Home Administrator on February 20, 2025, at 2:31 p.m. confirmed that Resident 25's one five mg tablet of Amlodipine, one five mg tablet of Amlodipine, and one 50 mg tablet of Hydralazine should not have been administered on the above dates, and confirmed that there was no documented evidence that the resident's heart rate was checked prior to the natural sleep time administration of the one 100 mg tablet of Atenolol and the before supper and the natural sleep time administrations of the one 50 mg tablet of Hydralazine. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated February 3, 2025, indicated that the resident was moderately cognitively impaired and had a weight loss. Physician's orders, dated February 1, 2024 and December 9, 2024, included orders for the resident to receive health shakes twice a day and a reduced concentrated sweets diet, soft and bite sized texture, fortified foods at meals, and bread. A nursing note, dated December 30, 2024, at 9:22 p.m. revealed that Resident 14 was readmitted from the hospital. A physician's order, dated December 30, 2024, included an order for the resident to receive a reduced concentrated sweets diet, soft and bite sized texture, and bread. A dietitian note, dated January 30, 2025, revealed that the resident had a weight loss and supplemental nutrition was ordered, which included health shakes twice a day and fortified foods at all meals. Interview with the Dietitian on February 19, 2025, at 2:29 p.m. revealed that she re-ordered the health shakes and fortified foods on January 30, 2025, when she realized that they were not ordered upon her re-admission from the hospital on December 30, 2024. She indicated that Resident 14 continued to receive health shakes twice a day and fortified foods with all meals, despite not having a physician's order. Interview with the Dietary Manager on February 19, 2025, at 2:50 p.m. confirmed that the resident continued to receive health shakes twice a day and fortified foods with all meals since her re-admission on December 30, 2024, according to her dietary supplement information. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 26 residents reviewed (Resident 32). Findings include: The facility's policy regarding medication administration, dated April 8, 2024, indicated that facility was to administer medications to residents in a safe manner that correlated with their daily activity and natural schedules. The facility's policy regarding physician's orders, dated April 8, 2024, revealed that physician's orders were to be followed in accordance with good nursing principles and practice and were to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated January 3, 2024, indicated that the resident was alert and oriented, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 32, dated January 2, 2025, included an order for the resident to receive 5 units of Insulin Lispro (fast acting insulin) subcutaneously (beneath the skin) before meals for diabetes and to hold the insulin if the resident's blood sugar was less than 140 milligrams/deciliter (mg/dL). Resident 32's Medication Administration Records (MARs) for December 2024 and January 2025 revealed that the resident's blood sugar at 8:00 a.m. on February 4 was 133 mg/dL and February 6 was 124 mg/dL; at 11:00 a.m. on January 9 was 126 mg/dL, January 23 was 125 mg/dL, February 15 was 98 mg/dL, and February 15 was 98 mg/dL; and at 4:00 p.m. on February 1 was 114 mg/dL and February 6 was 83 mg/dL. There was no documented evidence that Resident 32's insulin was held according to the physician-ordered parameters on the dates and times above. Interview with the Nursing Home Administrator on February 20, 2025, at 2:31 p.m. confirmed that the Insulin Lispro was not held as ordered on the dates and times above. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions. Findings include: Observations in the main kitchen on February 18, 2025, at 9:01 a.m.; February 19, 2025, at 11:15 a.m.; and on February 20, 2025, at 8:51 a.m. revealed that there was an accumulation of dust and food debris, a clear drinking glass, a small red bowl, and a [NAME] Cup (a lightweight, easy-to-grip adapted drinking cup designed to prevent spills) under and behind the ice machine, and there was an accumulation of dust and food debris under the stove. Interview with the Dietary Manager on February 20, 2025, at 8:58 a.m. confirmed that there was an accumulation of dust and food debris, a clear a drinking glass, small red bowl, and a [NAME] Cup under and behind the ice machine, and an accumulation of dust and food debris under the stove. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending April 3, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 20, 2025, identified repeated deficiencies related to accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), development of comprehensive care plans, quality of care, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), preventing significant medication errors, and food procurement-storing/preparing/serving food under sanitary conditions. The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending April 3, 2024, revealed that audits would be completed. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending April 3, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications. The facility's plan of correction for a deficiency regarding failure to be free from significant medication errors, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F760, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding residents being free from significant medication errors. The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending April 3, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to food procurement-storing/preparing/serving food under sanitary conditions. Refer to F641, F656, F684, F755, F760, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from verbal abuse for one of 26 residents reviewed (Resident 19). This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated April 8, 2024, revealed that it is the policy of the facility to treat all residents with kindness, respect, and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation, or mistreatment. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 19, dated October 29, 2024, revealed that the resident was understood, could understand others, exhibited no behaviors, was frequently incontinent of bladder, and always continent of bowel. Resident 19 had diagnoses that included a psychotic disorder (a group of mental health conditions characterized by a loss of touch with reality, leading to distorted perceptions, thoughts, and behaviors) and schizophrenia (a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and behaviors). A nursing note for Resident 19, dated October 31, 2024, revealed that the resident had a registered nurse assessment completed for allegations of verbal abuse. There were no signs or symptoms of bodily injury noted. Facility investigation documents for Resident 19, dated October 31, 2024, revealed that Resident 19 was verbally abused by Nurse Aide 1. The Nursing Home Administrator was on call with Registered Nurse Supervisor 2 regarding the behavior of Nurse Aide 1 towards residents. At that time, Registered Nurse Supervisor 2 stated that she had heard Nurse Aide 1 stating at approximately 10:00 p.m. on October 30, 2024, you can sit there with your d**k out and pi**ing on the floor. I'm not helping you. The Nursing Home Adminstrator and Director of Nursing questioned Registered Nurse Supervisor 2 why she did not pull Nurse Aide 1 off the floor and notify the Nursing Home Adminstrator and Director of Nursing regarding this. She replied that Nurse Aide 1 does not listen. The Nursing Home Adminstrator and Director of Nursing re-educated Registered Nurse Supervisor 2 on the facility's protocol for abuse reporting and timeline for abuse reporting. Upon further investigation, another nurse aide had stated that she heard Nurse Aide 1 say about keeping his d**k in his pants in the resident's room. Nurse Aide 1 was interviewed and reported that she stated to the resident, Do not take your penis out because you urinated on the floor. Resident 19 was interviewed but could not recall any issues or concerns of the matter. Nurse Aide 1 stated that she did not use swear words at the resident. Nurse Aide 1 was called and made aware of her suspension pending investigation. The residents on A Hall were interviewed. One resident stated that she heard a loud voice but could not make out what was said at the time that this occurred. No further issues were reported. All other residents reported that they did not hear or experience any staff member making inappropriate comments to them or any other resident. A statement completed by Nurse Aide 1, dated October 31, 2024, revealed that she told Resident 19 do not take your penis out because you urinated on the floor. A statement completed by Registered Nurse Supervisor 2, dated October 31, 2024, revealed that while she was in A Hall she heard Nurse Aide 1 say to Resident 19, You can sit there with your d**k out and pi**ing on the floor. I'm not helping you. Interview with the Nursing Home Administrator on February 19, 2025, at 9:30 a.m. confirmed that through their investigation that they were able to substantiate verbal abuse against Resident 19. Following notification of the incident that occurred on October 30, 2024, on October 31, 2024, the facility's corrective actions included: Nurse Aide 1 was suspended of her duties, and after the investigation her employment with the facility was terminated. An audit of residents was performed. Registered Nurse Supervisor 2 was re-educated regarding abuse. Re-education regarding abuse to staff was started. Daily random audits of residents were being completed, and interviews continue to ensure that no residents have been affected. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on November 7, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies, clinical records, investigation documents, and the Department of Health's Event Reporting System (ERS), as well as staff interviews, it was determined that the facility failed to ensure that staff reported allegations of verbal abuse in a timely manner for two of 26 residents reviewed (Resident 19, 136). This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated April 8, 2024, revealed that to protect the residents, the facility will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response, and corrective action. The following procedure will be implemented by the facility when an incident of abuse, neglect, exploitation or mistreatment including injuries of an unknown source, or misappropriation of resident property, and resident abuse, alleged or suspected. This includes allegations involving other residents, visitors, employees, or any other person. Any situation of abuse or suspected abuse will be reported as follows. The Nursing Home Administrator or Director of Nursing must be notified immediately. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 19, dated October 29, 2024, revealed that the resident was understood, could understand others, exhibited no behaviors, was frequently incontinent of bladder, and always continent of bowel. Resident 19 had diagnoses that included a psychotic disorder (a group of mental health conditions characterized by a loss of touch with reality, leading to distorted perceptions, thoughts, and behaviors) and schizophrenia (a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and behaviors). A nursing note for Resident 19, dated October 31, 2024, revealed that the resident had a registered nurse assessment completed for allegations of verbal abuse. There were no signs/symptoms of bodily injury noted. Facility investigation documents for Resident 19, dated October 31, 2024, revealed Resident 19 was verbally abused by Nurse Aide 1. The Nursing Home Administrator was on call with Registered Nurse Supervisor 2 regarding the behavior of Nurse Aide 1 towards residents. At that time, Registered Nurse Supervisor 2 stated that she had heard Nurse Aide 1 stating at approximately 10:00 p.m. on October 30, 2024, you can sit there with your d**k out and pi**ing on the floor. I'm not helping you. The Nursing Home Administrator and Director of Nursing questioned Registered Nurse Supervisor 2 as to why she did not pull Nurse Aide 1 off the floor and notify the Nursing Home Adminstrator and Director of Nursing regarding this. She replied that Nurse Aide 1 does not listen. The Nursing Home Adminstrator and Director of Nursing re-educated Registered Nurse Supervisor 2 on the facility's protocol for abuse reporting and timeline for abuse reporting. Upon further investigation of other staff members, another nurse aide had stated that she heard Nurse Aide 1 say about keeping his d**k in his pants in the resident's room. Nurse Aide 1 was interviewed and reported that she stated to the resident, Do not take your penis out because you urinated on the floor. Resident 19 was interviewed but could not recall any issues or concerns of the matter. Nurse Aide 1 stated that she did not use swear words at the resident. Nurse Aide 1 was called and made aware of suspension pending investigation. The residents in A Hall were interviewed. One resident stated that she heard a loud voice but could not make out what was said at the time that this occurred. No further issues reported. All other residents reported that they did not hear or experience any staff member making inappropriate comments to them or any other resident. A statement completed by Nurse Aide 1, dated October 31, 2024, revealed that she told Resident 19 do not take your penis out because you urinated on the floor. A statement completed by Registered Nurse Supervisor 2, dated October 31, 2024, revealed that while she was in A Hall she heard Nurse Aide 1 say to Resident 19, You can sit there with your d**k out and pi**ing on the floor. I'm not helping you. A quarterly MDS assessment for Resident 136, dated August 2, 2024, revealed that the resident was understood, could understand others, and had diagnoses that included a hip fracture and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing problems). A nursing note for Resident 36, dated October 31, 2024, revealed that the resident had a registered nurse assessment completed for allegations of verbal abuse. There were no signs/symptoms of bodily injury noted. A statement completed by Nurse Aide 3, October 31, 2024, revealed that last night at 10:15 p.m. he heard Nurse Aide 1 yelling at Resident 136 because she spilled her water on herself. She said this is the second time you did this, if you would set the f**k up and stop playing with yourself you wouldn't make that happen. A Department of Health ERS report, dated October 31, 2024, revealed that the Nursing Home Administrator was notified at approximately 10:00 a.m. on October 31, 2024, that a nurse aide staff came to Registered Nurse Supervisor 4 reporting that she had received a written statement from another staff member that Resident 136 was verbally abused by Nurse Aide 1 on October 30, 2024. The Nursing Home Administrator and Director of Nursing contacted the staff member who had written the statement and asked what occurred. Nurse Aide 3 reported that he was coming down the hall at approximately 10:15 p.m. on October 30, 2024, and Resident 136 had rung her bell saying that she was soaked because she spilled water on herself. Nurse Aide 1 replied this is the second f*****g time that you spilled water on yourself. If you would stop playing with yourself this wouldn't have happened. The Nursing Home Administrator asked Nurse Aide 3 if he reported this to anyone, and he replied that he did not say anything to any other staff until his union representative came in at 6:00 a.m. At that time, the staff member stated that he needed to write a statement. The Nursing Home Administrator and Director of Nursing provided education on the abuse policy and reporting. Resident 136 was interviewed by the Director of Nursing, and she stated that she does not recall anything that had happened. Interviews with other staff were conducted and none heard of this discussion between Resident 136 and Nurse Aide 1. Nurse Aide 1 stated that she did not cuss at Resident 136 and had said that she replied to the resident, This is your second time that you spilled water on yourself. Nurse Aide 1 was made aware of suspension pending investigation. Interview with the Nursing Home Administrator on February 19, 2025, at 9:30 a.m. revealed that Nurse Aide 3 came to her on October 31, 2024, regarding the incident between Resident 136 and Nurse Aide 1. She indicated that during the investigation into that incident, she then became aware of the incident that occurred on October 30, 2024, with Resident 19 and Nurse Aide 1. She confirmed that Nurse Aide 3 and Registered Nurse Supervisor 2 did not immediately notify the Nursing Home Administrator and/or the Director of Nursing as per the facility's policy of the incidents involving Nurse Aide 1 and Residents 19 and 136 on October 30, 2024. Following notification of the incidents that occurred on October 30 and 31, 2024, the facility's corrective actions included: Nurse Aide 1 was suspended of her duties, and after the investigation her employment with the facility was terminated. An audit of residents was performed. Nurse Aide 3 was re-educated regarding abuse. Registered Nurse Supervisor 2 was re-educated regarding abuse. Re-education regarding abuse to staff was started. Daily random audits of residents were being completed, and interviews continue to ensure that no residents have been affected. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F609 on November 7, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 26 residents reviewed (Residents 14, 24, 32). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415A was to be coded if the resident received an antipsychotic medication during the seven-day assessment period, and Section N0451K was to be coded if the resident received an anticonvulsant medication during the seven-day assessment period. Physician's orders for Resident 14, dated January 16, 2021, included an order for the resident to receive 100 milligrams (mg) of gabapentin (anticonvulsant medication) twice a day for rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness) and 300 mg of gabapentin at bedtime for rheumatoid arthritis. Medication Administration Records (MARs) for Resident 14, dated January and February 2025, revealed that staff administered 100 mg of gabapentin twice a day and 300 mg at bedtime from January 16 through February 19, 2025. However, Section N0415K1 of Resident 14's quarterly MDS assessment, dated February 3, 2025, was coded to indicate that the resident did not receive an anticonvulsant medication during the seven-day assessment. Physician's orders for Resident 24, dated January 10, 2025, included an order for the resident to receive 25 milligrams (mg) Seroquel (antipsychotic medication) every day. A quarterly MDS assessment for Resident 24, dated January 15, 2025, revealed that Section N0415A was coded indicating that the resident had not received an antipsychotic medication. Physician's orders for Resident 32, dated December 30, 2024, included an order for the resident to receive 100 mg of gabapentin three times a day for polyneuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). MARs for Resident 32, dated December 2024 and January 2025, revealed that staff administered 100 mg of gabapentin three times a day from December 31 through January 3, 2025. However, Section N0415K1 of Resident 32's quarterly MDS assessment, dated January 3, 2025, was coded to indicate that the resident did not receive an anticonvulsant medication during the seven-day assessment. Interview with the Nursing Home Administrator on January 30, 2025, at 11:35 a.m. confirmed that MDS assessments for Residents 14, 24, and 32 were coded inaccurately. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for one of 26 residents reviewed (Resident 6) who was on Enhanced Barrier Precautions (EBP) for having a surgically implanted drain. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 5, 2025, revealed that the resident was cognitively intact and dependent on staff for daily care tasks. Physician's orders for Resident 6, dated May 16, 2024, included an order that the resident may not be showered due to his surgically implanted percutaneous drain (gallbladder drain). Physician's order, dated June 12, 2024, included an order for the staff to flush the gallbladder drain vigorously daily. Observations of Resident 6 on February 18, 2024, at 10:08 a.m. revealed that the resident had a sign on his door indicating that he was on EBP and had personal protective equipment outside his door for staff to wear. There was no documented evidence that a care plan was developed to address Resident 6's care needs related to EBP. Interview with Nurse Aide 5 on February 18, 2025, at 10:08 a.m. revealed that Resident 6 was on Enhanced Barrier Precautions and that staff must wear a gown when entering his room and providing care for him. Interview with Nursing Home Administrator on February 20, 2025, at 10:29 a.m. confirmed that Resident 6's care plan did not address his care needs related to EBP. 28 Pa. Code 201.24(e)(4) Admission Policy.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's weight as recommended by the dietician for one of 23 residents reviewed (Resident 14). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding weights, dated April 8, 2024, revealed that if a weight is obtained and a five-pound weight loss or gain has occurred for individuals weighing greater than 100 pounds or a three-pound weight loss or gain occurred for individuals weighing less than 100 pounds, then a re-weight should be obtained within 24 hours of the first obtained weight. Staff were to ensure the individual was weighed on the same scale as previously used, and when the re-weight was obtained the weight should be documented in the medical record, stating that it was a re-weight and the previous weight should be struck out. All residents with a significant weight change would be assessed and referred to the dietitian for assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated February 3, 2025, indicated that the resident was moderately cognitively impaired and had a weight loss. A weight record, dated December 13, 2024, revealed that Resident 14 weighed 127.4 pounds. A weight record dated January 1, 2025, revealed the resident's weight was 117.8 pounds. A dietitian note for Resident 14, dated January 9, 2025, revealed that the resident's weight was 117.8 pounds, the weight was more than a five pound difference from the previous weight, a re-weight had been requested and was pending, and she would re-assess the weight status when a re-weight was obtained. However, there was no documented evidence that a re-weight had been obtained after the January 9, 2025, dietitian note. On January 16, 2025, the resident's weight was 136.2 pounds (gain of 18.4 pounds); however, there was no documented evidence that a re-weight had been obtained until January 21, 2025, when the resident's weight was 116.4 pounds. An interview with the Director of Nursing and Nursing Home Administrator on February 19, 2025, at 11:54 a.m. confirmed that Resident 14 was not re-weighed according to the dietitian's recommendations or facility policy. Following the identification on October 18, 2024, that they were not obtaining re-weights, the facility's corrective actions included: A weight team was developed to improve weight obtainment by nursing staff, which included nursing staff and other staff members. Audits were started on all residents to ensure that re-weights recommended by the dietitian were obtained. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews with staff regarding re-weights revealed that they were in compliance with F692 on February 1, 2025. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 26 residents reviewed (Resident 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated December 23, 2024, revealed that the resident was understood, could understand others, and had a diagnosis of anxiety. A care plan for the resident, dated October 14, 2024, revealed that the resident uses anti-anxiety medications related to an anxiety disorder, and staff was to administer the anti-anxiety medications to the resident as ordered by the physician. Physician's orders for Resident 33, dated December 20, 2024, included an order for the resident to receive a one milligram (mg) tablet of Clonazepam (a narcotic medication used to prevent and treat anxiety disorders) every eight hours as needed. Resident 33's controlled drug logs for January and February 2025 revealed that staff signed out doses of Clonazepam for administration to the resident on January 7, 2025, at 7:07 p.m.; January 12, 2025, at 7:05 a.m.; January 14, 2025, at 8:20 a.m.; January 29, 2025, at 6:30 a.m.; January 29, 2025, at 8:00 p.m.; February 5, 2025, at 4:00 a.m.; and on February 8, 2025, at 9:30 a.m. However, the resident's clinical record, including the Medication Administration Records (MARs) and the nursing notes, revealed no documented evidence that the Clonazepam was administered to the resident on these dates and times. Interview with the Nursing Home Administrator on February 20, 2025, at 3:40 p.m. confirmed that there was no documented evidence that the Clonazepam was administered to Resident 33 on the above-mentioned dates and times. 28 Pa. Code 211.9(j)(3) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 26 residents reviewed (Resident 33). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated December 23, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included anxiety. A care plan for the resident, dated October 14, 2024, revealed that the resident uses anti-anxiety medications related to an anxiety disorder, and staff was to administer the anti-anxiety medications to the resident as ordered by the physician and that staff should attempt non-pharmacological interventions (e.g., massage, music, quiet time, reading, watching TV, etc.) before the resident is offered the as needed psychotropic medication (medications that affect the mind and behavior). Physician's orders for Resident 33, dated December 20, 2024, included an order for the resident to receive a one milligram (mg) tablet of Clonazepam (a narcotic medication used to prevent and treat anxiety disorders) every eight hours as needed. Resident 33's Medication Administration Records (MARs) for January and February 2025 revealed that staff administered the one mg tablet of Clonazepam for anxiousness/restlessness on January 1, 2025, at 6:15 a.m. and 7:36 p.m.; January 2, 2025, at 6:58 p.m.; January 3, 2025, at 7:50 a.m. and 7:19 p.m.; January 4, 2025, at 9:03 p.m.; January 5, 2025, at 9:03 p.m.; January 6, 2025, at 7:38 a.m. and 6:50 p.m.; January 8, 2025, at 7:19 a.m. and 7:29 p.m.; January 9, 2025, at 7:02 a.m. and 8:53 p.m.; January 10, 2025, at 8:37 a.m. and 8:52 p.m.; January 11, 2025, at 8:23 a.m. and 7:19 p.m.; January 12, 2025, at 6:45 p.m.; January 13, 2025, at 8:10 a.m. and 9:31 p.m.; January 14, 2025, at 7:37 p.m.; January 15, 2025, at 7:44 a.m. and 6:21 p.m.; January 16, 2025, at 8:14 a.m. and 8:43 p.m.; January 17, 2025, at 8:41 a.m. and 6:48 p.m.; January 18, 2025, at 7:56 a.m. and 8:03 p.m.; January 19, 2025, at 9:15 p.m.; January 20, 2025, at 5:18 a.m. and 8:08 p.m.; January 21, 2025, at 5:05 a.m. and 9:29 p.m.; January 22, 2025, at 7:30 p.m.; January 23, 2025, at 6:43 a.m. and 7:06 p.m.; January 24, 2025 at 7:25 a.m. and 6:24 p.m.; January 25, 2025, at 8:02 a.m. and 6:24 p.m.; January 26, 2025, at 8:00 a.m. and 6:30 p.m.; January 27, 2027, at 9:27 a.m. and 10:07 p.m.; January 28, 2025, at 9:21 a.m. and 9:26 p.m.; January 30, 2025, at 6:24 a.m. and 6:52 p.m.; January 31, 2025, at 8:15 a.m. and 6:45 p.m.; February 1, 2025, at 9:38 a.m. and 9:50 p.m.; February 2, 2025, at 9:12 a.m. and 9:07 p.m.; February 4, 2025, at 6:22 a.m. and 7:38 p.m.; February 5, 2025, at 6:45 p.m.; February 6, 2025, at 9:25 a.m. and 6:42 p.m.; February 7, 2025, at 8:35 a.m. and 7:04 p.m.; February 8, 2025, at 8:05 p.m.; February 9, 2025, at 7:57 a.m. and 7:25 p.m.; February 10, 2025, at 7:26 a.m. and 8:24 p.m.; February 11, 2025, at 9:16 a.m. and 9:08 p.m.; February 12, 2025, at 9:13 a.m. and 9:23 p.m.; February 13, 2025, at 8:45 a.m. and 9:23 p.m.; February 14, 2025, at 8:52 a.m. and 6:51 p.m.; February 15, 2025, at 8:41 a.m. and 9:03 p.m.; February 16, 2025, at 8:39 a.m. and 9:36 p.m.; February 17, 2025, at 8:48 a.m. and 6:49 p.m.; February 18, 2025, at 9:10 a.m. and 10:11 p.m.; February 19, 2025, at 7:33 a.m. and 6:42 p.m.; and on February 20, 2025, at 8:35 a.m. There was no documented evidence that non-medication interventions were attempted prior to the administration of the as needed Clonazepam. Interview with the Nursing Home Administrator on February 20, 2025, at 3:21 p.m. confirmed that there was no documented evidence that staff attempted non-medication interventions prior to administering the as needed Clonazepam to Resident 33 on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 26 residents reviewed (Residents 1, 4, 12). Findings include: The facility's policy regarding care plan development and revision, dated October 12, 2023, indicated that resident care plans are reviewed and updated at least quarterly and as a resident's condition changes (such as when medications are added or discontinued, resident returns from the hospital, and with changes in mood, behaviors or care needs). A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. A care plan for Resident 1, dated March 22, 2023, revealed that the resident had oxygen related to respiratory illness. Observations of Resident 1 on April 1, 2024, at 10:00 a.m. revealed that the resident was sitting in her wheelchair beside her bed and did not have oxygen in her room. Physician's orders were reviewed, and the resident did not have orders for oxygen use. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that the Resident 1 was not on oxygen and the care plan should have been resolved. Physician orders for Resident 1, dated January 11, 2024, indicated that the resident was to have a fall mat to the left side of her bed. A fall care plan for Resident 1, dated January 19, 2024, indicated that the resident was to have a fall mat to the right side of her bed. Observation of Resident 1 on April 1, 2024, at 10:00 a.m. revealed that the resident was sitting in her wheelchair beside the bed and the fall mat was on the left side of her bed. An interview with the Director of Nursing on April 3, 2024, at 12:26 p.m. confirmed that Resident 1's fall mat should be on the left side of the bed and the care plan was inaccurate. An admission MDS assessment for Resident 4, dated February 15, 2024, indicated that the resident was cognitively intact, required partial to substantial assist with care needs, and had a Stage 2 pressure area (pressure wound with superficial skin loss) that was present on admission. Resident 4's care plan, dated February 14, 2024, included a focus for a Stage 2 pressure ulcer to the sacrum. A nurse's note for Resident 4, dated March 12, 2024, at 7:17 a.m. indicated that the Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved and the plan of care had been reviewed and updated. However, as of April 3, 2024, the care plan was not updated to reflect that the Stage 2 pressure area to the gluteal cleft/sacrum was resolved. An interview with the Director of Nursing on April 3, 2024, at 2:34 p.m. confirmed that Resident 4's Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved and that the care plan should have been resolved and it was not. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A care plan for Resident 12, dated July 14, 2023, indicated that the resident was at risk for self-injury related to not keeping the head of the bed elevated due to having a PEG tube (tube inserted into the stomach for nutrition), refusing to accept bolus feeding. A nurse's note for Resident 12, dated September 25, 2023, revealed that the PEG tube was removed. An interview with the Director of Nursing on April 2, 2024, at 3:29 p.m. confirmed that Resident 12 does not have a PEG tube and that the care plan should have been resolved. 28 Pa. Code 201.24(e)(4) Admission Policy.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 26 residents reviewed (Resident 1, 4, 12). Findings include: The facility's policy regarding physician's orders, dated October 12, 2023, revealed that physician's orders were to be followed in accordance with good nursing principles and practice and were to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated May 9, 2023, included an order for the resident to receive 60 milligrams (mg) of isosorbide mononitrate (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. Physician's orders, dated July 20, 2023, included an order for the resident to receive 2.5 mg of Lisinopril (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. Physician's orders, dated May 9, 2023, included an order for the resident to receive 50 mg of Metoprolol (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. A review of Resident's 1's Medication Administration Record for May 2023 through March 2024 revealed no documented evidence that the blood pressure was being monitored per physician order. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that there was no documented evidence that Resident 1's blood pressure was being monitored per physician order. An admission MDS assessment for Resident 4, dated February 15, 2024, indicated that the resident was cognitively intact, required partial to substantial assist with care needs, and had a Stage 2 pressure area (pressure wound with superficial skin loss) that was present on admission. Physician's order for Resident 4, dated February 16, 2024, included an order for Expedite (a nutritional supplement) to be given daily to aid in wound healing for 14 days or until the wound was healed. A nurse's note for Resident 4, dated March 12, 2024, indicated that the Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved. A dietary note for Resident 4, dated March 28, 2024, indicated that the resident's wound had been resolved and the Expedite had been discontinued. A review of Resident 4's clinical record revealed that he continued to receive Expedite through April 3, 2024 (22 days after the wound was resolved). Interview with Director of Nursing on April 3, 2024, at 2:34 p.m. confirmed that Resident 4's order for Expedite should have been discontinued and it was not. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). Physician's orders for Resident 12, dated September 20, 2023, included an order for the resident to receive 25 milligrams of Metoprolol (a medication for high blood pressure) one time a day and to hold the medication if systolic blood pressure was less than 100 mmHg and heart rate was less than 55 beats per minute. A review of Resident's 12's Medication Administration Record from September 2023 through March 2024 revealed no documented evidence that the blood pressure and heart rate were being monitored per physician's order. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that there was no documented evidence that Resident 12's blood pressure and heart rate were being monitored per physician's order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 26 residents reviewed (Residents 1, 30, 31). Findings include: The facility's policy regarding medication administration, dated October 12, 2023, indicated that medications administered will be documented on the Medication Administration Record (MAR). For as needed medications, the nurse will document initials and time of administration on the MAR. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnosis that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated December 28, 2023, included an order for the resident to receive 50 milligrams of Tramadol (a controlled medication used to treat pain) every six hours as needed. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 1 for January, 2024, indicated a dose of Tramadol was signed out on January 4, 2024, at 9:30 a.m.; January 5, 2024, at 11:43 a.m.; January 15, 2024, at 10:30 a.m.; January 28, 2024, at 11:30 p.m.; February 5, 2024, at 8:05 p.m.; February 14, 2024, at 7:00 p.m.; February 17, 2024, at 8:40 p.m.; February 21, 2024, at 6:59 p.m.; February 24, 2024, at 11:15 a.m.; March 17, 2024, at 9:04 a.m.; March 17, 2024, at 9:20 p.m.; and March 21, 2024, at 8:00 p.m. Review of Resident 1's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 2, 2024, at 3:28 p.m. confirmed that there was no documented evidence in Resident 1's clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 30, dated February 27, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, used supplemental oxygen, and had diagnoses including pulmonary fibrosis (a lung disease that causing scarring and stiffening of lung tissue, making it harder to breathe), respiratory failure (blood does not have enough oxygen and causes difficulty breathing), chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult), and anxiety disorder. Physician's order for Resident 30, dated February 21, 2024, included an order for the resident to receive 0.5 mg of Lorazepam (a controlled medication used to treat anxiety) every eight hours as needed for anxiety for three days. Physician's order for Resident 30, dated February 26, 2024, included an order for the resident to receive 0.5 mg of Lorazepam every four hours as needed for anxiety. Review of the controlled drug record for Resident 30 for February and March 2024 indicated that a dose of Lorazepam was signed out on February 22, 2024, at 10:30 p.m.; February 23, 2024, at 1:40 p.m.; March 5, 2024, at 8:30 p.m.; March 15, 2024, at 12:30 p.m.; March 22, 2024, at 6:45 p.m.; March 23, 2024, at 12:00 p.m.; March 26, 2024, at 12:30 p.m.; and March 27, 2024, at 11:30 a.m. Review of Resident 30's MAR and nursing notes revealed no documented evidence that the signed-out doses of Lorazepam were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 2, 2024, at 12:27 p.m. confirmed that there was no documented evidence in Resident 30's clinical records to indicate that the signed-out doses of Lorazepam were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 31, dated March 8, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, and was taking opioid medication (controlled narcotic pain medication). A care plan for Resident 31, dated March 11, 2024, revealed the resident had pain related to spinal fusion surgery. Physician's orders for Resident 31, dated March 7, 2024, and March 21, 2024, included orders for the resident to receive 5 mg of Oxycodone (a controlled medication used to treat pain) every four hours as needed for pain for 14 days for spinal fusion. Review of the controlled drug record for Resident 31 for March 2024 indicated that a dose of Oxycodone was signed out on March 17, 2024 at 5:15 p.m. and 7:15 p.m.; March 18, 2024, at 7:00 a.m. and 3:00 p.m.; March 20, 2024, at 1:00 p.m.; March 27, 2024, at 2:30 a.m.; March 28, 2024, at 2:00 a.m. and 1:20 p.m.; and March 29, 2024, at 2:00 a.m. Review of Resident 31's MAR and nursing notes revealed no documented evidence that the signed-out doses of Oxycodone were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 3, 2024, at 3:30 p.m. confirmed that there was no documented evidence in Resident 31's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a clean and homelike environment related to the cleanliness of wheelchairs for one of 26 residents reviewed (Resident 18). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated February 14, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for his daily care needs, had impairment on one side of the upper and lower extremities, and used a wheelchair. Observations on April 1, 2024, at 3:32 p.m. and April 3, 2024, at 11:05 a.m. revealed that Resident 18's wheelchair had a dried, brown/tan, removable substance on the metal bars of the chair. Interview with Nurse Aides 1 and 2 on April 3, 2024, at 11:07 a.m. confirmed that the chair had a dried, brown/tan, removable substance on the wheelchair that needed cleaned. Housekeeping and nursing staff were responsible for cleaning wheelchairs as needed and were not aware of a routine cleaning schedule. Interview with the Director of Nursing on April 3, 2024, at 11:09 a.m. revealed that wheelchairs were power washed twice a year, and Resident 18's had a removable substance on the chair that should have been washed.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Licensed Practical Nurse 3). Findings include: The facility's abuse policy, dated October 12, 2023, indicated that the facility developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. The facility's screening procedures included conducting reference checks of previous and present employers, criminal background checks on potential employees as well as contracted personnel, verification of nursing licenses with the State Board of Nursing, and verification of nurse aide standing with the state Nurse Aide Registry. The personnel file for Licensed Practical Nurse 3 revealed that she was hired on January 4, 2024, and as of April 2, 2024, (four months after hire) a professional licensure verification with the Pennsylvania State Board of Nursing had not been completed. Interview with Director of Nursing on April 2, 2024, at 11:39 a.m. confirmed that there was no documented evidence to indicate that Licensed Practical Nurse 3's professional licensure was verified with the State Board of Nursing prior to the nurse's hire date. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies, investigative reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility's policy regarding abuse prevention, dated October 6, 2020, indicated that each resident was to be free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect the residents, the facility was to implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response, and corrective action. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 13, 2021, revealed that the resident was alert, oriented, dependent on two staff for transfers, and was not steady and only able to stabilize with staff assistance when moving from a seated position to standing, when walking, and when turning around and facing the opposite direction while walking. The resident's care plan, dated February 10, 2020, and revised May 19, 2021, revealed that she required assistance with daily care tasks due to impaired balance and limited mobility, and she required the assistance from two staff for transfers. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note for Resident 1, dated July 24, 2021, at 7:33 p.m. revealed that the nurse was called to the resident's room by the nurse aide. The nurse aide was getting the resident out of her chair using her walker. The resident stood up to go toward her bed when the resident stated that her knees gave out. The resident's neck was sore from the fall. A nursing note for Resident 1, dated July 26, 2021, at 8:10 a.m. revealed that the resident was complaining of increased pain to her neck and was yelling out at times. She was protecting her neck by keeping it slightly to the right side and did not want to get out of bed. The physician was notified and gave orders to send the resident to the emergency room for further evaluation. Information submitted by the facility, dated July 26, 2021, revealed that the hospital faxed a copy of Resident 1's scans of the cervical spine that were completed on July 26, 2021, and which showed that the resident had an acute fracture through the left C6 pedicle facet joint (a fracture of the stub of bone in the sixth vertebrae in the neck). Investigative documents for Resident 1, dated July 26, 2021, revealed that on July 26, 2021, Nurse Aide 3 transferred the resident by herself and without assistance from a second staff member as care planned and as ordered by the physician. The facility's investigation determined that Nurse Aide 3 was educated regarding transferring residents requiring the assistance of two staff on March 30, 2020, and failed to adhere to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Nurse Aide 3 on July 29, 2021, at 3:10 p.m. confirmed that she transferred Resident 1 by herself on July 24, 2021, and did not have assistance from a second staff member. She indicated that she was assigned the resident's care in the past and was aware that she required the assistance of two staff for transfers. Interviews with the Nursing Home Administrator and Director of Nursing on July 29, 2021, at 3:30 p.m. confirmed that Nurse Aide 3 transferred Resident 1 by herself and without the assistance of a second staff member, and the resident should have been transferred with the assistance of two staff. 42 CFR 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 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, residents' clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure that physician-ordered and care-planned fall/injury prevention interventions were in place for one of four residents reviewed (Resident 1), resulting in a fractured wrist and hip for the resident. Findings include: The facility's policy regarding falls, dated October 6, 2020, indicated that residents who were determined to be at risk for falls would receive appropriate interventions to reduce the risk and minimize the potential to fall. A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 13, 2020, indicated that the resident was sometimes able to understand other, was usually understood by others, required extensive assistance from staff for daily care, and had diagnoses that included adult failure to thrive (a state of decline that is multifactorial). Physician's orders for Resident 1, dated June 4, 2020, included an order for the resident to have a bed alarm and a chair alarm to alert staff to attempts at unsafe movements. Resident 1's care plan, dated June 4, 2020, revealed that the resident was at risk for falls and was to have personal safety alarms when in the chair and bed. The care plan was revised on July 29, 2020, to include that the resident should have non-skid footwear on and to give the resident a purse filled with snacks and activities. A nursing note for Resident 1, dated June 6, 2020, revealed that the resident was found on the floor and that her alarm was not sounding. The facility's investigation report, dated June 9, 2020, revealed that the resident's personal safety alarm was not turned on, that the resident could not turn the alarm off herself, and that the licensed practical nurse and nurse aide were educated regarding alarm checks and resident safety. Resident 1's Task Review for June 2020 revealed that the resident's bed and chair alarm was to be checked each shift, and was last checked on June 6 at 11:09 a.m. There was no documented evidence that any new and/or revised fall/injury prevention interventions were initiated following this fall. A nursing note for Resident 1, dated June 27, 2020, revealed that the resident was lying on her floor, she did not have non-skid footwear on her feet, and her alarm was not sounding. The facility's investigation report, dated July 1, 2020, indicated that the resident was placed in her room in her chair by a therapy staff member prior to the fall. The investigation report indicated that the therapy staff was educated to ensure all safety measures are in place when leaving residents at bedside, and always informing floor staff about any changes or when leaving the resident. There was no documented evidence that any new and/or revised fall/injury prevention interventions were initiated following this fall. A nursing note for Resident 1, dated July 12, 2020, indicated that the resident was found on the floor and she stated that she was trying to get to the toilet. The facility's incident investigation report, dated July 13, 2020, contained a statement from a licensed practical nurse which indicated that the resident's personal alarm was not turned on. There was no documented evidence that this statement was investigated to determine why the alarm was not turned on. There was no documented evidence that any new and/or revised fall/injury prevention interventions were initiated following this fall. A nursing note for Resident 1, dated September 17, 2020, indicated that the resident was lying on the floor in front of the nursing station and that her personal alarm was not turned on. The facility's investigation report, dated September 18, 2020, revealed that the resident did not have her purse filled with snacks and activities, in accordance with her care plan, and that her personal safety alarm was not turned on at the time of her fall; however, the alarm was functional once it was turned on. The report indicated that the resident's personal safety alarm acted as a reminder for her safety and that due to the alarm not sounding, the resident was not reminded about safety and proceeded to stand without assistance and fell . A nursing note, dated September 17, 2020, indicated that the resident was sent to the emergency room and was diagnosed with a right hip fracture and a right wrist fracture. There was no documented evidence regarding why Resident 1's personal safety alarm was not turned on at the time of the falls on June 6, June 27, July 12 and September 17, 2020. Interview with the Director of Nursing on November 30, 2020, at 5:40 p.m. confirmed that she did not find any documentation regarding why Resident 1's personal safety alarms were not turned on at the times of her falls. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a pressure ulcer until the pressure ulcer deteriorated for one of five residents reviewed (Resident R5). Findings include: The facility's policy for notification of the power of attorney, dated 3/6/12, indicated that the licensed nurse on duty was to notify the physician of any changes observed in the resident. A quarterly Minimum Data Set assessment (MDS - a standardized assessment completed at specific intervals to identify resident care needs) dated 10/11/11, for Resident R5 revealed that the resident had no pressure sore at that time. Nursing notes and wound records, dated 2/5/12, indicated that there was a new Stage II pressure ulcer (an open area in the superficial surface layers of the skin) on the buttocks. The medication administration records for February and March 2012, indicated that staff were treating the area with a [MEDICATION NAME] dressing (an opaque patch that helps keep wounds moist so that they heal more quickly). There was no documented evidence that the physician was notified of the new Stage II pressure sore until 3/7/12, when nursing notes and wound records indicated that the pressure sore deteriorated to a Stage III (an open area that extended into the underlying subcutaneous tissue but not all the way to the bone). physician's orders [REDACTED]. Interviews on 5/2/12 at 2:35 p.m., with Registered Nurse 1 and at 2:38 p.m,. with Registered Nurse 2 confirmed that the physician was not notified of the pressure sore until it was a Stage III on 3/7/12, and the physician changed the treatment. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/14/11.