Every finding on record at Richland Nursing and Rehab

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for one of five residents reviewed (Resident 4). Findings include: The facility's policy regarding infection prevention and control program, dated May 27, 2026, revealed that hand hygiene shall be performed in accordance with the facility's hand hygiene procedures. The facility's policy regarding enhanced barrier precautions (EBP), dated May 27, 2026, revealed that gowns and gloves would be available immediately near or outside of the resident's room. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 2, 2026, revealed that the resident was cognitively impaired, dependent on staff for daily care needs, and had an indwelling urinary catheter. Observations on July 14, 2026, at 1:27 p.m. revealed that the resident had a sign outside her room indicating that she was on enhanced barrier precautions, however, there was no PPE visible outside or inside the residents room. Nurse Aide 1 and Nurse Aide 2 entered Resident 4's room to empty her urinary catheter bag and prepare to get out of bed to go to activities. Nurse Aide 2 donned gloves and then placed paper towels on the floor under the urinary catheter bag and then placed the graduate (a triangular shaped container used when emptying a urinary catheter) on the floor on top of the paper towels. She cleansed the urinary catheter spout with an alcohol wipe, opened the spout, and drained the urine into the graduate. The resident's urinary catheter filled the graduate two times. After emptying the graduate Nurse Aide 2 removed her gloves and then donned a new pair of gloves. Nurse Aide 2 put the resident's urinary catheter into a privacy bag and again removed her gloves and donned new gloves. Nurse Aide 2 removed Resident 4's brief and cleansed the resident. She removed the soiled brief and then applied a new brief. Nurse Aide 2 then placed the resident's left leg in a special boot, applied her shorts and repositioned the resident's urinary catheter bag. She removed her gloves and applied new gloves. They placed the lift sling under the resident, got a sock and shoe for her, and set up her wheelchair. The resident was lifted with a mechanical lift machine and placed into her chair. The nurse aides did not wear gowns while providing incontinence care to the resident and Nurse Aide 2 did not wash her hands between glove changes. Interview with Nurse Aide 2 on July 14, 2026, at 1:43 p.m. revealed that she did not wash her hands between glove changes and she should have. She further stated that she didn't think she needed a gown on to empty the urinary catheter or provide incontinence care to Resident 4. Interviews with the Director of Nursing on July 14, 2026, at 2:28 p.m. revealed that Nurse Aides 1 and 2 should have followed the enhanced barrier precautions and worn gowns while providing incontinence care to Resident 4. She further stated that Nurse Aide 2 should have washed her hands between glove changes. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to distribute and serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore appropriate hair coverings while preparing residents' food, and failing to monitor food temperatures in the kitchen. Findings include: The facility's policy regarding the use of hair restraints, dated November 26, 2025 revealed that dietary staff must wear hair nets or caps and/or beard restraints when cooking, preparing or assembling food as a preventive measure against the spread of illness and to prevent hair from contacting exposed food. Observations in the main kitchen on April 27, 2026, at 11:32 a.m., revealed that the Dietary [NAME] was plating corn and placing beef on soft tortilla shells to make quesadillas for the lunch meal. Observations at this time revealed that he had a beard but was not wearing a beard restraint.The facility's policy regarding recording food temperatures, dated November 26, 2025, revealed that food temperatures will be checked before trays are assembled. This practice helps to ensure food is at the proper serving temperatures needed to limit the growth of pathogens capable of causing disease.Observations of the food temperature logs in the kitchen on April 27, 2026, at 11:50 a.m., revealed that the following April 2026, food temperature logs were either not done or were incomplete; April 21 and 22, no lunch temperatures, April 23, no temperatures for breakfast, lunch or supper, April 24, no breakfast or lunch temperatures, and April 26, no breakfast lunch or supper temperatures taken.Interview with the Dietary Manager on April 27, 2026, at 12:10 p.m. confirmed that the Dietary [NAME] was plating food and was not wearing a beard restraint, and should have, and that for the above-mentioned days the food temperatures should have been taken and recorded as per facility policy, and they were not. 28 Pa. Code 211.6(f) Dietary services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure timely medication administration per physician's orders, and failed to notify the physician that a medication was available for administration per physician's orders resulting in a delay in treatment for one of eight residents reviewed (Resident 6). Findings include: A facility policy regarding medication administration, dated November 26, 2025, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 6, dated April 20, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, was frequently incontinent of bowel, and had a diagnosis of unspecified diarrhea. A nursing note for Resident 6, dated April 23, 2026, at 2:36 p.m. indicated that stool specimen results were received and indicated that the resident tested positive Clostridium difficile (C-diff-a highly contagious infection of the colon spread through contact). The resident was already on contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) and the physician was notified. A physician's order for Resident 6, dated April 23, 2026, included orders for the resident to receive 500 milligrams (mg) of Metronidazole (an antibiotic) three times daily for C-diff for 14 days. A nursing note for Resident 6, dated April 24, 2026, at 9:29 a.m. indicated that orders were received from the physician to discontinue the Metronidazole (Flagyl) and give Dificid (an antibiotic specifically used to treat C-diff) 200 mg twice daily for 10 days for treatment of C-diff. A physician's order for Resident 6, dated April 24, 2026, included orders for the resident to receive200 mg of Dificid twice daily for C-Diff for 10 days until May 4, 2026. A nursing note for Resident 6, dated April 25, 2026, at 11:51 p.m. indicated that the facility was waiting for the Dificid to arrive. A nursing note for Resident 6, dated April 26, 2026, at 7:28 p.m. indicated that the facility was waiting for the Dificid to arrive. A nursing note for Resident 6, dated April 27, 2026, at 5:40 a.m. indicated that the nurse spoke with a representative from Polaris pharmacy concerning the Dificid medication. She stated this was a high-cost medication and they would send the payment information and alternative medication from insurance. The form was to be completed by the Director of Nursing or Assistant Director of Nursing and faxed back to pharmacy once received. A nursing note for Resident 6, dated April 27, 2026, at 8:48 a.m. indicated that the facility was waiting for confirmation of the Dificid medication. Review of Resident 6's Medication Administration Record (MAR), for April 2026, revealed that the resident had not received the Dificid medication as ordered since April 24, 2026. There was no documented evidence in the resident's clinical record that the physician was notified that the medication was not available to administer to the resident. An interview with the Assistant Director of Nursing on April 27, 2026, at 1:27 p.m. revealed that Resident 6's Dificid medication was on backorder per the pharmacy, and it was being delivered immediately to the facility this day. Interview with Resident 6, on April 27, 2026, at 2:37 p.m. indicated that she had been waiting for her antibiotic since Friday. She stated she had been asking them all weekend where her antibiotic was, and they stated that it was ordered. She stated that she wanted to get the infection resolved so she could go home. She indicated that there were people that were immuno-compromised at home and wanted to be free from infection when she went home. Interview with the Director of Nursing on April 27, 2026, at 2:47 p.m. confirmed that the physician should have been notified that Resident 6's Dificid medication was not available, and should have been informed that the resident did not receive the Dificid as ordered for treatment of her C-diff. She indicated that she spoke to the Certified Registered Nurse Practitioner (CRNP) this day, and he stated that he did not want to change Resident 6's Dificid medication due to it being more effective for the treatment of C-diff; however, he had not been notified until this day that the resident had not been receiving treatment for her C-diff infection. 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's care plan reflected the resident's specific care needs for two of 35 residents (Resident 2 and Resident 61). Findings Include:A facility policy for comprehensive care plans, dated November 26, 2025, indicated that it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 12, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD. There was no documented evidence that Resident 2's care plan reflected the diagnosis of PTSD with associated triggers. Interview with the Social Worker on January 30, 2026, at 09:18 a.m. revealed that the facility was not completing trauma informed care assessments and that they should be. In addition, the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 2. Interview with the Director of Nursing on January 30, 2026, at 10:18 a.m. confirmed that Resident 2's care plan should have been updated to reflect the diagnosis of PTSD and potential triggers to avoid. A quarterly MDS assessment for Resident 61, dated November 14, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, received antidepressant medications (a psychotropic medication used to treat depression) and had diagnoses that included anxiety and depression. Psychotropic medications are medications used to treat mental health disorders by altering brain chemistry. A physician's order for Resident 61, dated December 31, 2025, included an order for the resident to receive 5 milligrams (mg) of Olanzapine (a psychotropic medication classified as an antipsychotic medication used to treat mental health disorders) daily at bedtime related to major depression. There was no documented evidence in Resident 61's medical record that a comprehensive care plan was developed to reflect the resident's need for an antipsychotic medication. Interview with the Director of Nursing on January 29, 2026, at 5:45 p.m. confirmed that there was no documented evidence in Resident 61's medical record that a comprehensive care plan was developed to reflect the resident's need for an antipsychotic medication. 28 Pa. Code 211.11(d) Resident care plan

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 35 residents reviewed (Resident 80). Findings include: A facility policy for Medication Administration, dated November 26, 2025, indicated that medications will me administered as per the the physicians orders. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 80, dated January 17, 2026, revealed that the resident was moderately cognitively impaired, had clear speech, understood and understands and had diagnoses that included heart disease and high blood pressure, and on May 13, 2025, was originally ordered 5 milligrams (mg) Lisinopril (a medication to treat high blood pressure) one time a day. A nursing note for Resident 80, dated October 8, 2025, at 12:07 p.m. indicated that the resident had an episode of dizziness and a blood pressure of 92/60 millimeters of mercury (mm/Hg). Physician's orders for Resident 80, dated October 9, 2025, included an order for the resident to receive 2.5 (mg) of Lisinopril one time a day, from October 9, 2025 to January 28, 2026, with the following blood pressure perimeters; hold if systolic (top number, when blood pushes out the heart) is less than or equal to 120 mm/Hg. A review of Resident 80's Medication Administration Record (MAR) for October 2025 through January 2026 revealed that on the following dates the resident received her lisinopril despite the blood pressure being too low to administer; October 23, 2025, 116/78 mm/Hg; November 2, 2025, 116/74 mm/Hg ; November 7, 112/70 mm/Hg; and November 20, 118/76 mm/Hg; December 28, 116/70 mm/Hg; January 1, 2026, 108/68 mm/Hg ; January 5, 108/66 mm/Hg; January 10, 114/76 mm/Hg; January 17, 110/60 mm/Hg; January 19, 112/66 mm/Hg; January 20, 120/88 mm/Hg; January 21, 112/62 mm/Hg; and January 28, 116/58 mm/Hg. On the following dates the resident did not receive the lisinopril despite the blood pressure being within the appropriate range to receive it, November 20, 2025, 124/70 mm/Hg and January 16, 2026, 142/88 mm/Hg . Interview with the Assistant Director of Nursing on January 29, 2026, at 11:20 a.m. confirmed that Resident 80's Lisinopril was not held or administered on the above dates and times as ordered by the physician.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine) for one of 35 residents reviewed (Resident 94). Findings include: The facility's policy regarding urinary catheter care, dated November 26, 2025, indicated that the purpose of this policy was to prevent catheter-associated urinary tract infections. General guidelines related to infection control indicated to make sure the catheter tubing and drainage bag were kept off the floor. An admission note for Resident 94, dated January 27, 2026, indicated that the resident was admitted to the facility for a three-day respite stay. A care plan for the resident, dated January 28, 2026, indicated that the resident had an indwelling urinary catheter related to urinary retention. Physician's orders for Resident 94, dated January 28, 2026, included an order for the resident to have an indwelling urinary catheter due to urinary retention. Observations on January 28, 2026, at 1:06 p.m. revealed that Resident 94 was lying in a low bed with his catheter bag hanging on the left side of his bed in a privacy bag with the catheter tubing lying in direct contact with the floor. Interview with Nurse Aide 1, on January 28, 2026, at 1:09 p.m. confirmed that Resident 94's catheter tubing was lying in direct contact with the floor and it should not have been. Interview with the Director of Nursing on January 28, 2026, at 5:36 p.m. confirmed that Resident 94's catheter tubing should not have been in direct contact with the floor. She indicated that they used to have hooks/clips to help keep the tubing off the floor. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 35 residents reviewed (Resident 2).Findings include: Trauma informed care policy dated November 26, 2025, revealed that the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 12, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD. A review of Resident 2's care plan, dated September 29, 2025, indicated that the resident had PTSD and dementia. There was no documented evidence the facility identified Resident 2's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Social Worker on January 30, 2026, at 09:18 a.m. revealed that the facility was not completing trauma informed care assessments and that they should be. In addition, the facility did not assess or identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 2. 28 Pa Code 211.12(a)(d)(3)(5) Nursing services. 28 Pa Code 211.11(d) Resident care plan. 28 Pa. Code 211.16(a) Social 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 multi-dose containers of medications with the date they were opened in one of two medication carts reviewed (C hall cart).The facility's policies regarding medication storage and disposal, dated November 26, 2025, revealed that the facility would properly date medication vials after they were opened. An undated package insert for Degludec (a diabetic medication) revealed that it should be used within 56 days upon opening. An undated package insert for NovoLog (a diabetic medication) revealed that the medication should be used within 28 days of opening. An undated package inserts for Humalog Kwikpen (a diabetic medication) revealed that it should be used after 28 days of opening.Observations in the C Hall cart on January 28, 2026, at 9:54 a.m. revealed that there was an 100 unit/ml Humalog Kwik Pen for Resident 31 open and undated, a 100 unit/ml Novolog Flex Pen and a 100 unit/ml Degludec FlexTouch pen for Resident 94 open, undated, and did not have a cap.Interview with Licensed Practical Nurse 3 on January 28, 2026, at 10:08 a.m. confirmed that the medication should have been dated upon opening.Interview with the Director of Nursing on January 28, 2026, at 4:15 p.m. confirmed that the medications should have been dated upon opening, and it should have had a cap.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of facility policies, and clinical records, as well as observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to assist with eating in accordance with physician's orders for one of 35 residents reviewed (Resident 63). Findings include: The facility's policy regarding assistive devices and equipment, dated November 26, 2025, revealed thatcertain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include specialized eating utensils and equipment. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated November 25, 2025, revealed that the resident was cognitively impaired, required set-up assistance with eating, had limited range of motion to his upper extremity on one side, and had a diagnosis of monoplegia (paralysis affecting one limb) following a cerebral vascular accident (stroke) affecting his left side. A nutrition care plan for Resident 63, dated June 21, 2025, indicated that the resident was to have adaptive equipment as ordered. Physician's orders for Resident 63, dated January 5, 2026, included an order for the resident to have an inner lip plate (plate that reduces food spillage) for meals. A nutrition note for Resident 63, dated January 13, 2026, at 9:44 a.m. indicated that the resident utilizes an inner lip plate for adaptive equipment. Observations of Resident 63 during the breakfast meal on January 30, 2026, at 8:38 a.m. revealed that the resident was sitting up in bed eating his breakfast meal served on a regular plate. The resident was having difficulty getting the food onto his fork and he had a large amount of food resting on his chest. The resident's meal ticket on his tray at that time indicated that the resident was to have an inner lip plate for meals. An interview with LPN 2 on January 30, 2026, at 8:40 a.m. confirmed that Resident 63 did not have an inner lip plate for breakfast and should have per his meal ticket. She stated she would address it with dietary. An interview with the Director of Nursing on January 30, 2026, at 8:42 a.m. confirmed that Resident 63 should have had an inner lip plate as ordered. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include: Observations of the walk-in cooler on January 28, 2026, at 9:42 a.m. revealed one quarter bushel of moldy cucumbers. Observations of the walk-in freezer on January 28, 2026, at 9:40 a.m. revealed that there was half of a box of Tony's pizzas, half of a bag of chicken tenders, one box of breadsticks that were opened, undated and exposed to the air. Observations of the small refrigerator in the kitchen on January 28, 2026, at 9:47 a.m. revealed half of a container of heavy whipping cream that was opened and undated. Observations of the residents' refrigerator on January 28, 2026, at 9:53 a.m. revealed half of a container of soup that was undated, with a brown and white removable substance around the lid. Interview with the Dietary Director on January 28, 2026, at 9:53 a.m. confirmed that food should be dated when it is opened and should be properly sealed for storage, and that resident food should be thrown out when it shows signs of spoilage.28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 207.4 Ice Containers and Storage.

Based on review of facility policies, clinical record reviews, as well as 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 for one of 4 residents reviewed (Resident 2).Findings include:The facility's policy regarding medication administration, dated November 21, 2024, revealed that medications were to be administered in accordance with written orders of the attending physician. A admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 10 2025, revealed that the resident was moderately cognitively impaired, sometimes understood, required extensive assistance for daily care needs, and had diagnoses that included acute respiratory failure, heart attack, stroke, myasthenia gravis (weakness of muscles) and dementia. Physician's orders for Resident 2, dated July 9, 2025, included an order for Rivastigmine (Exelon) Transdermal Patch (a medicated patch used to treat dementia) 24 Hour 13.3 MG/24HR. Apply 1 patch one time a day related to vascular dementia and remove per schedule. Resident 2's Medication Administration Record (MAR) for July 2025, indicated that staff administered Exelon transdermal patch on July 19, 2025, and July 20, 2025, as per order (Old patch removed when new patch applied).A late entry nursing note dated July 21, 2025, at 9:00 a.m. indicated that the facility was made aware that Resident 2 was found to have two medication patches on when he arrived at the hospital on July 21, 2025.Interview with Licensed Practical Nurse 1, on August 5, 2025, at 1:30 p.m. revealed that she administered the Exelon patch on July 20, 2025, at 8:00 a.m., and indicated that she always takes the old patch off, reviews and administers the resident's pills and then applies the new patch. She went on to say that she was surprised to be informed by administration that Resident 2 was found to have two Exelon patches on him when he arrived at the hospital on July 21, 2025. Interview with the Director of Nursing on August 5, 2025, at 1:44 p.m. revealed that she was notified by Senior Life Care Services (a company that provides assistance for elder adults) that the hospital found two medication patches on Resident 2 when he arrived at the hospital on July 21, 2025. The facility began an investigation regarding the patch administration. She went on to say that the clinical documentation and verbal interview from the staff member involved indicated that the medication administration was done correctly. However, she understands that mistakes are made and that the hospital would not make up the story. She remarked that it was obvious that her staff must not have removed the old patch prior to putting on a new one, and she should have.28 Pa. Code 211.12(d)(1)(3)(5) Nursing 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 oxygen was provided as ordered by the physician for one of four residents reviewed (Resident 3). Findings include: The facility's policy regarding oxygen use, dated May 8, 2024, indicated that the facility was to verify the physician's order and provide safe oxygen administration. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 20, 2024, revealed that the resident was severely cognitively impaired and received oxygen. A care plan, dated November 27, 2024, revealed that Resident 3 was at risk for respiratory impairment related to congestive heart failure (CHF) and had a history of pneumonia. Physician's orders, dated November 30, 2024, included an order for the resident to receive oxygen at zero to four liters per minute (lpm) every shift to maintain an oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in arterial blood) of 90 percent or more. Observations of Resident 3 on January 29, 2025, at 12:56 p.m. revealed that the resident had oxygen in use at 3 lpm via nasal cannula (tube that delivers oxygen through the nose). Resident 3 requested to use the bed pan. Nurse Aide 1 and Nurse Aide 2 removed Resident 3's oxygen and transferred her into bed using a full body mechanical lift but did not reapply her oxygen. Resident 3 was confused and did not use her call bell when finished, she just yelled out that she wanted off the bed pan. She was provided care and repositioned in the bed at 1:33 p.m. by Nurse Aides 1 and 2. Resident 3 said that she was not comfortable and that her neck and chest did not feel right. Licensed Practical Nurse 3 got a pulse oximeter (measures the oxygen saturation of arterial blood) measurement at 2:04 p.m. with a reading of 87 percent. Interview with Nurse Aide 1 at 2:04 p.m. confirmed that Resident 3's oxygen was not reapplied after she was transferred to the bed and it should have been. Interview with Nurse Aide 2 at 2:05 p.m. confirmed that Resident 3 did not have her oxygen reapplied, and that is why she got so upset and angry. Interview with Director of Nursing on January 29, 2025, at 5:05 p.m. confirmed that Resident 3 should have been provided her oxygen therapy as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of planned, written menus, and recipes, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu and recipes. Findings included: Review of the posted menus for the lunch meal on Thursday, December 19, 2024, revealed that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine. A facility recipe card for chicken and vegetable stew, dated September 6, 2015, indicated that the chicken and vegetable stew contained the following 19 ingredients: fully cooked 1/2-inch diced chicken that was 80 percent dark and 20 percent white, chopped ham, chicken broth, baby lima beans, corn, crushed tomatoes, diced celery, chopped onions, minced garlic, ketchup, red wine vinegar, sugar, Worcestershire sauce, paprika; marjoram, pepper, salt, hot sauce, and margarine. Observations on December 19, 2024, at 11:46 a.m. during the lunch tray delivery revealed that the residents received a bowl containing the spaghetti noodles and the chicken vegetable stew, and a small bowl containing the pineapple tidbits. However, there was no dinner roll or margarine placed on the residents' lunch tray. Observations during a test tray on December 19, 2024, at 12:00 p.m. revealed that the Chicken Vegetable Stew did not contain any chopped ham, lima beans, crushed tomatoes, diced celery, and minced garlic, the Pineapple Tidbits did not contain a cream, and there was no dinner roll on the tray. Interview with the Dietary Manager on December 19, 2024, at 12:04 p.m. confirmed that the dinner roll and margarine were not placed on the residents' trays, and that the pineapple tidbits did not contain the cream. He indicated that the cream was to be delivered today on the truck. Interview with [NAME] 8 on December 19, 2024, at 12:25 p.m. revealed that the supply truck had not arrived yet and that he tried to make the Chicken Vegetable Stew as hardy as possible with what he had available. There was no documented evidence that the change in the menu was discussed with the resident council president. 28 Pa. Code 211.6(a) Dietary Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for six of 37 residents reviewed (Residents 9, 28, 36, 37, 43, 62). Findings include: A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that the resident had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that a written notice of Resident 9's transfer to the hospital and reason for hospitalization was provided to the resident's representative. A nursing note for Resident 28, dated October 22, 2024, at 8:06 p.m., revealed that the resident was transferred to the hospital and admitted with a heart attack. There was no documented evidence that a written notice of Resident 2's transfer to the hospital and reason for hospitalization was provided to the resident's representative. A nursing note for Resident 36, dated November 10, 2024, at 4:46 p.m., revealed that the resident was transferred to the hospital and admitted with a urinary tract infection. There was no documented evidence that a written notice of Resident 36's transfer to the hospital was provided to the resident's representative. A nursing note for Resident 37, dated June 29, 2024, at 3:00 a.m., revealed that the resident was transferred to the hospital and admitted with altered mental status. There was no documented evidence that a written notice of Resident 9's transfer to the hospital and reason for hospitalization was provided to the resident's representative. A nursing note for Resident 43, dated September 7, 2024, at 5:19 a.m., revealed that the resident had a fall and complained of the left hip pain. The physician was notified and the resident was sent to the hospital for an evaluation and was admitted . There was no documented evidence that a written notice of Resident 43's transfer to the hospital and reason for hospitalization was provided to the resident's representative. A nursing note for Resident 62, dated November 9, 2024, at 9:26 p.m., revealed that the resident was transferred to the hospital and admitted with a diagnosis of status epilepticus (long-acting multiple seizures). There was no documented evidence that a written notice of Resident 62's transfer to the hospital was provided to the resident's representative. Interview with the Director of Nursing on December 18, 2024, at 10:33 a.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital and/or the reason for hospitalization . 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of the Pennsylvania's Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for three of 37 residents reviewed (Residents 19, 63, 76). 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. Physician's orders for Resident 19, dated October 11, 2024, included an order for staff to flush the resident's feeding tube (a medical device that provides nutrition, fluids, and medication to people who are unable to eat or drink safely by mouth) with 50 milliliters (ml) of water before and after administering medications and flush with 5 ml of water between each medication administered. A nutritional note for Resident 19, dated December 3, 2024, revealed that the resident was aware of his oral intake being improved. The resident made it known that he did not want the tube feeding to be restarted. He agreed to the use of oral supplementation if needed. A progress note for Resident 19, dated December 11, 2024, revealed that a care plan meeting was held that date indicating that the resident's tube feeding was recently discontinued. Interview with Licensed Practical Nurse 3 on December 18, 2024, at 9:10 a.m. revealed that Resident 19 still has the feeding tube in place, that she does not use it for administering his medications, and that she gives all of his medications by mouth. Interview with Resident 19, 2024, at 9:25 a.m. revealed that he takes everything by mouth now and that they do not use the feeding tube to administer any feedings and/or medications. He indicated that he is hoping that they soon get rid of the feeding tube. There was no documented evidence that Resident 19's physician was contacted to clarify how the resident's feeding tube was to be flushed, since he does not receive his medications by the feeding tube. Interview with the Director of Nursing December 18, 2024, at 12:30 p.m. confirmed that there was no documented evidence that Resident 19's physician was contacted to clarify how the resident's feeding tube was to be flushed, since he does not receive his medications by the feeding tube. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated November 14, 2024, indicated that the resident was cognitively intact, could understand others and was understood, and had a diagnosis of diabetes. Physician's orders for Resident 63, dated November 14, 2024, included an order for the resident to receive 14 units of insulin lispro (a fast-acting medication to help regulate blood sugar levels in persons with diabetes) at 8:00 a.m., 12:00 p.m., and 5:15 p.m. Review of Resident 63's Medication Administration Record (MAR) for November and December 2024 revealed that the resident did not receive the 14 units of insulin lispro on November 14, 2024, at 5:15 p.m.; November 15, 2024, at 5:15 p.m.; November 20, 2024, at 8:00 a.m.; November 21, 2024, at 8:00 a.m.; November 22, 2024, at 8:00 a.m.; November 23 2024, at 8:00 a.m.; November 24, 2024, at 5:15 p.m.; November 25, 2024, at 8:00 a.m.; November 26, 2024, at 8:00 a.m.; November 29, 2024, at 8:00 a.m.; November 30, 2024, at 8:00 a.m.; and December 3, 2024, at 5:15 p.m. Interview with Assistant Director of Nursing on December 19, 2024, at 11:11 a.m. confirmed that the insulin was not given to Resident 63 on the dates and times listed above, and that previously Resident 63 had orders to hold the insulin if the blood sugar was less than or equal to 150 mg/dl. The orders were recently changed by pharmacy and signed off by the site medical director and did not include holding the insulin. The new orders should have been clarified by the physician before holding the insulin. A quarterly MDS assessment for Resident 76, dated December 6, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart failure and hypotension (low blood pressure). Physician's orders for Resident 76, dated November 18 and December 2, 2024, included orders for the resident to receive 5 milligrams (mg) of Midodrine (a medication used for low blood pressure) with meals three times on Mondays, Wednesdays, Fridays, and Sundays, and to be given if the resident's systolic blood pressure (pressure within heart when heart is pumping) was less than 90 mmHg and to hold if the resident's systolic blood pressure was greater than 120 mmHg or above. Resident 76's Medication Administration Records (MAR's) for November and December 2024 indicated that the resident's blood pressure at 5:30 a.m. was 101/66 mmHg on November 24, 104/52 mmHg on November 25, and 114/76 mmHg on November 27; at 12:30 p.m. was 104/60 mmHg on December 9, 116/70 mmHg on December 4, 110/60 mmHg on December 9, and 116/64 mmHg on December 16; at 5:30 p.m. was 118/60 mmHg on November 20, 107/63 mmHg on November 25, 100/56 mmHg on November 27, 118/78 mmHg on December 4, and 110/74 mmHg on December 6, 2024. However, according to the MAR's, staff administered Midodrine on these days when the medication order should have been clarified for what to do when the resident's systolic blood pressure was between 90 and 120 mmHg. Interview with the Assistant Director of Nursing on December 18, 2024, at 2:39 p.m. confirmed that staff should have clarified the Midodrine order with the physician when the resident's systolic blood pressure was between 90 and 120 mmHg. 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 complete neurological checks per protocol following a fall for one of 37 residents reviewed (Resident 37) and failed to ensure that medications were provided as ordered by the physician for one of 37 residents reviewed (Resident 76). Findings include: The facility's examination and assessment policy, dated November 21, 2024, indicated that the purpose was to examine and assess the resident for any abnormalities in their health status, one way to do this was to use a neurological assessment flow sheet. The neurological assessment form indicated that neurological checks would be completed every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated October 9, 2024, indicated that the resident was moderately cognitively impaired and had diagnoses that included peripheral vascular disease (a slow, progressive disorder of the blood vessels) and atrial fibrillation (an irregular heartbeat). Nursing notes indicated that on June 28, 2024, at 3:30 a.m. Resident 37 was found lying on his floor mat between the wall and bed, assessments were done, and no injury was noted. Later that day the resident did not appear to be himself, spilling his pills all over himself, presenting with right-sided weakness and pain, mouth drooping, and the inability to tell staff where he was. A neurological assessment form was started as per the facility protocol and the resident examination and assessment policy. A review of the neurological assessment form check list for Resident 37's June 28, 2024, fall revealed that the assessments were not completed as per the facility's protocol. The facility's medication administration policy, dated November 21, 2024, indicated that medications should be given as per physicians orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 76, dated December 6, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart failure and hypotension (low blood pressure). Physician's orders for Resident 76, dated November 9 and December 2, 2024, included orders for the resident to receive 5 milligrams (mg) of Midodrine (a medication used for low blood pressure) with meals three times on Tuesdays, Thursdays and Saturdays and to hold if the resident's systolic blood pressure (pressure within the heart when the heart is pumping) was 120 millimeters of mercury (mmHg) or above. Resident 76's Medication Administration Records (MAR's) for November and December 2024 indicated that the resident's blood pressure at 5:30 a.m. was 141/78 mmHg on November 28 and 122/70 mmHg on November 30; at 12:30 p.m. was 138/76 mmHg on December 3, 130/74 mmHg on December 7, and 136/88 mmHg on December 12; and at 5:30 p.m. was 126/58 mmHg on November 19, 2024. However, according to the MAR's, staff administered Midodrine on these days when the medication should have been held. Interview with the Assistant Director of Nursing on December 18, 2024, at 2:39 p.m. confirmed that staff should have completed the neurological assessments for Resident 37 as per facility protocol, and the Midodrine should have been held for Resident 76 when the resident's systolic blood pressure was more than 120 mmHg. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 37 residents reviewed (Residents 36, 59). 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 36, dated November 21, 2024, revealed that the resident was cognitively intact, was understood and understands, required assistance with care needs, had occasional pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders for Resident 36, dated April 16, 2024, included and order for the resident to receive 10 milligrams (mg) of Oxycodone every six hours as needed for pain related to chronic pain syndrome. An investigation by the facility, dated June 7, 2024, revealed that during audits for drug diversion it was noted that 60 tablets of Oxycodone 10 mg were unable to be accounted for. There were two cards containing 60 tablets each delivered on May 23, 2024, and only one of those cards could be located. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated October 26, 2024, revealed that the resident was moderately cognitively impaired, was understood and understands, required assistance with care needs, had continuous pain, received pain medication three times a day, and received an opioid (a controlled pain medication). Physician's orders for Resident 59, dated March 26, 2024, included and order for the resident to receive 5 milligrams (mg) of Oxycodone every eight hours for pain related to polyneuropathy (disease of the nervous system causing pain, numbness and weakness). An investigation by the facility, dated May 26, 2024, revealed that during audits for drug diversion it was noted that 60 tablets of Oxycodone 5 mg were unable to be accounted for. There were two cards containing a total of 88 tablets delivered on May 8, 2024, and only one of those cards could be located. Interview with the Director of Nursing on December 17, 2024, at 12:24 p.m. confirmed that the facility was unable to locate the missing cards of pain medications for Residents 36 and 59. Following the identification of missing narcotics, the facility's corrective actions included: The facility was unable to identify a perpetrator. Drug testing was completed on licensed practical nurses that were assigned to the B wing medication cart during the time of the missing narcotics. New narcotic accountability forms were created and placed in the accountability binders for each medication cart. Education was completed on the new narcotic accountability sheets that were placed in the narcotic accountability binders. Narcotic accountability audits would be completed weekly for three weeks , then monthly for two months, or until compliance was met. A review of the facility's corrective actions revealed that they were in compliance with F755 on June 24, 2024. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 37 residents reviewed (Residents 19, 62, 76). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was 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 November 21, 2024, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); PPE is changed before caring for another resident, and face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; bathing/showering; transferring; providing hygiene, changing linens; changing briefs or assisting with toileting; device care, and wound care (any skin opening requiring a dressing). EBP's are indicated for residents with wounds and/or indwelling medical devices. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 3, 2024, revealed that the resident was understood, could understand others, had a diagnosis which included Stage 4 Pressure Ulcer (damage extends through all layers of skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue) to his left heel, and a non-stageable pressure ulcer (unable to determine the depth of the wound) to another site. A care plan for the resident, dated November 6, 2024, revealed that the resident had an actual skin breakdown to his left great toe. A care plan, dated September 22, 2024, revealed that the resident was on EBP, and staff was to use gown and gloves during high contact activities (e.g., dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, wound care, therapy). Physician's orders for Resident 19, dated October 29, 2024, included an order for the resident to be on EBPs. Observations of Resident 19's wound care to his left heel and left great toe on December 16, 2024, at 12:51 p.m. revealed that Licensed Practical Nurse 4 washed her hands then placed clean gloves on; however, she did not apply a gown. She then performed the wound treatment to the resident's left heel and left great toe. Interview with Licensed Practical Nurse 4 on December 16, 2024, at 1:18 p.m. confirmed that she did not apply a gown prior to performing Resident 19's wound treatment. She indicated that the resident was no longer on EBP because his feeding tube was discontinued. Interview with the Assistant Director of Nursing/Infection Control Preventionist on December 16, 2024, at 2:00 p.m. confirmed that Licensed Practical Nurse 4 should have applied a gown prior to performing Resident 19's wound treatment. The facility's policy regarding wound care and hand washing/hand hygiene, dated November 21, 2024, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task. A significant change in status Minimum Data Set (MDS) assessment for Resident 62, dated November 24, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for care tasks, had diagnoses that included chronic obstructive pulmonary disease and stroke, and had an alteration of skin integrity related to immobility and incontinence. Physician's orders, dated December 9, 2024, included an order to cleanse the bilateral buttocks twice a day with soap and water, apply Dermagran (a vitamin enriched wound dressing), and cover with an abdominal pad. Observations of Resident 62's wound care on December 17, 2024, at 10:26 a.m. revealed that Licensed Practical Nurse 4 washed her hands and put on gloves prior to cleaning the area on the resident's right and left buttocks with a wash cloth and soap and water, she then patted the area dry with a dry wash cloth, removed her gloves, washed her hands, donned new gloves, applied Dermagran to her gloved hands, rubbed her hands together, applied the Dermagran to the bilateral buttocks area, and covered the area with an abdominal pad. Licensed Practical Nurse 4 then turned off the resident's oxygen, adjusted her pillow, and covered her up with the sheet. She then removed her gloves and sanitized her hands. Licensed Practical Nurse 4 did not remove her gloves and wash her hands after providing wound care and before turning off the oxygen and adjusting the resident's pillow and sheets. Interview with Licensed Practical Nurse 4 on December 17, 2024, at 10:38 a.m. confirmed that she did not remove her gloves and wash her hands after Resident 62's wound care and prior to turning off the oxygen and adjusting the resident's pillow and sheets. Interview with the Assistant Director of Nursing on December 17, 2024, at 12:38 p.m. confirmed that Licensed Practical Nurse 4 should have removed her gloves and washed her hands after Resident 62's wound care, and prior to turning off the oxygen and adjusting the resident's pillow and sheets. The facility's policy regarding medication administration, dated November 21, 2024, indicated that gloves should be worn whenever dosage forms are handled. Physician's orders for Resident 45, dated April 13, 2023, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. Physician's orders for Resident 45, dated April 13, 2023, included an order for the resident to receive 50 micrograms (mcg) of cholecalciferol (vitamin D3) daily. Physician's orders for Resident 45, dated October 15, 2023, included an order for the resident to receive 8.6-50 mg of Senna-s (a laxative) twice daily. Observations during medication administration on December 17, 2024, at 7:39 a.m. revealed that Licensed Practical Nurse 9 removed the medications listed above for Resident 45 from individual bottles into his bare hands. He then placed them into a medication cup with Resident 45's other medications and administered them to the resident. Physician's orders for Resident 47, dated November 15, 2024, included an order for the resident to receive 1,000 mcg of vitamin B12 daily. Observations during medication administration on December 17, 2024, at 7:39 a.m. revealed that Licensed Practical Nurse 9 poured a vitamin B12 tablet for Resident 47 from a bottle into his bare hands. He then placed the medication into a medication cup with Resident 47's other medication and administered it to the resident. He returned to the medication cart and proceeded to prepare medications for Resident 45 without performing hand hygiene. Interview with Licensed Practical Nurse 9 on December 17, 2024, at 7:52 a.m. confirmed that he should have performed hand hygiene after administering medications to Resident 47 and before preparing medications for Resident 45 and confirmed that he should not have poured the medications for Residents 45 and 47 into his bare hands. Interview with the Director of Nursing on December 17, 2024, at 11:58 a.m. confirmed that nurses should perform hand hygiene between residents when administering medications and should not place medications in ungloved, bare hands. A quarterly MDS assessment for Resident 76, dated December 6, 2024, revealed that the resident was cognitively intact, received dialysis, and had diagnoses that included renal failure. A nursing note for Resident 76, dated December 2, 2024, at 9:30 p.m. revealed that the resident was readmitted from the hospital and had a dialysis port to her right side. A physician's order for the resident, dated December 2, 2024, included an order for staff to cover the resident's dialysis catheter with plastic wrap prior to showers. A physician's order, dated December 17, 2024, included an order for EBP. Observations of Resident 76 on December 16, 2024, at 9:13 a.m. revealed that the resident had no signage at the entrance to her room or in her room to indicate infection control measures for EBP were in place related to her dialysis catheter. Interview with the Assistant Director of Nursing/Infection Preventionist on December 19, 2024, at 10:27 a.m. confirmed that Resident 76 did not have EBP in place related to her dialysis catheter until December 17, 2024. 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 facility policy and clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 37 residents reviewed (Resident 2). Findings include: The facility's policy regarding call bells, dated November 21, 2024, revealed that the call bell should be within reach of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident was understood and could understand, was cognitively impaired, and was dependent on staff for all care needs. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach. Observations of Resident 2 on December 16, 2024, at 10:15 a.m. revealed that the resident was lying in bed and was asking for her call bell. The call bell was in her nightstand drawer and was not within her reach. Interview with Nurse Aide 1 at that time revealed that Resident 2 could use her call bell and that it should have been placed within her reach. Interview with Director of Nursing on December 16, 2024, at 3:20 p.m. confirmed that the call bell should have been within reach. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for three of 37 residents reviewed (Residents 9, 37, 43). This deficiency was cited as past noncompliance. Findings include: A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that Resident 9 had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that Resident 9 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital. A nursing note for Resident 37, dated June 29, 2024, at 3:00 a.m. revealed that Resident 37 was found lying on his floor mat between the wall and bed. No injuries were noted, and he was transferred to the hospital and admitted with altered mental status. There was no documented evidence that Resident 37 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital. A nursing note for Resident 43, dated September 7, 2024, at 5:19 a.m. revealed that the resident had a fall and complained of the left hip pain. The physician was notified and wanted the resident sent to the hospital for an evaluation and was admitted . There was no documented evidence that Resident 43 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital. Interview with the Director of Nursing (DON) on December 18, 2024, at 12:50 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to the above residents and/or their responsible party at the time of the transfers to the hospital. The DON also revealed that the new Business Office Manager had identified this as a concern on September 9, 2024. Following the identification on September 9, 2024, that they were not providing the bed-hold notices to the resident and/or the resident's representative when the resident was transferred to the hospital, the facility's corrective actions included: The new Business Office Manager will review the transfers daily with the interdisciplinary team and will call any resident representative regarding transfers to notify them of the bed-hold policy and inform them that they will be receiving a written notice in the mail. Audits were started on all residents that were transferred to the hospital. Utilization of a binder showing the date the bed-hold notification was made, and a copy of the returned, signed notification from the resident representative. 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 F625 on September 18, 2024. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(a) Resident Rights.

Based on review of clinical records and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of one resident reviewed (Resident 1), resulting in a fractured ankle for the resident. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 22, 2019, indicated that the resident was alert and oriented; required extensive assistance for bed mobility, transfers, and locomotion on and off the unit; and had [DIAGNOSES REDACTED]. Resident 1's care plan, dated as revised on (MONTH) 6, (YEAR), and a focus sheet (a pocket guide for nurse aides that contains information about the resident's individual care needs and abilities), dated (MONTH) 20, 2019, indicated that the resident required the assistance of two persons for transfers. A nursing note for Resident 1, dated (MONTH) 20, 2019, at 5:07 p.m. and information submitted by the facility on (MONTH) 21, 2019, indicated that the registered nurse supervisor was called to Resident 1's room and found the resident sitting on the floor. Upon assessment, the resident complained of discomfort in the right ankle and her attending physician, who evaluated her in the facility, noted complaints of right ankle pain, decreased range of motion, and tenderness to touch, and recommended transfer to the emergency department for an evaluation and x-rays. An x-ray report for Resident 1, dated (MONTH) 20, 2019, revealed that the resident had a closed, non-displaced fracture of right fibular malleolus (right ankle). A nursing note revealed that the resident returned to the facility on (MONTH) 21, 2019, with a soft cast on the right ankle. Information submitted by the facility, dated (MONTH) 21, 2019, revealed that Nurse Aide 1 attempted to transfer Resident 1 independently, and the resident's transfer status was that she needed the assistance of two, which was on the resident's care plan, in Point of Care (electronic medical record system that is accessible to nursing staff), and on the resident's focus sheet. The information indicated that Nurse Aide 1 did not check this information. Review of training records for Nurse Aide 1, dated (MONTH) 20, 2019 and (MONTH) 29, 2019, revealed that she acknowledged that she received education regarding implementing the resident's care plan and regarding transfers, including obtaining assistance of another person if the transfer status indicated to use two persons. A written statement completed by Nurse Aide 1, dated (MONTH) 20, 2019, indicated that Resident 1 rang her call bell and stated that she had to go to the bathroom. She did not check the focus sheet for Resident 1 and she thought she could transfer the resident herself, but the resident fell . Interview with the Nursing Home Administrator on (MONTH) 27, 2019, at 1:50 p.m. confirmed that Nurse Aide 1 neglected to follow the transfer instructions for Resident 1 that were listed on the focus sheet and the resident's care plan. 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/17/19. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/19, 11/23/18, 9/6/18, 8/15/18, 4/27/18.