Every finding on record at Redstone Highlands Health Care

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 30 residents reviewed (Residents 4, 5, 11). Findings include: The facility's policy for medication administration, dated July 11, 2025, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 17, 2026, revealed that the resident had moderated cognitive impairment, requires assistance from staff and had diagnoses that included arthritis (inflammation, pain, and stiffness in one or more joints), and Parkinson's Disease (progressive neurodegenerative disorder that causes tremors and rigid limbs).Physician's orders for Resident 4, dated February 10, 2026, included an order for the resident to receive 5 mg of oxycodone, two tablets, every six hours as needed for severe pain. Review of the controlled drug records for Resident 4 dated February, March, and April 2026, revealed that two five mg oxycodone tablets were signed out on February 21, 2026, at 7:21 p.m., March 2, 2026 at 5:20 a.m., and on April 9, 2026, at 9:00 p.m.; However, there was no documented evidence in Resident 4's clinical record that the signed-out doses of controlled medication were administered to the resident on the above-mentioned dates and times.An admission MDS assessment for Resident 5, dated March 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included spinal fusion (a surgical procedure that permanently connects two or more vertebrae (bones) in the spine,) and was receiving as needed pain medication. Physician's orders for Resident 5, dated February 12, 2026, included an order for the resident to receive 5 mg of oxycodone, two tablets, every six hours as needed for severe pain. Physician's orders dated March 3, 2026, included an order for the resident to receive 5 mg of oxycodone, two tablets, every six hours as needed for pain. Review of the controlled drug records for Resident 5 dated February and April, 2026, revealed that two five mg oxycodone tablets were signed out on February 14, 2026, at 10:25 a.m. and on April 2, 2026, at 3:48 p.m.; However, there was no documented evidence in Resident 5's clinical record that the signed-out doses of controlled medication were administered to the resident on the above-mentioned dates and times.A quarterly Minimum Data Set assessment for Resident 11, dated March 19, 2026, revealed that the resident was cognitively impaired, required assistance with personal care needs, and had diagnoses that included heart failure, spinal stenosis and rheumatoid arthritis. Physician's orders for Resident 11, dated January 16, 2026, included an order for the resident to receive 0.5 mg of alprazolam every twelve hours as needed for anxiety. Review of the controlled drug record for Resident 11, dated December 2025, revealed that 0.5 mg of alprazolam was signed out on December 12, 2025, at 11:50 a.m.; December 19, 2025, at 8:05 p.m.; December 29, 2025, at 4:10 p.m.; January 9, 2026, at 7:50 p.m. and February 28, 2026, at 8:53 a.m. However, there was no documented evidence in Resident 11's clinical record that the signed-out doses of controlled medications were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 16, 2026, at 10:40 a.m. confirmed that there was no documented evidence in the clinical records of Residents 4, 5 and 11 to indicate that the signed-out doses of controlled medications mentioned above were administered. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that an anticoagulant medication was held per physician's orders for one of 30 residents reviewed (Resident 3). Findings include: Facility policy for medication errors, dated July 11, 2025, indicated that the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the resident had a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm), and warfarin to be administered as ordered, laboratory tests as ordered, and abnormal results to be reported to physician. Physician's orders for Resident 3, dated April 6, 2026, included an order for four milligrams (mg) of warfarin (a blood thinner) to be administered daily at bedtime and to check the PT/INR (a test that indicates how much time it takes for the blood to clot) on April 13, 2026. Laboratory facsimile report sent to facility with results of Resident 3's PT/INR on April 13, 2026 indicated a critical INR of 5.7 with results also called to the facility. A physician's order written on the facsimile indicated to hold the warfarin for three days and check INR daily for five days. A review of Resident 3's medication administration record (MAR) revealed that the warfarin was administered at bedtime on April 13, 2026 and April 14, 2026. However, per physician orders, warfarin should have been held and not administered. Interview with the Director of Nursing on April 15, 2026, at 8:57 a.m. confirmed that Resident 3 should have had the warfarin held on April 13, 2026, and April 14, 2026, as ordered by the physician and that it was not. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of a change in condition and obtain physicians orders for one of 30 residents reviewed (Resident 2).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 2 dated February 6, 2026, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnoses that include anxiety, depression, gastrostomy status (a tube inserted into the stomach to provide nourishment). A nurse's note for Resident 2, dated April 13, 2026, at 1:17 p.m. revealed that the resident went to therapy where they stood her several times. Upon returning from therapy staff stated the resident was very tired all of the sudden. Resident 2 went to lunch and did not eat. At 12:20 p.m. she was brought out to the nurse's station where eyes were closed, very diaphoretic, blood sugar was 164 mg/dl, temperature 98.0 Fahrenheit, pulse 72 bpm, respirations 18, and blood pressure of 61/43 mmHg. She opened her eyes to name but spoke very little. She was placed back to bed, legs elevated, given 500cc water via Gastrostomy tube. Her Blood pressure at 12:50 p.m. was 92/54 mmHg much more alert and talking. Another 500cc water bolus was given via gastrostomy tube and Blood pressure at 1:15 p.m. was 110/68 mmHg. A review of Resident 2's clinical record revealed that staff did not obtain a physician's order or notify the physician of the resident's change in condition until after the second 500 cc water bolus was given through the resident's gastrostomy tube.Interview with the Director of Nursing on April 15, 2026, confirmed that the registered nurse did not notify or obtain a physician's order to administer two 500 cc boluses of water through Resident 2's gastrostomy tube.28 Pa. Code 211.12(d)(1)(3)(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 after a change in condition for one of 30 residents reviewed (Resident 54).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 20, 2026, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of heart failure.A nursing note dated March 10, 2026, at 3:00 a.m. indicated that the resident felt as though she is falling out of bed and everything is just wrong. An on call practitioner was contacted and orders of orthostatic vitals in the morning.An advanced practice nursing note for resident 54 dated March 10, 2026, at 1:49 a.m. central time, indicated the resident was complaining of the room spinning while lying in bed. The staff were to perform orthostatic vital signs (measurements of blood pressure and heart rate taken while lying, sitting, and standing) in the morning.There was no documented evidence in Resident 54's clinical record to indicate that orthostatic blood pressures were obtained by facility staff as ordered.Interview with the Director of Nursing on April 15, 2022, at 12:44 a.m. confirmed that there was no documented evidence that orthostatic vital signs were obtained as ordered for Resident 54 after her change in condition 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for two of 30 residents reviewed (Residents 100 and 105). Findings include:A facility policy for Care Planning dated July 11, 2025, indicated that the licensed nurse will initiate a baseline care plan upon admission to facility and complete within 48 hours. On the first business day following admission the licensed nurse will review and update the care plan and complete a comprehensive care plan. Review of admission records for Resident 32 dated April 11, 2026, revealed that the resident was admitted to the facility for aftercare following a joint replacement and she had a foley catheter (a flexible tube inserted into the bladder to drain urine) in place. Observations of Resident 100 on April 13, 2026, at 10:58 a.m. revealed the resident lying in bed with a urinary drainage bag visible, hanging on the right side of the Resident's bed frame. Observations of Resident 100 on April 15, 2026, at 12:08 p.m. revealed that the resident was sitting in her wheelchair on the left side of her bed eating her lunch. Her urinary catheter drainage bag was attached to the bed frame on the left side of her bed. Interview with the Director of Nursing on April 16, 2026, at 10:54 a.m. confirmed the Resident 100's baseline care plan did not include care and treatment needs required for the resident's foley catheter use and should have. Review of admission records for Resident 105 dated April 4, 2026, revealed that the resident was admitted to the facility for aftercare following urinary tract infection (UTI) and he had a midline catheter (a soft tube inserted into the vein to provide intravenous therapy) in place. A nursing note dated April 4, 2026, at 2:18 p.m. indicated that the resident arrived at the facility and he had a midline in his left upper arm.Physician's orders for Resident 105, dated April 4, 2026, included an order for the resident to be restricted to 500 milligrams of Ertapenem Sodium (antibiotic medication) every day related to an urinary tract infection intravenously (administered into the vein) .Observations of Resident 105 on April 13, 2026, at 12:27 p.m. revealed that the resident was sitting up in bed eating his lunch. He had a midline catheter in his left upper arm. His daughter, who was in the room, said the resident was admitted to the facility for treatment of his urinary tract infection, and he needed to be on long term intravenous antibiotic for about four weeks.Interview with the Director of Nursing on April 16, 2026, at 10:54 a.m. confirmed the Resident 105's baseline care plan did not include care and treatment needs required for the resident's use of intravenous antibiotics use and should have. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for one of 30 residents reviewed (Residents 16).Findings include: The facility's pneumococcal vaccine policy, dated July 11, 2025, indicated that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The resident/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the refusal of pneumococcal vaccination.An annual Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated March 13, 2026, revealed that the resident was admitted to the facility on [DATE]. The sections of the MDS assessment related to the resident's pneumococcal vaccination revealed that the resident's pneumococcal vaccination was not up to date due to being offered but declining the vaccine. There was no documented evidence that the facility offered, or the resident declined the pneumococcal vaccine. Interview with the Infection Control Nurse on April 16, 2026, at 11:17 a.m. confirmed that there was no documented evidence that Resident 16 was offered the pneumococcal vaccine at the time of their admissions or at any time afterward. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 30 residents reviewed (Resident 5). Findings include:CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.The facility's policy regarding EBP, dated July 11, 2025, indicated that EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove used during high contact resident care activities. An order for EBP will be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 5 dated March 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included fusion of the spine and had surgical wounds. Physician's orders for Resident 5 dated March 17, 2026, included for staff to cleanse her mid back wound with normal sterile saline (NSS- sterile salt water), dry, pack the open wounds on the mid back with black foam, (bridge away from bony prominences if necessary) and apply wound VAC (vacuum-assisted closure- is a therapeutic technique using a suction pump, tubing, and a foam dressing to remove excess fluid, bacteria, and debris from complex or chronic wounds) at -125mmhg (millimeters of mercury) continuously. Change three times a week on Monday, Wednesday and Friday and as needed for dislodgement. Wound VAC must be removed if the resident must go out of the facility for any reason. There was no documented evidence that orders where obtained indicating that the resident required EBP related to her wound. Observation of Resident 5 on April 13, 2026, at 10:53 a.m. revealed the resident sitting in her wheelchair in her room with a wound VAC canister on her bedside table connected to tubing attached to the resident. There were no signs indicating that the resident was on EBP and no PPE available in the resident's room. Interview with the Director of Nursing on April 14, 2026, at 2:53 p.m. confirmed that there were no orders for EBP and no EBP in place for Resident 5, however there should have been.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing 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 correct quality deficiencies 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's ending March 20, 2025, April 8, 2025, August 5, 2025, 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 April 16, 2026, identified repeated deficiencies related to baseline care plans, develop/implement comprehensive care plan, services provided meet professional standards, quality of care, residents are free of significant med error, pharmacy records, and infection prevention and control. The facility's plan of correction for a deficiency regarding baseline care plans, cited during the survey ending March 20, 2025, revealed that baseline care plans would be monitored by QAPI. The results of the current survey, cited under F655, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding baseline care plans. The facility's plan of correction for a deficiency regarding develop/implement comprehensive care plan, cited during the survey ending March 20, 2025, and April 8, 2025, revealed that the develop/implement comprehensive care plan would be monitored by QAPI. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding develop/implement comprehensive care plan. The facility's plan of correction for a deficiency regarding services provided meet professional standards, cited during the survey ending March 20, 2025, revealed that services provided meet professional standards, would be monitored by QAPI. The results of the current survey, cited under F658, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding services provided meet professional standards. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 20, 2025, revealed that quality of care would be monitored by QAPI. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with quality of care. The facility's plan of correction for a deficiency regarding pharmacy records, cited during the survey ending March 20, 2025, and August 5, 2025, revealed that pharmacy records would be monitored by QAPI. The results of the current survey, cited under F755, revealed that the QAPI committee was ineffective in maintaining compliance with pharmacy records. The facility's plan of correction for a deficiency regarding residents are free of significant med error, cited during the survey ending August 5, 2025, revealed that residents are free of significant med error would be monitored by QAPI. The results of the current survey, cited under F760, revealed that the QAPI committee was ineffective in maintaining compliance with residents are free of significant med error. The facility's plan of correction for a deficiency regarding infection prevention and control, cited during the survey ending March 20, 2025, revealed that infection prevention and control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with infection prevention and control. Refer to F655, F656, F658, F684, F755, F760, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of 30 residents reviewed (Resident 3). Findings include: Facility policy for laboratory tests, dated July 11, 2025, indicated that when a physician has ordered laboratory test for a resident, there will be a systemic way in which that order is processed to ensure accuracy in completion of the order and promote that the physician receives timely results. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 15, 2026, indicated that the resident was cognitively impaired and was receiving an anticoagulant (blood thinner). A care plan, dated February 24, 2026, indicated that the resident had a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm), and warfarin to be administered as ordered, laboratory tests as ordered, and abnormal results to be reported to physician. Physician's orders for Resident 3, dated April 6, 2026, included an order for four milligrams (mg) of warfarin (a blood thinner) to be administered daily at bedtime and to check the PT/INR (a test that indicates how much time it takes for the blood to clot) on April 13, 2026. Facsimile report from laboratory sent to facility with critical INR of 5.7 with results called to facility with read back from nursing staff. Written order on facsimile from physician to hold coumadin for three days and check INR daily for five days. A review of Resident 3's clinical record revealed that staff failed to obtain the INR on April 14, 2026, as ordered. Interview with the Director of Nursing on April 15, 2026, at 8:57 a.m. confirmed that Resident 3 should have but did not have an INR drawn on April 14, 2026, as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 30 residents reviewed (Resident 100) who had an indwelling urinary catheter.Findings include:Review of admission records for Resident 100 revealed she was admitted to the facility on [DATE], with a diagnosis of aftercare following joint replacement surgery and had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). Observations of Resident 100 on April 15, 2026, at 12:08 p.m. revealed that the Resident was sitting in her wheelchair on the left side of her bed eating her lunch. Her urinary catheter drainage bag was attached to the bed frame on the left side of her bed, visible form the Resident's doorway, with no privacy bag on the urinary drainage bag and yellow urine visible in the bag. Interview with Registered Nurse 1 on April 15, 2026, at 12:11 p.m. confirmed that there was no dignity or privacy bag on the Resident 100's urine drainage bag. Interview with the Nursing Home Administrator on April 15, 2026, at 12:24 p.m. confirmed that urinary catheter drainage bags should be kept in dignity/privacy bags. Interview with the Director of Nursing on April 15, 2026, at 1:08 p.m. confirmed that Resident 100's urinary catheter bag was not in a dignity/privacy bag, and it should have been. 28 Pa. Code 201.29(a) Resident Rights.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of 30 residents reviewed for unnecessary medications (Resident 2).Findings included: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated July 11, 2025, indicated that psychotropic medications are not used unless clinically indicated, are prescribed at the lowest effective dos, and are subject to gradual dose reduction and behavioral interventions in accordance with federal regulations and informed consent will be obtained per state law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 6, 2026, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnosis that includes anxiety and depression. Physician orders for Resident 2 dated July 4, 2025, included orders for the resident to receive 2 milligrams of Aripiprazole (an antipsychotic) one time a day for confusion. The facility was unable to provide evidence of informed consent for the psychotropic medication aripiprazole, and it was not available in the clinical record for review. During an interview with the Director of Nursing on April16, 2026, at 9:30 AM, it was confirmed the facility failed to ensure that Resident 2 had an informed consent prior to administering an antipsychotic medication. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 30 residents reviewed (Residents 5 and 42). Findings include: A facility policy for Comprehensive Care Planning, dated July 11, 2025, included that all residents will have a comprehensive care plan that provides guidance to the interdisciplinary team related to care needs, and when appropriate, discharge plans and goals. Care plans will be updated by the licensed nurse and interdisciplinary team as needed with changes. The licensed nurse will make every effort to update the care plan within 24 hours of changes. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 5 dated March 9, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included fusion of the spine and had surgical wounds. Physician's orders for Resident 5 dated March 17, 2026, included for staff to cleanse her mid back wound with normal sterile saline (NSS- sterile salt water), dry, pack the open wounds on the mid back with black foam, (bridge away from bony prominences if necessary) and apply wound VAC (vacuum-assisted closure-a therapeutic technique using a suction pump, tubing, and a foam dressing to remove excess fluid, bacteria, and debris from complex or chronic wounds) at -125mmhg (millimeters of mercury) continuously. Change three times a week on Monday, Wednesday and Friday and as needed for dislodgement. Wound VAC must be removed if the resident must go out of the facility for any reason. There was no documented evidence that a care plan was developed to address Resident 5's care and treatment needs related to the use of a wound VAC. An interview with the Director of Nursing on April 14, 2026, at 2:53 p.m. confirmed there was no care plan developed to address Resident 5's care and treatment needs related to the use of a wound VAC and there should have been. An annual MDS assessment for Resident 42 dated January 4, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis that included paraplegia (paralysis affecting the lower half of the body).Physician's orders for Resident 42 dated April 10, 2026, included that the resident could have a midline catheter (long, flexible tube inserted into a vein in the upper arm, with the tip resting at the armpit level, just below the shoulder) placed for administration of intravenous antibiotics.Observations of Resident 42 on April 15, 2026, at 2:11 p.m. revealed that the resident had a midline catheter in his right upper arm. There was no documented evidence that a care plan was developed to address Resident 42's care and treatment related to the use of a midline catheter.An interview with the Director of Nursing on April 16, 2026, at 10:54 a.m. confirmed there was no care plan developed to address Resident 42's care and treatment related to the use of a midline catheter and there should have been. 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 environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of four residents reviewed (Resident 3) who required assistance with transferring from a bed to a chair. This deficiency is being cited as Past Non-Compliance. Findings include:The facility's policy for Using the Kardex in PCC: a quick guide, dated July 11, 2025, indicated that the Kardex (nursing documentation system used for quick, daily reference of patient care information, such as medications, allergies, activity levels, and treatment plans) is an essential tool within PCC (Point Click Care- type of electronic health record) for organizing, updating, and accessing crucial patient care information. Check at the start of your shift to make sure you have accurate information on transfer status, bed mobility, etc. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 25, 2026, revealed that the resident was cognitively impaired, required substantial to maximum assistance for chair/bed-to-chair transfers, and had diagnoses that included dementia. The resident's care plan, dated January 20, 2025, revealed that the resident had self-care deficit because of decreased mobility and required the assistance of two staff for transfers. A nursing note for Resident 3, dated February 12, 2026, at 7:00 p.m. revealed that the resident complained of left knee pain, and that the knee was red, warm to touch, and had slight edema (swelling). A physician's progress note for Resident 3 dated February 13, 2026, at 2:38 p.m. revealed that the resident had left knee swelling, erythema (redness), and pain that developed the prior evening. On examination today, she continues to have erythema and swelling, as well as warmth to the left knee. Staff report that she experiences pain with weight-bearing, though the patient herself denies any pain. An X-ray of the left knee was ordered. A physician progress note dated February 16, 5:39 p.m. revealed that the resident was seen for an evaluation of left knee pain and swelling that started on Friday. It was initially thought to be pseudogout (form of inflammatory arthritis causing sudden, severe pain, swelling, and warmth in joints, most commonly the knee or wrist), however an x-ray revealed a nondisplaced patella fracture (knee injury where the kneecap breaks into two or more pieces but remains properly aligned). The reason for the fracture is unclear as the patient reports no fall. A documented interview by the Director of Nursing with Nurse Aide 1 on February 16, 2026, at 4:00 p.m. revealed that Nurse Aide 1 admitted to providing care to Resident 3 on February 12, 2026, and transferring the resident by herself. She revealed that she believed that Resident 3 required the assistance of one staff for transfers, and she did not look at the transfer status of the resident that day. She knew you had to [NAME] on something on the kiosk to find the Kardex. Around lunch time the resident stated her leg hurt, and in the evening, she could not put any weight on it and was complaining of pain, and she reported it to the nurse. Review of an accident/injury report completed by the facility on February 16, 2026, revealed that the resident had an acute fracture to the left knee and neglect was substantiated in the incident. Interview with Nurse Aide 1 on March 12, 2026, at 12:57 p.m. revealed that on February 12, 2026, she transferred Resident 3 from her bed to her wheelchair by herself like she always did, because she thought she was a one assist transfer. During the transfer, the resident stated, oh my leg. Nurse Aide 1 did not notice any obvious injuries or complaints of pain at the time of the transfer. Later in the day she noticed her knee was red and told the nurse. She had not accessed Resident 3's Kardex to identify what her transfer status was, she knew it was found on the kiosk but did not remember how to access it, and she never looked at the Kardex's for her residents. Interview with the Nursing Home Administrator and Director of Nursing on March 12, 2026, at 2:23 p.m. confirmed that Nurse Aide 1 failed to follow care plan interventions for transfers for Resident 3 which resulted in an injury. A review of the facility's plan of correction included the following:Caregiver immediately suspendedRN and physician completed an assessment of the resident, which revealed no further injuries or complaintsStatements collected from all applicable parties and thoroughly reviewedAll nursing staff were reeducated on F689 (Free of Accident hazards/supervision/devices); Kardex process specifically related to care plans and resident transfer statusInitiated resident transfer status audits.Interviews with nursing staff on March 12, 2026 revealed that they had been educated on the Kardex process related to care plans and transfer status.Review of the facility's corrective actions revealed that they were in compliance with F689 on February 16, 2026.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Residents 3), resulting in a fracture. This deficiency is being cited as Past Non-Compliance. The facility's policy for Abuse Prohibition dated July 11, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility's policy for Using the Kardex in PCC: a quick guide, dated July 11, 2025, indicated that the Kardex (nursing documentation system used for quick, daily reference of patient care information, such as medications, allergies, activity levels, and treatment plans) is an essential tool within PCC (Point Click Care- type of electronic health record) for organizing, updating, and accessing crucial patient care information. Check at the start of your shift to make sure you have accurate information on transfer status, bed mobility, etc. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 25, 2026, revealed that the resident was cognitively impaired, required substantial to maximum assistance for chair/bed-to-chair transfers, and had diagnoses that included dementia. The resident's care plan, dated January 20, 2025, revealed that the resident had self-care deficit because of decreased mobility and required the assistance of two staff for transfers. A nursing note for Resident 3, dated February 12, 2026, at 7:00 p.m. revealed that the resident complained of left knee pain, and that the knee was red, warm to touch, and had slight edema (swelling). A physician's progress note for Resident 3 dated February 13, 2026, at 2:38 p.m. revealed that the resident had left knee swelling, erythema (redness), and pain that developed the prior evening. On examination today, she continues to have erythema and swelling, as well as warmth to the left knee. Staff report that she experiences pain with weight-bearing, though the patient herself denies any pain. An X-ray of the left knee was ordered. A physician progress note dated February 16, 5:39 p.m. revealed that the resident was seen for an evaluation of left knee pain and swelling that started on Friday. It was initially thought to be pseudogout (form of inflammatory arthritis causing sudden, severe pain, swelling, and warmth in joints, most commonly the knee or wrist), however an x-ray revealed a nondisplaced patella fracture (knee injury where the kneecap breaks into two or more pieces but remains properly aligned). The reason for the fracture is unclear as the patient reports no fall. A documented interview by the Director of Nursing with Nurse Aide 1 on February 16, 2026, at 4:00 p.m. revealed that Nurse Aide 1 admitted to providing care to Resident 3 on February 12, 2026, and transferring the resident by herself. She revealed that she believed that Resident 3 required the assistance of one staff for transfers, and she did not look at the transfer status of the resident that day. She knew you had to [NAME] on something on the kiosk to find the Kardex. Around lunch time the resident stated her leg hurt, and in the evening, she could not put any weight on it and was complaining of pain, and she reported it to the nurse. Review of an accident/injury report completed by the facility on February 16, 2026, revealed that the resident had an acute fracture to the left knee and neglect was substantiated in the incident. Interview with Nurse Aide 1 on March 12, 2026, at 12:57 p.m. revealed that on February 12, 2026, she transferred Resident 3 from her bed to her wheelchair by herself like she always did, because she thought she was a one assist transfer. During the transfer, the resident stated, oh my leg. Nurse Aide 1 did not notice any obvious injuries or complaints of pain at the time of the transfer. Later in the day she noticed her knee was red and told the nurse. She had not accessed Resident 3's Kardex to identify what her transfer status was, she knew it was found on the kiosk but did not remember how to access it, and she never looked at the Kardex's for her residents. Interview with the Nursing Home Administrator and Director of Nursing on March 12, 2026, at 2:23 p.m. confirmed that Nurse Aide 1 neglected to follow care plan interventions for transfers for Resident 3 which resulted in an injury. A review of the facility's plan of correction included the following:Caregiver immediately suspendedRN and physician completed an assessment of the resident, which revealed no further injuries or complaintsStatements collected from all applicable parties and thoroughly reviewedAll nursing staff were reeducated on F600 (Freedom from Abuse, Neglect and Misappropriation); Kardex process specifically related to care plans and resident transfer statusInitiated resident transfer status audits.Interviews with nursing staff on March 12, 2026 revealed that they had been educated on the Kardex process related to care plans and transfer status.Review of the facility's corrective actions revealed that they were in compliance with F600 on February 16, 2026. 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.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of policies, manufacturer's operations manual, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure adequate interventions and supervision to prevent elopements which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for one of three residents identified at risk for elopement (Resident 3). The facility further relied on it's alarm system to prevent unsupervised exits, which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. This deficiency was cited as past non-compliance. Findings include:The facility policies for elopements and Wander Guards (a bracelet that triggers an alarm and can lock monitored doors to prevent the resident from leaving unattended), dated July 11, 2025, indicated that an Elopement Risk Observation would be completed by a licensed nurse upon admission, re-admission, and/or with any significant change in status whereby an elopement may become an increased possibility. Upon completion of an Elopement Risk Observation, it would be determined by the charge nurse as to what interventions would be initiated. Upon determination of appropriate interventional devices to be utilized to maintain resident safety, a physician order would be obtained for any such device. Upon high risk determination, the resident would be issued a Wander Guard bracelet to be placed on his/her wrist or ankle. Placement of the Wander Guard apparatus would assist in alerting interdisciplinary team members that a resident has, or is attempting to exit the nursing unit. All residents having orders for, or utilizing the Wander Guard bracelet, would have placement and function assessed every shift while awake and out of bed to chair. Individual care plans would be updated accordingly. If a resident eloped and was found, staff were to notify the Nursing Home Administrator, Director of Nursing, Executive Director, [NAME] President of Quality Services, Director of Building Services, and the responsible party when the resident was found. Nursing would complete a head to toe assessment, provide appropriate immediate care, if warranted, and document the findings and details of the episode in the resident's medical record. Nursing staff would complete a n internal incident report and communicate a shift to shift report for the next 72 hours regarding the resident's condition. Nursing Administration would notify the State Department of Health following initial steps to address the emergencyThe operator's manual for the wanderer monitoring system, undated, indicated that wander monitoring transmitters should be tested daily for proper operation. If a device was in a low battery state, the battery or device was to be replaced as soon as possible. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 1, 2025, indicated that the resident could usually make her self understood and understand others, was cognitively impaired, used a wander/elopement alarm, and had diagnoses that included dementia. Current physician's orders for Resident 3, included orders for a wander guard to be used and it's function and placement checked every shift. A care plan, dated July 11, 2024, indicated the resident was to use a wander guard and have the placement checked every shift. A social service note, dated April 8, 2025, revealed that Resident 3 required a wander guard due to her making her way down the elevator at times. An elopement assessment, dated September 2, 2025, revealed that Resident 3 was at risk for elopement. A nursing note for Resident 3, dated September 16, 2025, at 8:01 p.m. revealed the resident was escorted back into the building by EMS (Emergency Medical Services) personnel from the back entrance and she was unable to explain why she was out there. A wander guard was attached to her Broda chair (specialized wheelchair). A facility investigation, dated September 17, 2025, revealed that on September 16, 2025, at 2:52 p.m. Resident 3 eloped by accessing the elevator, going down to the ground floor, headed to personal care, and left the facility. The resident self propels in her wheelchair around the unit. Administration was notified of the elopement on September 17, 2025, at 8:30 a.m. and upon checking Resident 3's wander guard, it was noted in the system as of 6:45 a.m. in the morning that her battery status was low. Resident 3's wander guard was changed immediately upon notification and an elopement assessment was completed on all residents.A Treatment Administration Record (TAR) for September 2025 revealed that on September 16, 2025, staff charted - for the wander guards functioning for the first, second, and third shift. A system status report, dated September 16 and 17, 2025, revealed that Resident 3's wander guard battery status was low for these days.A witness statement from Registered Nurse 1, dated September 17, 2025, revealed that around 3:50 p.m. EMS brought Resident 3 back to the unit and reported that she was outside by receiving and she notified the resident's nurse immediately.A witness statement from Registered Nurse 2, dated September 17, 2025, revealed that she was notified around 4:30- 5:00 p.m. that EMS had brought Resident 3 back into the facility and she didn't know where she was. It was told that EMS found the resident outside. She reported that she did not do a physical assessment of the resident or call the family because she didn't think it was an elopement because the resident wandered. Registered Nurse 1 told her the phone did not trigger with the wander guard, and Registered Nurse 2 reported that she did not check the function of the alarm when the resident returned. A witness statement from Registered Nurse 3, dated September 17, 2025, revealed that Registered Nurse 2 called him around 4:00 p.m. and she stated that Resident 3 got outside and that EMS brought her back in. She asked what needed done, and she was told to put a note in and do a full assessment.Interview with the Nursing Home Administrator on October 15, 2025, at 12:44 p.m. and 1:30 p.m. confirmed that Resident 3 eloped from the building and the wander guard system did not alarm. He could not get a clear answer from the nurse why she charted the function of the wander guard as - for the first shift. He indicated that the nurse did not consider the resident leaving the facility as an elopement; therefore administrative staff were not notified of the incident until the next day. He confirmed that if the alarm was not functioning properly prior to Resident 3's elopement it should have been changed, and confirmed that the resident's wander guard had a low battery on September 16, 2025, when the resident eloped, and it should have been checked/changed after the resident was returned to the facility. He confirmed that staff did not check the alarm following Resident 3's elopement and did not implement any new interventions to ensure that Resident 3 did not elope again; until the morning of September 17, 2025 when he was notified of the elopement.On October 15, 2025, at 3:45 p.m. the Director of Nursing was given the Immediate Jeopardy template and informed that the health and safety of Resident 3 was placed in Immediate Jeopardy as past non-compliance due to the failure to ensure that supervision and adequate interventions were in place to prevent elopements while using the wander guard alarm system.Following the incident on September 16, 2025, the facility's corrective actions included:Immediately upon discovery on September 17, 2025 Resident 3's wander guard transmitter was replaced with a new transmitter and checked for function.A facility wide sweep was conducted on all in house wander guard transmitters to ensure proper function and battery life. Any transmitters with a low battery life or improper function were replaced at the time of discovery.Disciplinary action was enforced with the staff member who failed to respond to the incident in a timely and appropriate manner.All licensed nursing staff were re-educated on the elopement policy and procedure. All licensed nursing staff were also re-educated on the wander guard system function and documentation. Education was completed on September 18, 2025. All new staff and agency staff will receive the education. The Director of Nursing or designee added checking the transmitter battery life to the weekly audit tool which was initiated on September 17, 2025 and the weekly audit tool would include wander guard placement and battery status. Any transmitters with a low battery status would be replaced at the time of discovery. The wander guard system check was completed daily and will continue to be checked for function daily. System check audits would be completed by the Building Services Director or designee daily for three months and transmitter audits would be completed weekly for four months, and then monthly for three months.Upon admission, all residents would receive an elopement assessment and the assessments would determine interventions as needed. Updates would be added to the resident care plan and discussed with the interdisciplinary team.Audit results would be reported to the Quality Assurance Performance Improvement committee to identify trends, further opportunities for quality improvement, and needs for additional education/re-education. The Immediate Jeopardy was lifted on October 15, 2025, at 5:28 p.m. when it was confirmed that the corrective action plans developed on September 17, 2025, were completed by September 18, 2025, and that the wander guards were being checked as ordered and replaced as needed, and all residents that used the wander guard system had no elopements. The facility's date of compliance was September 18, 2025.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(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 clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of four residents reviewed (Resident 2) resulting in a critically abnormal blood clotting time.Findings include:An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 2 dated April 20, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included heart failure. Review of clinical records revealed she was discharged from the facility on May 17, 2025. A medication error report for Resident 2 revealed that on May 11, 2025, a medication discrepancy was identified. The medication nurse realized that the pills in the resident's medication card labeled by the pharmacy as rosuvastatin calcium (a statin medication used to lower bad cholesterol and triglycerides) was actually Warfarin (coumadin-a blood thinner) tablets and not rosuvastatin calcium. Resident 2 was administered the coumadin tablets for several days before the error was noted. A nursing note for Resident 2, dated May 11, 2025 at 6:53 p.m. revealed that a medication discrepancy was identified. The resident is alert and appears at baseline. The physician was notified and new orders were received to obtain a CBC (a common blood test that provides information about different types of cells in your blood: red blood cells, white blood cells, and platelets) and PT/INR (a blood test that measures how long it takes for your blood to clot, assessing the effectiveness of your body's blood clotting process) in the morning. A nursing note for Resident 2, dated May 12, 2025, at 1:15 p.m. revealed that this nurse was made aware of the medication error of Warfarin pills in a medication card labeled Rosuvastatin Calcium 40mg, sent from pharmacy. This nurse immediately reached out to the physician who reviewed the resident's lab work drawn this morning. The resident's INR was 7.0 (the target range is typically between 2.0 and 3.0 for most patients taking warfarin and anything higher indicates an increased risk of bleeding because the blood is taking too long to clot). The physician gave an order for 5 milligrams (mg) STAT of Phytonadione Oral (Vitamin K) and to check the INR daily for three days. This nurse immediately called family and explained the situation at hand. Review of Resident 2's Medication Administration Record for May, 2025, revealed that the resident received 5 mg of Vitamin K orally on May 12, 13, and 14, 2025. A nurse's note for Resident 2 dated May 12, 2025, at 2:08 p.m. revealed that staff spoke to the director of the pharmacy regarding the wrong pills being labeled as rosuvastatin calcium. The card was to be replaced with a new card containing the correct medication and a representative from the pharmacy was to retrieve the wrong medication card. There was no documented evidence that the facility investigated the error to determine if other medication cards in the facility had been labeled incorrectly by the pharmacy. Interview with the Nursing Home Administrator on August 5, 2025, at 3:23 p.m. confirmed that Resident 2 received the wrong medication for several days due to the pharmacy packaging the medication incorrectly. The facility ended their contract with that pharmacy on July 31, 2025, due to a breach in contract for services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispensing and administration of medication to meet the needs of a resident for one of four residents reviewed (Resident 2).A facility policy for Medication Administration dated July 11, 2025, indicated that medications are administered as prescribed in accordance with Manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 2 dated April 20, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included heart failure. Review of clinical records revealed she was discharged from the facility on May 17, 2025.Physician's orders for Resident 2 dated April 16, 2025, indicated that the resident was to receive 40 milligrams (mg) of rosuvastatin calcium (medication used to lower the amount of cholesterol in the blood) at bedtime for hyperlipidemia (abnormally high levels of lipids (fats) in the bloodstream).A medication error report for Resident 2 dated May 12, 2025, indicated that the medication card delivered to the facility from the pharmacy was labeled as rosuvastatin calcium, however, it contained coumadin (a blood thinner) tablets instead of the labeled rosuvastatin calcium tablets and Resident 2 was administered coumadin for several days before the error was noted.An Advanced Practice Nurse's note for Resident 2 dated May 12, 2025, indicated that on May 11, 2025, at 5:49 p.m. she was made aware that a medication ordered for Resident 2 was packaged wrong from the pharmacy, that Resident 2 had received Coumadin instead of rosuvastatin calcium, and orders were given to obtain lab work including a Prothrombin Time (PT-test used to help detect and diagnose a bleeding disorder or excessive clotting disorder), International Normalized Ratio (INR-used to monitor how well the blood-thinning medication is working to prevent blood clots) and a complete blood count. A nurse's note for Resident 2 dated May 12, 2025, at 1:15 p.m. revealed that staff was made aware of a medication error that identified coumadin pills were in a medication card sent to the facility from the pharmacy that was labeled as rosuvastatin calcium and was administered to the resident. The nurse immediately reached out to the physician. The resident's lab work that was ordered and drawn on the morning of May 12, 2025, was reviewed. The resident's INR was elevated and the physician ordered Vitamin K (can reverse the effects of blood thinners likes coumadin), and to check the resident's INR for three days. Interview with the Nursing Home Administrator on August 5, 2025, at 3:23 p.m. revealed that Resident 2 did receive that wrong medication for several days due to the pharmacy packaging the medication incorrectly. The facility ended their contract with that pharmacy on July 31, 2025, due to a breach in contract for services.28 Pa. Code 211.9(a)(1) Pharmacy Services.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and job descriptions, as well as staff interviews, it was determined that the facility failed to follow pressure ulcer treatment recommendations from a wound consultation for one of four residents reviewed (Resident 3).Findings include: The facility's job description for the wound care coordinator, dated July 2024, indicates that the wound care coordinator maintains documentation and care coordination in the electronic medical record for each resident and coordinates care with the attending physician and rounds with the in-house wound physician regularly.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2025, indicated that the resident was cognitively impaired, required assistance for her care needs, and had diagnoses that included atherosclerotic heart disease (hardening of your arteries from plaque building up gradually inside them). Census data revealed the resident was discharged on July 25, 2025.Physician's orders for Resident 3 dated July 8, 2025, included an order to apply skin prep to the resident's heels every shift to maintain skin integrity.A nurse's note for Resident 3 dated July 17, 2025, indicated that the resident had a blood-filled blister on his left heel. Skin prep and a bordered foam dressing was applied. Orders were obtained for a wound consult. A skin check note for Resident 3 dated July 18, 2025, indicated that the resident had a Stage 2 pressure ulcer (a shallow, open wound or blister) to his left heel. The wound care consultant assessed the resident for an initial evaluation of a blood blister to the left heel. No new orders were obtained.A wound consultation for Resident 3 dated July 18, 2025, indicated that the resident had a pressure ulcer to his left heel and treatment recommendations included to apply skin prep the base of the wound and secure it with bordered foam.A skin check note for Resident 3 dated July 25, 2025, at 10:38 a.m. indicated that the resident had Stage 3 pressure ulcer to his left heel.Review of Resident 3's Treatment Administration Records for July 2025 revealed that the treatments to the left heel did not include the application of a bordered foam dressing from July 18 through July 25, 2025.Interview with the Assistant Nursing Home Administrator on August 5, 2025, at 3:23 p.m. revealed that wound care orders that included a foam dressing were not added to the resident's wound orders, resulting in wound care not being completed as recommended by the wound consultant.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of three residents reviewed (Resident 1) who was identified as a fall risk, resulting in a fall and fracture for the resident. This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). The resident's care plan, dated September 17, 2020, revealed that the resident was at risk for falls related to the need for assistance with his balance. A care plan, dated October 10, 2023, revealed that the resident had a communication problem related to his cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and staff was to ensure/provide a safe environment. A care plan, dated May 15, 2024, revealed that the resident had a ADL self-care deficit related to his decreased mobility and was as assist from two staff for his bed mobility and transfers. A nursing note for Resident 1, dated March 28, 2025, at 3:20 p.m. revealed that the nurse aide informed the nurse that the resident had fallen. The nurse entered the room, and the resident was observed on the left side of the bed on the floor on his right side. The resident stated that he fell and his hip hurts. The resident was assessed by the nurse prior to moving him from the floor and back into bed. The resident had small scratches to his right elbow. The areas were cleansed with saline and left open to air. No other injuries were noted at this time. The physician, hospice, and the resident's family member were notified of the incident. New orders were received for an x-ray of his right hip and right femur (the upper leg bone, extending from the hip to the knee) and bilateral landing mats (mats placed to cushion the fall of a resident who rolls out of bed). The resident was medicated with Oxycodone (a narcotic pain medication to treat moderate to severe pain) for pain and will monitor. A nursing note for Resident 1, dated March 28, 2025, at 3:37 p.m., revealed that at 2:16 p.m. that the resident was receiving care from the nurse aide and the resident fell from his bed. The reason for the fall was that the resident leaned too far over causing him to fall out of his bed. A nursing note for Resident 1, dated March 28, 2025, at 6:45 p.m., revealed that the x-ray of the resident's right hip shows an intertrochanteric fracture (a break in the bone (femur) just below the hip joint). The exact clinical age indeterminate (not exactly known) although appears likely either subacute (rather recent onset) or old healed rather than acute (sudden and severe, but of short duration). A physician's note for Resident 1, dated April 2, 2025, revealed that the resident was evaluated for right hip pain. The patient fell a few days ago and reported pain in the right hip. X-rays done with a reading of chronic verses acute fracture of his right hip. The patient is hospice, and family is not interested in sending to the hospital. On the exam he had swelling to his right hip. Plan: Right hip fracture. On the exam, there was tenderness and edema. Likely an acute fracture. Will manage with pain medications. Repeat x-ray in one week. A statement completed by Agency Nurse Aide 1, dated March 28, 2025, revealed that she was doing last rounds, went into change Resident 1. He was rolled onto his left side to be changed due to having a large bowel movement. No issues rolling. All of a sudden, he was reaching for something off his nightstand and rolled out of bed and fell on to the floor. A statement completed by Resident 1, dated March 28, 2025, revealed that the nurse aide asked him to roll on his side. She asked which way was best, and he told her to his left. He started rolling to his left and kept going onto the floor. He landed on his right hip on the floor. A statement completed via conference call with Agency Nurse Aide 1, dated March 31, 2025, revealed that around 1:30 p.m. on March 28, 2025, she went in to check on Resident 1. He was cockeyed in the bed, so she straightened him out and pulled him to the middle of the bed. She asked what side he rolls better toward, and he said to his left. She noticed he had a bowel movement, so she proceeded to start cleaning him. The resident then reached for his bedside table and quickly rolled out of bed before she knew it. Nurse Aide 1 stated that should not have done it and feels horrible, but she thought she could handle it. Since the incident she has been educated on the electronic medical record and the Kardex (a nursing worksheet that includes a summary of resident information, such as prescribed medications, clinical follow-ups, and daily care schedules). If she knew then what she knows now, this would not have happened. Investigative documents for Resident 1, dated March 28, 2025, revealed that on March 28, 2025, at approximately 2:30 p.m. Agency Nurse Aide 1 alerted the nurse that Resident 1 had a fall from bed during routine afternoon care. Upon investigation it was determined that Agency Nurse Aide 1 was providing care in bed with only one assist, while Resident 1 is care planned for two assist with his bed mobility. After the thorough investigation it was determined that Agency Nurse Aide 1 did not following the resident's care plan. Agency Nurse Aide 1 was re-educated and removed from duties as it relates to resident care. Interview with the Nursing Home Administrator on April 8, 2025, at 1:55 p.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan requiring the assistance from two staff for his bed mobility. Following the investigation on March 28, 2025, the facility's corrective actions included: Agency Nurse Aide 1 was suspended pending the results of the investigation, and after the investigation was completed, she was placed on a do not return to the facility list. Facility staff as well as agency staff education on accessing and following the resident's care plan for assistance with bed mobility/transfers was completed. Audits to identify any issues with following a resident's care plan for assistance with bed mobility/transfers were started. The results of these audits will be brought to 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 F656 on April 2, 2025. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

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 a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of three residents reviewed (Resident 1), resulting in a fall and fracture for the resident. Findings include: The facility's policy regarding resident abuse, dated September 27, 2024, revealed that all management and staff are responsible to ensure that every resident will be free from verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, retaliation, humiliation or misappropriation of resident property. That neglect refers to a failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to nutrition, medication, therapies and ADL's. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2025, revealed that the resident was understood, could understand others, and had a diagnosis of morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). The resident's care plan, dated September 17, 2020, revealed that the resident was at risk for falls related to the need for assistance with his balance. A care plan, dated October 10, 2023, revealed that the resident had a communication problem related to his cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and staff was to ensure/provide a safe environment. A care plan, dated May 15, 2024, revealed that the resident had an ADL self-care deficit related to his decreased mobility and was as assist from two staff for his bed mobility and transfers. A nursing note for Resident 1, dated March 28, 2025, at 3:20 p.m. revealed that the nurse aide informed the nurse that the resident had fallen. The nurse entered the room, and the resident was observed on the left side of the bed on the floor on his right side. The resident stated that he fell and his hip hurts. The resident was assessed by the nurse prior to moving him from floor and back into bed. The resident had small scratches to his right elbow. The areas were cleansed with saline and left open to air. No other injuries were noted at this time. The physician, hospice, and the resident's family member were notified of the incident. New orders were received for an x-ray of his right hip and right femur (the upper leg bone, extending from the hip to the knee) and for bilateral landing mats (mats placed to cushion the fall of a resident who rolls out of bed). The resident was medicated with Oxycodone (a narcotic pain medication to treat moderate to severe pain) for pain and will monitor. A nursing note for Resident 1, dated March 28, 2025, at 3:37 p.m., revealed that at 2:16 p.m. the resident was receiving care from the nurse aide and the resident fell from his bed. The reason for the fall was that the resident leaned too far over causing him to fall out of his bed. A nursing note for Resident 1, dated March 28, 2025, at 6:45 p.m. revealed that the x-ray of the resident's right hip showed an intertrochanteric fracture (a break in the bone (femur) just below the hip joint). The exact clinical age indeterminate (not exactly known) although appears likely either subacute (rather recent onset) or old healed rather than acute (sudden and severe, but of short duration). A physician's note for Resident 1, dated April 2, 2025, revealed that the resident was evaluated for right hip pain. The patient fell a few days ago and reported pain in the right hip. X-rays done with a reading of chronic verses acute fracture of his right hip. The patient is hospice, and family is not interested in sending to the hospital. On the exam he had swelling to his right hip. Plan: Right hip fracture. On the exam, there was tenderness and edema. Likely an acute fracture. Will manage with pain medications. Repeat x-ray in one week. A statement completed by Agency Nurse Aide 1, dated March 28, 2025, revealed that she was doing last rounds and went into change Resident 1. He was rolled onto his left side to be changed due to having a large bowel movement. No issues rolling. All of a sudden, he was reaching for something off his nightstand and rolled out of bed and fell on to the floor. A statement completed by Resident 1, dated March 28, 2025, revealed that the nurse aide asked the resident to roll on his side. She asked which way was best, and the resident told her to his left. The resident started rolling to his left and kept going onto the floor. The resident landed on his right hip on the floor. A statement completed via conference call with Agency Nurse Aide 1, dated March 31, 2025, revealed that around 1:30 p.m. on March 28, 2025, she went in to check on Resident 1. He was cockeyed in the bed, so she straightened him out and pulled him to the middle of the bed. She asked what side the resident rolls better toward, and he said to his left. She noticed that he had a bowel movement, so she proceeded to start cleaning him. The resident then reached for his bedside table and quickly rolled out of bed before she knew it. She stated that she should not have done it and feels horrible, but thought she could handle it. Since the incident, the Nurse Aide 1 has been educated on the electronic medical record and the Kardex (a nursing worksheet that includes a summary of resident information, such as prescribed medications, clinical follow-ups, and daily care schedules). She stated that if she knew then what she knows now, this would not have happened. Investigative documents for Resident 1, dated March 28, 2025, revealed that on March 28, 2025, at approximately 2:30 p.m. Agency Nurse Aide 1 alerted the nurse that Resident 1 had a fall from bed during routine afternoon care. Upon investigation it was determined that Agency Nurse Aide 1 was providing care in bed with only one assist, while Resident 1 is care planned for two assist with his bed mobility. After the thorough investigation neglect was substantiated due to not following the resident's care plan. Agency Nurse Aide 1 was re-educated and removed from duties as it relates to resident care. Review of Nurse Aide 1's personnel file revealed that she had completed training regarding preventing, recognizing, and reporting abuse on February 1, 2025. Interview with the Nursing Home Administrator on April 8, 2025, at 1:55 p.m. confirmed that the facility's investigation substantiated neglect because Nurse Aide 1 did not follow Resident 1's care plan requiring the assistance from two staff for his bed mobility. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the investigation reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of three residents reviewed (Resident 1) resulting in a fall with fracture. This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems). The resident's care plan, dated September 17, 2020, revealed that the resident was at risk for falls related to the need for assistance with his balance. A care plan, dated October 10, 2023, revealed that the resident had a communication problem related to his cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and staff was to ensure/provide a safe environment. A care plan, dated May 15, 2024, revealed that the resident had a ADL self-care deficit related to his decreased mobility and was as assist from two staff for his bed mobility and transfers. A nursing note for Resident 1, dated March 28, 2025, at 3:20 p.m. revealed that the nurse aide informed the nurse that the resident had fallen. The nurse entered the room, and the resident was observed on the left side of the bed on the floor on his right side. The resident stated that he fell and his hip hurts. The resident was assessed by the nurse prior to moving him from floor and back into bed. The resident small scratches to his right elbow. The areas were cleansed with saline and left open to air. No other injuries were noted at this time. The physician, hospice, and the resident's family member were notified of the incident. New orders received for an x-ray of his right hip and right femur (the upper leg bone, extending from the hip to the knee) and bilateral landing mats (mats placed to cushion the fall of a resident who rolls out of bed). The resident was medicated with Oxycodone (a narcotic pain medication to treat moderate to severe pain) for pain and will monitor. A nursing note for Resident 1, dated March 28, 2025, at 3:37 p.m., revealed that at 2:16 p.m. that the resident was receiving care from the nurse aide and the resident fell from his bed. The reason for the fall was that the resident leaned too far over causing him to fall out of his bed. A nursing note for Resident 1, dated March 28, 2025, at 6:45 p.m., revealed that the x-ray of the resident's right hip shows an intertrochanteric fracture (a break in the bone (femur) just below the hip joint). The exact clinical age indeterminate (not exactly known) although appears likely either subacute (rather recent onset) or old healed rather than acute (sudden and severe, but of short duration). A physician's note for Resident 1, dated April 2, 2025, revealed that the resident was evaluated for right hip pain. The patient fell a few days ago and reported pain in the right hip. X-rays done with a reading of chronic verses acute fracture of his right hip. The patient is hospice, and family is not interested in sending to the hospital. On the exam he had swelling to his right hip. Plan: Right hip fracture. On the exam, there was tenderness and edema. Likely an acute fracture. Will manage with pain medications. Repeat x-ray in one week. A statement completed by Agency Nurse Aide 1, dated March 28, 2025, revealed that she was doing last rounds, went into change Resident 1. He was rolled onto his left side to be changed due to having a large bowel movement. No issues rolling. All of a sudden, he was reaching for something off his nightstand and rolled out of bed and fell on to the floor. A statement completed by Resident 1, dated March 28, 2025, revealed that the nurse aide asked him to roll on his side. She asked which way was best, and he told her to his left. He started rolling to his left and kept going onto the floor. He landed on his right hip on the floor. A statement completed via conference call with Agency Nurse Aide 1, dated March 31, 2025, revealed that around 1:30 p.m. on March 28, 2025, she went in to check on Resident 1. He was cockeyed in the bed, so she straightened him out and pulled him to the middle of the bed. She asked what side he rolls better toward, and he said to his left. She noticed he had a bowel movement, so she proceeded to start cleaning him. The resident then reached for his bedside table and quickly rolled out of bed before she knew it. Nurse Aide 1 stated that she should not have done it and feels horrible, but she thought she could handle it. Since the incident she has been educated on the electronic medical record and the Kardex (a nursing worksheet that includes a summary of resident information, such as prescribed medications, clinical follow-ups, and daily care schedules). If she knew then what she knows now, this would not have happened. Investigative documents for Resident 1, dated March 28, 2025, revealed that on March 28, 2025, at approximately 2:30 p.m. Agency Nurse Aide 1 alerted the nurse that Resident 1 had a fall from bed during routine afternoon care. Upon investigation it was determined that Agency Nurse Aide 1 was providing care in bed with only one assist, while Resident 1 is care planned for two assist with his bed mobility. After the thorough investigation it was determined that Agency Nurse Aide 1 did not following the resident's care plan. Agency Nurse Aide 1 was re-educated and removed from duties as it relates to patient care. Interview with the Nursing Home Administrator on April 8, 2025, at 1:55 p.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan requiring the assistance from two staff for his bed mobility. Following the investigation on March 28, 2025, the facility's corrective actions included: Agency Nurse Aide 1 was suspended pending the results of the investigation, and after the investigation was completed, she was placed on a do not return to the facility list. Facility staff as well as agency staff education on accessing and following the resident's care plan for assistance with bed mobility/transfers was completed. Audits to identify any issues with following a resident's care plan for assistance with bed mobility/transfers were started. The results of these audits will be brought to 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 F689 on April 2, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.