Every finding on record at Ridgeview Healthcare & Rehab Center

Based on observations, a review of clinical records, and resident, resident representative, and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of prescribed therapeutic measures, compression stockings, for two residents out of 26 sampled (Residents 25 and 66).Findings include: A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia (condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident 25's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 20, 2025, revealed that Resident 25 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A physician order for Resident 25 dated February 12, 2026, noted an order for TED compression stockings (thrombo-embolus deterrent compression stockings, or anti-embolism stockings, which are specially designed to promote circulation and help reduce the risk of developing deep vein thrombosis or blood clots) in the morning and removed in the evening for venous insufficiency (long-term condition where leg veins struggle to send blood back to the heart, causing blood to pool in the legs and ankles, leading to swelling, pain, and aching). A review of Resident 25's March 2026 Treatment Administration Record (TAR) revealed that on March 17, 2026, staff did not document the application of the TED stockings nor was the reason for the TED stockings not being applied documented. Observation on March 17, 2026, at 12:00 PM, confirmed that Resident 25 was not wearing TED stockings. Observation on March 18, 2026, at 1:05 PM revealed that Resident 25 was not wearing TED stockings as ordered and no TED stockings were observed in the resident's room. This observation was confirmed by Employee 5, licensed practical nurse (LPN). A review of the March 2026 TAR revealed staff documented TED stockings were applied at 6:00 AM on March 18, 2026. This documentation was inconsistent with observation findings that the resident was not wearing the ordered TED stockings. A review of Resident 66's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia and depression. A review of Resident 66's admission MDS dated [DATE], revealed that Resident 66 was severely cognitively impaired with a BIMS score of 5 (a score of 0 through 7 indicates severe cognitive impairment). A physician order dated February 12, 2026, directed staff to apply TED compression stockings in the morning and remove them in the evening for venous insufficiency. During an interview on March 17, 2026, at 11:30 AM, Resident 66's Resident Representative reported that staff did not consistently apply the resident's TED stockings. Observation on March 17, 2026, confirmed Resident 66 was not wearing TED stockings. A review of the March 2026 TAR revealed staff did not document application of TED stockings on March 17, 2026, and did not document a reason the stockings were not applied. Observation on March 18, 2026, at 1:10 PM confirmed Resident 66 was not wearing TED stockings as ordered. This observation was confirmed by Employee 1, Registered Nurse (RN). A review of the March 2026 TAR revealed staff documented TED stockings were applied at 6:00 AM on March 18, 2026. This documentation was inconsistent with observation findings that the resident was not wearing the ordered TED stockings. During an interview on March 19, 2026, at 9:30 AM, the Director of Nursing (DON) confirmed the facility did not consistently ensure implementation of physician orders related to the application and removal of TED compression stockings for Residents 25 and 66. 28 Pa. Code 211.5(f)(ix) Medical Records. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services.

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance for 1 resident out of 26 residents reviewed. (Resident 1).Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of morbid obesity (excess amount of body fat that significantly increases the risk of serious health problems) and irritable bowel syndrome (IBS, a chronic disorder of the digestive system causing recurrent abdominal pain, bloating, gas, diarrhea, and constipation). A review of Resident 1's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 6, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 1's comprehensive care plan, last revised on February 6, 2026, revealed a focus on bowel and bladder incontinence (inability to control urine or stool) with a history of chronic urinary tract infections and IBS, with interventions to include staff checking the resident for incontinence and changing the resident every two hours and as needed. Further review of the care plan revealed the resident required extensive assistance from two staff members for bed mobility. During an interview with Resident 1 on March 17, 2026, she rang her call bell at 11:30 AM and then stated, I better ring before they start passing meal trays, otherwise, I'll be stuck waiting until after lunch. When Resident 1 was questioned about what she meant by that, she stated that the Nurse Aides will make her wait until after meal trays are distributed and lunch is finished before getting changed if she rings during meal tray pass or mealtimes. She explained that staff will not provide any incontinent care during a meal, so if she needs assistance at that time, she is forced to wait longer. It was observed that Employee 5, a licensed practical nurse (LPN), answered Resident 1's call bell at 11:43 AM, and when she answered, Resident 1 mentioned she needed to be changed. Employee 5 stated to Resident 1, I'll tell the girls. Employee 5 exited the resident's room without providing care, and proceeded to the hallway where four additional staff members were present waiting for the meal cart delivery for tray pass on the second floor. Employee 5 informed the Nurse Aides (NAs) present that Resident 1 needed to be changed. One staff member was heard stating, We just changed her not even a half hour ago. Staff, including Employee 5, remained in the hallway waiting for the meal cart for approximately five additional minutes. When the tray cart arrived, staff proceeded with tray pass, including delivery of a meal tray to Resident 1, and no staff were observed providing incontinence care at that time. During interview on March 17, 2026, at 12:10 PM, Employee 5 confirmed she informed the Nurse Aides present in the hallway that Resident 1 needed to be changed, however, she was unable to identify which staff member stated the resident had recently been changed or who the staff were present at the time. Employee 5 stated that when residents activate the call bell requesting bathroom assistance or incontinence care during tray pass, staff typically complete tray pass first and assist the resident afterward. Interview with Resident 1 on March 17, 2026, at 12:15 PM revealed the resident was completing her lunch tray and stated she had not yet been changed and would wait until she finished eating. Follow-up interview with Resident 1 on March 17, 2026, at 1:00 PM revealed the resident activated the call bell again at approximately 12:30 PM after finishing lunch to request assistance with incontinence care. At approximately 12:35 PM, one hour and five minutes after the initial call bell activation, a nurse aide provided incontinence care. Review of the facility-provided staffing assignment for March 17, 2026, revealed seven nurse aides were scheduled to work on the second-floor day shift at the time of the observation, with three nurse aides assigned to provide care for Resident 1. During interview on March 17, 2026, at 2:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed the above information and indicated residents should not experience extended wait times for call bell response. The DON stated that when residents request assistance during tray pass or mealtimes, staff should be reassigned as needed to ensure resident care needs are addressed. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of resident council meeting minutes, review of resident activities fundraising account information, and resident and staff interviews, it was determined the facility failed to ensure the views and recommendations of residents regarding life in the facility were considered, including decisions related to the use of resident activity fundraising funds, for five of five residents interviewed (Residents 53, 54, 61, 75, and 76).Findings include:A review of a Resident Activities Fundraising Account ledger from January 2026 through March 2026 revealed resident fundraising activities occurred on January 9, 2026, February 5, 2026, March 4, 2026, and March 18, 2026. Debits from the Resident Activities Fundraising Account included the purchase of bingo prizes on January 26, 2026, dye bottles on February 28, 2026, and fundraising supplies on February 28, 2026, and March 15, 2026. A review of Resident Council meeting minutes from December 2025 through February 2026 revealed no documented evidence that the facility considered the views and recommendations of residents determining how resident activity fundraising funds were used. In addition, there was no documented evidence the facility reviewed the resident activities fundraising account information, including debits (money spent), credits (money added), or account balances, with the resident council. During a resident group interview conducted on March 18, 2026, at 10:00 AM, five of five residents in attendance (Residents 53, 54, 61, 75, and 76) indicated they were not afforded the opportunity to express their views or make recommendations regarding how resident activity fundraising funds were spent. The residents stated they were not informed of the balance of the resident activities fundraising account and indicated the facility did not review resident fundraising account information during resident group meetings. During the resident group interview on March 18, 2026, Resident 61 indicated dissatisfaction that residents were not asked for input regarding fundraising activities and expressed a desire for the opportunity to discuss how resident fundraising funds are used. Resident 61 indicated that review of resident fundraising account information had occurred during resident council meetings in the past but had not occurred in recent months. During an interview on March 20, 2026, at 10:30 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to provide documented evidence that residents were afforded the opportunity to express their views or recommendations regarding the use of resident activities fundraising funds. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to include sufficient minimum healthcare information in the resident's baseline care plan to address the resident's immediate safety needs upon admission for 1 of 26 residents sampled (Resident 74).Findings: A review of the facility policy titled Care Plans-Baseline, last reviewed by the facility April 15, 2025, indicated that it is the policy of the facility to ensure a baseline care plan to meet the resident's immediate needs, which should be developed for each resident within forty-eight (48) hours of admission. The Interdisciplinary Team (IDT) will review the healthcare plan to meet the resident's immediate care needs, including but not limited to initial goals based on admission orders, physician's orders, dietary orders, therapy services, social services, and PASRR (Preadmission Screening and Resident Review, a federally required evaluation completed prior to nursing facility admission to determine whether a person with serious mental illness or intellectual disability requires specialized services) recommendations, if applicable. Clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses which included adjustment disorder with mixed anxiety and depressed mood (an unhealthy emotional reaction to a specific stressor of a defined identifiable life change) and Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Resident 74's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 9, 2026, revealed Resident 74 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 74's PASRR dated March 1, 2026, revealed the resident reported passive death wishes in December 2025 and stated she had a plan but did not want to share with anyone and reported she wanted to harm herself. Due to the resident's Alzheimer's diagnosis, she was not a candidate for specialized services. A review of a nurse progress note dated March 3, 2026, at 4:01 PM, documented the resident was admitted to the facility following a seventy (70) day hospitalization related to suicidal ideation (thoughts of harming oneself or ending one's life) and a spontaneous hip fracture after admission to the hospital. Review of the baseline care plan initiated March 3, 2026, did not include individualized interventions, monitoring considerations, or care approaches to address the resident's immediate safety needs related to the resident's history of suicidal ideation. During interviews on March 18, 2026, at 12:30 PM, and on March 20, 2026, at 10:30 AM, the above information was reviewed with the nursing home administrator (NHA) and the director of nursing (DON). The NHA and DON were unable to provide documented evidence that the facility developed and implemented a baseline care plan for Resident 74's care plan had been developed to address the resident's history of suicidal ideation. The facility was unable to provide documented evidence the baseline care plan included sufficient information to guide staff in addressing the resident's immediate safety needs upon admission. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services.

Based on a review of clinical records, select facility policy, and resident representative and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address dental needs for one out of 26 residents sampled (Resident 66). Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, last reviewed April 15, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. A review of Resident 66's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia (condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and depression. A review of Resident 66's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed that Resident 66 was severely cognitively impaired with a BIMS score of 5 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). The assessment did not identify dental concerns at that time. Review of a nurse's note dated February 5, 2026, revealed the resident's diet was downgraded from regular texture to mechanical soft (foods that are chopped, ground, or mashed to make chewing and swallowing easier) due to the loss of the resident's upper denture. The note indicated a speech therapy consult (referral to a specialist to evaluate swallowing and chewing safety) was ordered. During interview on March 17, 2026, at 11:30 AM, the secondary Resident Representative reported the resident's upper denture had been missing for approximately one month and the loss had been reported to nursing staff when first identified. Review of correspondence from the dentist dated February 16, 2026, indicated services to replace the denture required completion of consent forms and prepayment prior to scheduling. Interview with the Nursing Home Administrator on March 18, 2026, at 9:00 AM confirmed the facility was responsible for replacing the lost denture; however, the required prepayment had not yet been provided by the corporate office at that time. The Administrator confirmed payment was subsequently made and a dental appointment was scheduled. Review of the clinical record revealed no documented evidence the facility revised the comprehensive person-centered care plan to reflect the resident's change in condition, specifically the loss of the upper denture, altered diet texture, need for dental evaluation, or interventions to address chewing ability, nutrition needs, or oral health. During interview on March 18, 2026, at 10:00 AM, the Nursing Home Administrator confirmed the facility is responsible for ensuring each resident's comprehensive person-centered care plan reflects identified problems and services necessary to assist the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The Nursing Home Administrator confirmed Resident 66's comprehensive person-centered care plan did not reflect the resident's current dental needs, including replacement of the missing upper denture. Refer F791 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures to maintain accurate records of controlled medications and ensure accurate administration of controlled drugs for 1 of 26 residents sampled (Resident 56).Findings include: A review of the facility policy titled Controlled Substances, last reviewed by the facility on April 15, 2025, revealed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss or diversion and detection. The system of reconciling the receipt, dispensing, and disposition of controlled substances includes a record of personnel access and usage, medication administration records, declining inventory records, and destruction, waste, and return to pharmacy records. The consultant pharmacist, or designee, routinely monitor controlled substance storage records. Clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome (a long-term condition where pain persists or recurs for more than three to six months, often lasting beyond the expected healing time of an initial injury).A physician's order for Resident 56 to receive Tramadol 50 mg (a schedule IV controlled substance, classified as a narcotic and opioid pain medication with a low-to-moderate potential for abuse and dependency) with instructions to give one tablet by mouth every eight hours as needed for pain level on a pain scale (standardized pain rating scale ranging from 0 through 10, where 0 indicates no pain and 10 is the worst pain), of 7 through 10 was initiated on February 9, 2026.A physician's order for Resident 56 to receive Tramadol 25 mg with instructions to give one tablet by mouth two times a day for chronic pain initiated on February 9, 2026, and discontinued on March 4, 2026.A review of Resident 56's clinical record revealed a controlled substance record (a required medication log used to track the receipt, storage, administration, wasting and remaining count of controlled medications to ensure accurate accountability and prevent loss or diversion) for Tramadol 25 mg and a controlled substance record for Tramadol 50 mg. The controlled substance log for Tramadol 25 mg indicated that the last dose of Tramadol 25 mg was administered on February 14, 2026.However, a review of the Medication Administration Record (MAR a legal record used to document medications administered to a resident) for February 2026 revealed Resident 56 was administered Tramadol 25 mg on the following dates and times:February 15, 2026, at 9:00 AM with a pain level 6.February 15, 2026, at 9:00 PM with a pain level 5.February 16, 2026, at 9:00 AM with a pain level 7.February 16, 2026, at 9:00 PM with a pain level 5.February 17, 2026, at 9:00 AM with a pain level 0.February 19, 2026, at 9:00 PM with a pain level 0.February 20, 2026, at 9:00 AM with a pain level 0.February 20, 2026, at 9:00 PM with a pain level 0.February 21, 2026, at 9:00 AM with a pain level 0.February 21, 2026, at 9:00 PM with a pain level 0.February 22, 2026, at 9:00 AM with a pain level 0.February 22, 2026, at 9:00 PM with a pain level 0.February 23, 2026, at 9:00 AM with a pain level 0.February 23, 2026, at 9:00 PM with a pain level 0.February 24, 2026, at 9:00 AM with a pain level 0.February 24, 2026, at 9:00 PM with a pain level 0.February 25, 2026, at 9:00 AM with a pain level 6.February 25, 2026, at 9:00 PM with a pain level 0.February 26, 2026, at 9:00 AM with a pain level 0.February 26, 2026, at 9:00 PM with a pain level 0.February 27, 2026, at 9:00 AM with a pain level 6.February 27, 2026, at 9:00 PM with a pain level 0.February 28, 2026, at 9:00 AM with a pain level 5.February 28, 2026, at 9:00 PM with a pain level 0. The controlled substance log did not reflect removal or reconciliation of Tramadol 25 mg corresponding with these documented administrations after February 14, 2026. The controlled substance log indicated Tramadol 50 mg was removed from the medication supply on the following dates and times:February 15, 2026, at 9:00 AM.February 15, 2026, at 9:00 PM.February 16, 2026, at 9:00 AM.February 16, 2026, at 9:00 PM. February 17, 2026, at 9:00 AM.February 18, 2026, at 9:00 AM.February 19, 2026, at 9:00 PM.However, review of the February 2026 MAR did not indicate administration of Tramadol 50 mg on these dates and times. During an interview on March 20, 2026, at 10:30 AM, the above findings were reviewed with the Nursing Home Administrator and Director of Nursing. The facility was unable to provide a controlled substance log accounting for 24 doses of Tramadol 25 mg after February 14, 2026, and was unable to reconcile discrepancies between the controlled substance inventory records and the Medication Administration Record for Tramadol 25 mg and Tramadol 50 mg. During an interview on March 20, 2026, at 10:30 AM, the above findings were reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON). At the time of the interview, the facility was unable to provide a controlled substance record (required log used to track the receipt, administration, and remaining quantity of regulated medications with potential for abuse) accounting for the quantity of Resident 56's Tramadol 25 mg after February 14, 2026, despite the Medication Administration Record (MAR, legal record documenting medications administered to a resident) indicating the medication was administered 24 times between February 15, 2026, and February 28, 2026. Additionally, the controlled substance record for Tramadol 50 mg reflected seven removals of medication between February 15, 2026, and February 19, 2026, while the MAR did not indicate administration of Tramadol 50 mg on those dates. The facility was unable to reconcile the discrepancies between the controlled substance records and the MAR. The facility failed to implement procedures to maintain accurate controlled substance records and ensure documentation of administration of controlled medications corresponded with inventory records. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medication vials in two of two medication storage rooms (second and third floor medication rooms).Findings include: A review of the facility policy titled Medication Labeling and Storage, last reviewed by the facility April 15, 2025, indicated that it is the policy of the facility to ensure that multi-dose vials (medication that can be punctured by a needle more than once to withdraw multiple doses) that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the second-floor medication room on March 19, 2026, at 8:10 AM, in the presence of Employee 3, licensed practical nurse (LPN), of medication stored in the medication refrigerator, revealed two multi-dose vials of Aplisol (solution used for screening tuberculosis) that had been opened and available for use but not dated when initially opened. A review of the manufacturer's dosage and administration recommendation for Aplisol revealed that vials in use for more than 30 days should be discarded. An interview with Employee 3. LPN at the time of the observation on March 19, 2026, at 8:10 AM, confirmed the Aplisol had been opened and not dated to determine how long the vial was available for use, and the medications should have been removed from the medication refrigerator and discarded. An observation of the third-floor medication room on March 19, 2026, at 8:45 AM, in the presence of Employee 4, Registered Nurse (RN), of medication stored in the medication refrigerator, revealed two multi-dose vials of Aplisol (solution used for screening tuberculosis) that had been opened and available for use but not dated when initially opened. An interview with Employee 4 RN, at the time of the observation on March 19, 2026, at 8:45 AM, confirmed the Aplisol had been opened and not dated, and the medications should have been removed from the medication refrigerator and discarded. An interview with the Director of Nursing on March 19, 2026, at 8:50 AM, confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications.28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of clinical records, select facility policy, payor source data, and resident representative and staff interview, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident 66) out of 26 residents reviewed.Findings include: Review of the facility Availability of Services, Dental policy last reviewed April 15, 2025, indicated that oral and dental services will be provided for each resident. Residents with lost or damaged dentures will be promptly referred to a dentist. A review of Resident 66's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia (condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and depression. A review of Resident 66's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 21, 2025, revealed that Resident 66 was severely cognitively impaired with a BIMS score of 5 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment) The assessment identified no dental concerns. During an interview on March 17, 2026, at 11:30 AM the secondary Resident Representative for Resident 66 noted that the resident's upper denture had gone missing about a month ago. The secondary Resident Representative noted that she reported the missing upper denture to nursing at the time she had noticed the upper denture was missing. A Resident Grievance Form which was filed on February 5, 2026, by nursing on behalf of the secondary Resident Representative for Resident 66 noted that the resident's dentures were missing. The resolution dated February 10, 2026, which was signed by the Social Services Director and Nursing Home Administrator noted a referral was made for the dentist to replace the resident's dentures. The resident's primary Resident Representative was made aware of the resolution and was in agreement. Review of a correspondence from the dentist dated February 16, 2026, noted that a consent form for services and a prepayment would first need to be completed before services could be provided. Interview with the Administrator on March 18, 2026, at 9:00 AM confirmed that the facility was responsible for replacing the resident's lost upper denture, but the corporate office had not yet provided the prepayment to the dentist for the services to be completed. Upon surveyor inquiry the Nursing Home Administrator confirmed the required payment was made and the resident was subsequently scheduled for a dental appointment to replace the missing upper denture. The administrator affirmed that it is the facility's responsibility to ensure residents promptly receive the required dental services. Refer F65628 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa Code 211.10 (c) Resident care policies

Based on clinical record review and staff interview, it was determined that the facility failed to ensure clinical records were accurate and complete and reflective of the resident's current status for two of 26 sampled residents (Residents 7 and 85).Findings include: Clinical record review revealed that Resident 85 had a diagnosis of dementia (condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 9, 2026, revealed that Resident 85 had a BIMS score of 15, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 85's clinical record revealed documentation dated January 18, 2026, at 8:30 AM, of a body audit (a head-to-toe skin assessment performed to identify skin conditions such as bruising, wounds, or other abnormalities) indicated no skin alterations were observed. A nurse's note dated January 18, 2026, at 11:35 AM documented Resident 85 returned to the facility following a brief hospital visit and had bruising to the bilateral upper extremities (both arms). The nurse's note did not include measurements, color, characteristics, or further description of the bruise. A subsequent nurse's note dated January 20, 2026, at 7:53 AM documented Resident 85 had bruising to the left shoulder; however, the documentation did not include the size, appearance, progression, or resolution of the bruising. The clinical record did not contain documentation identifying when bruising to the right upper extremity resolved. An interview conducted with the Director of Nursing on March 20, 2026, at 11:30 AM confirmed the facility was unable to provide additional documentation regarding Resident 85 clarifying the discrepancy between the January 18, 2026, 8:30 AM body audit indicating no skin alterations and the January 18, 2026, 11:35 AM nurse's note documenting bilateral upper extremity bruising, including when the bruising occurred, the extent of the bruising, or when bruising to the right upper extremity resolved. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).Resident 7's clinical record review revealed a physician's order dated February 26, 2026, for ampicillin-sulbactam sodium intravenous solution reconstituted 3 grams (a combination antibiotic medication administered through a vein) with directions to administer 3 grams intravenously over 30 minutes every six hours for cholecystitis (inflammation of the gallbladder). Review of Resident 7's Medication Administration Record (MAR, a clinical record used to document medications administered to a resident) for March 2026 revealed no documented evidence the resident received ampicillin-sulbactam sodium intravenous solution 3 grams as ordered on March 7, 2026, at 6:00 AM and March 14, 2026, at 6:00 AM. During an interview conducted on March 20, 2026, at 10:30 AM, the above information was reviewed with the Nursing Home Administrator and Director of Nursing. The facility indicated that the medication was administered as ordered, however, the clinical record did not contain documentation confirming administration of the medication on March 7, 2026, at 6:00 AM and March 14, 2026, at 6:00 AM failing to ensure the clinical record was complete and accurate regarding administration of physician-ordered medication for Resident 7. 28 Pa Code 211.5(f)(xi) Medical records. 28 PA. Code 211.12 (c)(d)(1)(3) (5) Nursing services.

Based on clinical record review, select facility policy review, observation, and staff interview, it was determined the facility failed to implement physician-ordered infection control precautions for one of 26 sampled residents (Resident 10) Findings include:Clinical record review revealed Resident 10 had a current diagnosis of rectal cancer. An admission Minimum Data Set assessment, (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care), dated December 18, 2025, a BIMS score of 15, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 12 through 15 indicates the resident is cognitively intact). Current physician orders indicated Resident 10 was prescribed capecitabine (an oral chemotherapy medication used to treat cancer). Capecitabine has known potential side effects including neutropenia (a decreased number of white blood cells, which help the body fight infection). Due to increased risk for infection, current physician orders directed staff to implement neutropenic precautions (protective infection control measures intended to protect individuals with weakened immune systems from exposure to bacteria, viruses, and other infectious organisms that may be carried into the environment by others such as staff, family members and visitors). Observation of Resident 10's room on March 17, 2026, at 10:30 AM revealed signage posted indicating Enhanced Barrier Precautions (infection control interventions intended to prevent transmission of certain organisms from the resident to others through use of protective gowns and gloves during high-contact care activities). The posted Enhanced Barrier Precautions signage did not reflect physician-ordered neutropenic precautions, which focus on protecting the resident from potential exposure to infectious organisms brought into the room by staff or visitors. Review of the facility's Neutropenic Precautions policy, reviewed April 15, 2025, indicated residents identified as requiring neutropenic precautions would follow precautions as ordered by the physician. Observation on March 19, 2026, at 11:50 AM revealed Employee 2, Nurse Aide, obtained a meal tray from the nourishment cart and entered Resident 10's room without performing hand hygiene (cleaning hands using soap and water or alcohol-based sanitizer to reduce spread of germs) and without wearing a face mask or protective garments intended to reduce the potential exposure of the resident to infectious organisms. Employee 2 did not perform hand hygiene when exiting the resident's room. Interview with Employee 2 on March 19, 2026, at 11:52 AM revealed the employee was unaware any resident on the nursing unit required special precautions, including neutropenic precautions requiring use of personal protective equipment (items worn to reduce spread of germs such as masks, gloves, or gowns) and hand hygiene before entering and after leaving the resident's room. Review of Resident 10's care plan dated December 18, 2025, failed to include resident-specific interventions related to implementation of neutropenic precautions necessary to guide staff in protecting the resident from potential exposure to infection. Interview with the Assistant Director of Nursing on March 19, 2026, at 2:00 PM confirmed neutropenic precautions are intended to protect the residents from exposure to infectious organisms from the environment, staff, and visitors. The Assistant Director of Nursing was unable to provide evidence that staff received training or education regarding implementation of neutropenic precautions. Signage reflecting neutropenic precautions with resident-specific interventions was not posted until after surveyor inquiry. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policies and procedures, and staff interviews it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff demonstrated the knowledge, skills, and documented competencies necessary to safely care for a resident with a central tunneled line catheter for one out of 26 residents reviewed (Resident 7). Findings include: Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of the comprehensive care plan initiated February 26, 2026, revealed Resident 7 was identified as having potential for complications related to a central tunneled line (a thin flexible tube placed into a large vein under the skin to allow long-term delivery of medications or fluids directly into the bloodstream) to the right subclavian vein (a large vein located under the collarbone). A physician's order dated February 26, 2026, directed administration of ampicillin-sulbactam (a combination antibiotic medication used to treat bacterial infections) 3 grams (2 gm - 1 gm) intravenously (administered directly into a vein) over 30 minutes every six hours for cholecystitis (inflammation of the gallbladder). A review of the March 2026 Medication Administration Record (MAR, a clinical record used to document medications administered to a resident) revealed Employee 6, Licensed Practical Nurse (LPN), administered ampicillin-sulbactam intravenously through the subclavian central line on March 2, 2026, March 4, 2026, March 5, 2026, March 7, 2026, March 9, 2026, and March 12, 2026, at 6:00 PM. The MAR further revealed Employee 7, LPN, administered ampicillin-sulbactam intravenously through the subclavian central line on March 6, 2026, at 12:00 AM.During an interview on March 19, 2026, at 9:30 AM, the Regional Nurse Consultant (RNC) was unable to provide documented evidence Employee 6 LPN or Employee 7 LPN demonstrated competency in central line management prior to administering intravenous medications through the central line. The RNC confirmed the facility's annual licensed nursing competency and skills review did not include training related to central line care. The RNC was unable to provide documentation of initial or annual competency validation for central line management through the conclusion of the survey on March 20, 2026. During a follow-up interview on March 20, 2026, at 10:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide documented evidence the facility developed or implemented central line management in the annual licensed nursing competency/skills reviews. The facility failed to develop, implement, and maintain an effective training program, including topics such as central line management, based on the resident population and the facility assessment, prior to licensed nursing staff providing care for residents with central lines. Pennsylvania State Board of Nursing regulations Title 49, Chapter 21. 21.148(a)(1), 21.12(3) require that Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) 21.148(a)(1) performing intravenous therapy, including central line care, complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision. The facility failed to demonstrate it used the facility assessment to identify the need for central line care training based on the resident population. The facility failed to develop, implement, and maintain an effective training program, including initial and annual competency validation for central line management, prior to licensed nursing staff providing intravenous medication administration through a central tunneled line catheter.28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of the facility's surety bond, resident fund accounts, and staff interviews, it was determined the facility failed to ensure the amount of the surety bond was sufficient to cover the total amount of resident funds held by the facility on two of three months reviewed (February 2026 and March 2026).Findings include: A review of the resident fund checking account statement from January 2026 through March 2026 revealed that the aggregate resident account fund managed by the facility was $216,243.06 on February 3, 2026, and $208,438.08 on March 3, 2026. A review of the facility's surety bond (a legal agreement protecting personal money that facility providers manage for residents) in place since November 1, 2020, revealed the coverage amount was $200,000.00, which was not sufficient to cover the resident fund balances on February 3, 2026, and March 3, 2026. During an interview on March 18, 2026, at 1:30 PM, the above information was reviewed with the regional nurse consultant (RNC). The RNC was not able to provide documented evidence that a surety bond was in place in February 2026 or March 2026 to sufficiently cover facility-managed resident funds. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18(b)(2) Management.

Based on a review of facility staffing information, Payroll-Based Journal (PBJ) system and staff interviews, it was determined the facility failed to ensure accurate submission of staffing information to the PBJ system for one of two quarters reviewed (Quarter 4 2025).Findings include:A review of the Payroll-Based Journal (PBJ) Staffing Data Report (a federal electronic system nursing homes must use to report staffing hours) and Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D (a federal report that identifies potential staffing compliance concerns based on PBJ data), for fiscal year quarter 4 2025 (July 1-September 30) revealed that the facility's data triggered for no registered nurse (RN) hours on September 24, 2025, September 25, 2025, September 26, 2025, September 27, 2025, September 28, 2025, September 29, 2025, and September 30, 2025. A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 4, 2025 (July 1 - September 30) revealed that the facility's data triggered for failing to have licensed nursing coverage 24 hours a day on September 24, 2025, September 25, 2025, September 26, 2025, September 27, 2025, September 28, 2025, September 29, 2025, and September 30, 2025.A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had RN staffing working on each date that triggered no RN hours on the PBJ Staffing Data Reports in September 2025. A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had licensed nursing coverage 24 hours a day on each date that triggered no licensed nursing coverage 24 hours a day on the PBJ Staffing Data Reports in September 2025. During an interview on March 20, 2026, at 10:30 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA stated the facility transitioned to a different reporting system in September 2025 and indicated a lapse in data transmission occurred during the transition process. The NHA confirmed the facility had Registered Nurses and licensed nurses working on the identified dates but indicated the staffing information was not accurately transmitted to the PBJ system. 28 Pa. Code 201.18 (e)(2) Management

Based on observations, review of clinical records, select facility policies, and staff and resident interviews, it was determined the facility failed to ensure the resident environment was free from potential accident hazards related to unsecured medications on two out of two nursing units reviewed (Units 2 and 3) and for three out of eight residents sampled (Residents 1, 5, and 13). Findings include: A review of the facility policy titled Administering Medications, last reviewed July 28, 2025, revealed it is the facility's policy that medications are administered in a safe and timely manner and only as prescribed.A review of the facility policy titled Self-Administration of Medications, last reviewed July 28, 2025, revealed it is the facility's policy that medications permitted for self-administration are stored in a safe and secure manner and are not accessible to other residents. The policy further states that if safe storage is not possible in the resident's room, medications are to be stored on a central medication cart or in the medication room. A clinical record review revealed Resident 13 was admitted to the facility on [DATE]. Review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 23, 2025, revealed that Resident 13 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A clinical record review revealed a Medication Self-Administration Screen dated April 16, 2025, which indicated Resident 13 was appropriate for self-administration of medications. An observation conducted on February 5, 2026, at 9:15 AM revealed an orange oblong pill partially obscured by papers on the bedside table in Resident 13's room. During an interview conducted on February 5, 2026, at 9:15 AM, Resident 13 stated the pill must have fallen out of her medication cup. During an interview conducted on February 5, 2026, at 9:20 AM, Employee 1, Licensed Practical Nurse (LPN), collected and secured the medication and identified it as methocarbamol 750 mg (a muscle relaxant medication used to relieve muscle spasms). Employee 1 confirmed Resident 13 had a current physician's order for methocarbamol 750 mg. An additional observation on February 5, 2026, at 9:24 AM in Resident room [ROOM NUMBER] revealed two pills and a clear medication cup on the floor near the window-side bed. One pill was oval shaped and salmon-colored with an 894 imprint. The second pill was yellow and oblong with a dividing line and an imprint of 1 and 8. During an interview on February 5, 2026, at 9:26 AM, Employee 2, LPN, confirmed the medications should not have been on the floor and secured the pills. During an interview on February 5, 2026, at 11:15 AM, the Nursing Home Administrator (NHA) identified the salmon-colored pill as Eliquis 5 mg (an anticoagulant medication used to prevent blood clots) and the yellow pill as sertraline 100 mg (a selective serotonin reuptake inhibitor, a class of medication commonly used to treat depression and anxiety). The aforementioned information was reviewed with the NHA. The facility failed to ensure the resident environment was safe from accident hazards, specifically residents having access or ingestion to unsecured medications A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include muscle weakness and osteoporosis (disease where bones become weak, porous, and brittle, significantly increasing fracture risk). A review of an admission MDS dated [DATE], revealed that Resident 1 was cognitively intact with a BIMS score of 15. The clinical record review revealed no documentation indicating Resident 1 had been assessed or approved to self-administer medications.An observation conducted on February 5, 2026, at 9:30 AM revealed a tube of hydrocortisone 1 percent cream (a medicated topical corticosteroid used to reduce skin inflammation and irritation) at Resident 1's bedside. The tube lacked instructions for use, dosage information, and labeling. A review of the clinical record revealed no physician order for hydrocortisone cream. During an interview on February 5, 2026, at 9:34 AM, Employee 3, Registered Nurse Supervisor, confirmed Resident 1 should not have had the hydrocortisone cream at her bedside. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnosis to include diabetes (a chronic condition characterized by high blood sugar levels) and muscle weakness. Review of an admission MDS dated [DATE], revealed Resident 5 was cognitively intact with a BIMS score of 15. An observation conducted on February 5, 2026, at 10:00 AM revealed a tube of zinc oxide 20 percent ointment (a topical skin protectant used to prevent and treat minor skin irritation) at Resident 5's bedside. The tube was labeled with the resident's name and room number written in marker. During an interview at the time of observation, Resident 5 stated staff routinely left the ointment at her bedside for application. The resident further stated she did not apply the medication herself but could if she chose to, and that staff routinely left medications at her bedside, the resident stated the cream is always left at her bedside. During an interview on February 5, 2026, at 11:00 AM, the Nursing Home Administrator was informed of and reviewed the above findings related to nursing staff leaving medicated creams and ointments at residents' bedsides, accessible for use, despite residents not having documentation of assessment or approval to self-administer medications. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 19 residents sampled (Residents 5, 68, and 80) and one resident representative (Resident 11).Findings include: A clinical record review revealed Resident 68 was admitted to the facility on [DATE], with diagnoses that include peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2025, revealed that Resident 68 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and end-stage renal failure (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 11 was severely cognitively impaired with a BIMS score of 03; a score of 0-07 indicates cognition is severely impaired). A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that include morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues). A review of a quarterly MDS dated [DATE], revealed that Resident 5 is cognitively intact with a BIMS score of 15; score of 13-15 indicates cognition is intact. A clinical record review revealed Resident 80 was admitted to the facility on [DATE], with diagnoses that include cerebral palsy (a condition characterized by brain damage or abnormal development shortly after birth that affects movement, muscle tone, and coordination). A review of an admission MDS dated [DATE], revealed that Resident 80 is cognitively intact with a BIMS score of 14; a score of 13-15 indicates cognition is intact. During an interview on September 30, 2025, at 10:05 AM, Resident 80 explained that he was dependent on staff for care and was frustrated and upset about the long wait times he experiences for care. Resident 80 indicated that he has only been at the facility for a few weeks but usually waits about 40 minutes before staff are able to assist him with care. He explained that the longest he waited was one and a half hours for staff to respond to him for assistance. He indicated that he was frustrated because he brought this issue up to social services and the Director of Nursing, but nothing had been done to fix the problem. Resident 80 became tearful, stating that it is not right that there are no staff available to assist him when he needs help. During an interview on September 30, 2025, at 11:15 AM, Resident 11's resident representative explained that she is angry and frustrated by the long wait times Resident 11 experiences for care. She explained that Resident 11 receives hours of dialysis treatment (a procedure where a machine filters the blood through an artificial kidney). After his dialysis treatment, Resident 11 is left weak, disoriented, and uncomfortable and then waits 45 minutes to an hour before staff respond to his call bell to be assisted back into bed. Resident 11's representative indicated she has brought this issue up to nursing staff and the Director of Nursing (DON) but was told there is nothing that can be done to improve the situation. During an interview on September 30, 2025, at 11:30 AM, Resident 68 explained that he was happy with the facility but upset that he sometimes waits 30 minutes or 45 minutes for staff to respond to his call bell for assistance. He indicated he needs staff to help him get cleaned up and to transfer to the bathroom, but the wait times for staff can be long. During an interview on October 1, 2025, at 10:00 AM, Resident 5 indicated that she was frustrated and upset that she waits from 45 minutes to two hours for staff to provide her care after she rings her call bell for assistance. She explained the wait times are like this on all shifts. Resident 5 indicated she has brought this issue up to nursing staff and during resident group meetings, but nothing has been done to address her concerns. During an interview on October 1, 2025, at 1:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that all residents should be treated with dignity and respect and provided care in a manner that promotes each resident ' s quality of life. The concerns related to residents ' reports of untimely staff responses to requests for assistance and care were reviewed with the NHA and DON; however, no explanation was provided at the time of the interview. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on a review of clinical records, facility policy, and resident representative and staff interviews, it was determined that the facility failed to timely notify the resident's representative of a hospitalization after a fall for one resident out of 19 sampled (Resident 11).Findings include:A review of the facility policy titled Change in a Resident's Condition or Status, last reviewed by the facility on July 28, 2025, revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical or mental condition or status. The policy indicates the nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury or when it is necessary to transfer the resident to a hospital or treatment center.A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood) and end-stage renal failure (the final stage of kidney decline where the kidneys are no longer able to function to meet the body ' s needs).A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 19, 2025, revealed that Resident 11 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-07 indicates cognition is severely impaired).A progress note dated June 20, 2025, at 8:35 PM revealed Resident 11 was found on the floor in his room. Resident 11 was found on his back in a supine position with his head resting against the closet door. The resident stated he fell out of his wheelchair while trying to stand up. The resident was alert with periods of confusion. The resident was assessed with two new superficial abrasions noted to the mid-occipital region of the head (back middle of the head). The areas were cleansed with wound cleanser and dried. The nursing supervisor was notified and assessed the resident. After assessment, the physician was notified, and a new order was placed to send the resident to the community emergency department by way of emergency medical services for further evaluation.A progress note dated June 20, 2025, at 11:31 PM indicated an order to send Resident 11 to the emergency department for treatment and evaluation and the physician and resident representative were made aware (this progress note was documented as written two and a half hours after Resident 11 was sent to the emergency department).During an interview on September 30, 2025, at 11:15 AM, Resident 11's resident representative explained she was angry and upset that Resident 11 was sent to the emergency department after his fall on June 20, 2025, and the facility never notified her that he was there until the following day. She explained she felt it was awful that Resident 11 was in the emergency department by himself overnight and she was never informed. She explained that two weeks prior to Resident 11's fall and hospitalization, she provided the facility an updated phone number, but the facility failed to record the information. She also explained t there was a secondary emergency contact that was not called when Resident 11 was hospitalized on [DATE]. Resident 11's representative indicated that she was made aware of the hospitalization when the facility contacted the second emergency contact to let them know he returned from the hospital. She expressed that she was frustrated when she found out that Resident 11 was hospitalized without her knowledge.A review of Resident 11's facility admission record revealed two emergency contacts were listed with corresponding phone numbers.During an interview on October 1, 2025, at 1:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide evidence the facility provided timely notification to the resident representative that Resident 11 was transferred to the emergency room on June 20, 2025. The facility failed to ensure Resident 11's representative was provided timely notification of his transfer from the facility to the emergency department. 28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy review, and staff interview it was determined that the facility failed to ensure that one resident (Resident 53) of an 18 resident sample was free of chemical restraints that were not necessary to treat the resident's medical symptoms, were without justification, and did not demonstrate individualized, nonpharmacological approaches to careFindings include:A review of the facility policy, Identifying Involuntary Seclusion and Unauthorized Restraint, last reviewed on April 15, 2025, defines a chemical restraint as any drug used for discipline or staff convenience, and not required to treat medical symptoms. The policy further indicated residents must be free from chemical restraints not used to address medical conditions. According to the facility policy, psychotropic medications (drugs that affect one ' s mental state) will not be administered without documented indication for use and without evaluating for potential underlying causes for distressed behavior. Resident 53 was admitted to the facility on [DATE], with a diagnosis of an encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (care received after surgical procedure) and non-pressure chronic ulcer of other part of unspecific foot (a wound that is not related to pressure that will not heal).A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals) dated September 22, 2025, indicated Resident 53 was moderately cognitively impaired with a BIMS score of 12 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information). A score of 12 indicates moderate cognitive impairment.A review of the Resident 53 ' s physician orders revealed the following:September 16, 2025: Alprazolam (a medication used primarily for anxiety and panic disorders) 0.5 mg one tablet by mouth every 24 hours as needed (PRN) for anxiety, discontinue September 17, 2025.September 17, 2025: Alprazolam 0.5 mg one tablet by mouth every 24 hours as needed for anxiety for 14 days, discontinue October 2, 2025.A review of the electronic medication administration record (eMAR) revealed that Resident 53 received PRN (as needed) Alprazolam 0.5 mg on seven occasions between September 17 and September 30, 2025. The administration occurred on September 17 at 3:03 PM; September 19 at 9:57 AM; September 23 at 12:31 AM; September 26 at 12:24 AM; September 27 at 8:59 PM; September 28 at 9:00 PM; and September 30 at 12:16 AM.For all seven administrations, the clinical record did not contain documentation indicating that staff attempted any non-pharmacological interventions (interventions that do not involve medication, such as redirection, conversation, or environmental modification) before the medication was given.In addition, on three of these dates, September 17 at 3:03 PM, September 19 at 9:57 AM, and September 28 at 9:00 PM, the record also lacked documentation of any behavioral symptoms or clinical justification supporting the need for Alprazolam administration.Further review of the MDS Section E (section documenting resident behavioral symptoms) completed by Employee 4 (Registered Nurse Assessment Coordinator) documented that Resident 53 did not exhibit any behavioral, verbal, or physical symptoms during the assessment period of September 16, 2025, through September 22, 2025. During this time, Alprazolam was administered twice on September 17 and 19, 2025.The administration of Alprazolam 0.5 mg in the absence of documented behavioral symptoms or medical justification indicated the drug was not used to treat a specific medical condition and therefore constituted a chemical restraint.A review of Resident 53 ' s plan of care initiated September 17, 2025, documented psychosocial well-being problems related to depression and bipolar disorder. Interventions included administering medications as ordered, introducing Resident 53 to other residents with similar interests, providing familiar items from home, and allowing the resident to express concerns when upset. However, there was no documentation showing that these interventions were implemented prior to the administration of Alprazolam.The Activities Evaluation dated September 17, 2025, indicated that Resident 53 spoke three languages. Greek, German, and Russian, had interests in cars, specifically [NAME], and enjoyed photography. Despite these documented interests, the clinical record contained no evidence that staff used individualized, non-pharmacological interventions related to these preferences to address distress or anxiety before administering the PRN medication.Interviews with the Director of Nursing (DON) on October 1, 2025, could not provide documentation showing medical justification for the administration of Alprazolam or evidence that non-pharmacologic interventions were attempted prior to its use.28 Pa. Code 211.2(3) Medical director.28 Pa. Code 211.5(i)(ii)(viii)(xi) Clinical records28 Pa. Code 211.8 (e) Use of restraints.28 Pa. Code 211.9(b)(2) Pharmacy services.28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 19 sampled (Resident 5).Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section N Medications Subsection N0350A: Insulin, indicate the number of days during the 7-day look-back period that the resident received insulin (a hormone medication used to treat diabetes) injections.A clinical record review revealed Resident 5 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 8, 2025, Section N Medication Subsection N0350. Insulin revealed that Resident 5 received seven injections of insulin during the 7-day look-back period.A review of Resident 5's medication administration record dated August 2025, and September 2025 revealed no documented evidence Resident 5 received any insulin injections during the seven-day look-back period. During an interview on October 1, 2025, at 1:50 PM, the Nursing Home Administrator confirmed Resident 5 did not receive insulin injections during the seven-day look-back period, as indicated in the resident MDS assessment dated [DATE]. After inquiries made during the survey, the facility corrected the error and submitted a modification to September 8, 2025, MDS assessment for Resident 5. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review, facility policy review, observation, and staff and resident interviews, it was determined the facility failed to incorporate and address an identified resident preference and behavior into the care planning process for one of 19 sampled residents (Resident 1).Findings include:The clinical record review indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of Anoxic Brain Damage (a condition that occurs when oxygen flow to the brain is cut off or severely reduced, causing brain cell injury and impaired neurological function).The clinical record also revealed Brief Interview for Mental Status assessment (BIMS, a tool to assess the residents attention, orientation and ability to register and recall new information) dated August 13, 2025, with a score of 12, indicating moderate cognitive impairment (moderate impairment means the resident has some loss of memory, reasoning, or judgment but retains partial decision-making ability and may need staff assistance to make safe choices).On September 30, 2025, at 10:15 AM, an interview was conducted with Resident 77, who resided on the same unit. Resident 77 stated that on September 27, 2025 (Saturday), Resident 1 was observed smoking in the third-floor dining room.On September 30, 2025, at 1:00 PM, interviews were conducted with Employee 3 (Registered Nurse) and the Nursing Home Administrator (NHA). Both employees acknowledged that Resident 1 had previously possessed vaping materials (defined as the act of inhaling vapor produced by an electronic cigarette or similar device that heats a liquid containing nicotine or other substances) but denied knowledge of the reported September 27 incident. The NHA explained that a visitor was known to supply Resident 1 with vaping materials and stated that Resident 1 ' s room was consistently checked for vaping supplies; however, the NHA could not verify when the most recent check had been conducted, how often such checks occurred, or provide documentation of those checks.A review of a social-service progress note dated September 8, 2025, at 10:50 AM documented that while being transported to a medical appointment, Resident 1 attempted to vape in the facility vehicle. The social service worker documented that Resident 1 was educated on facility policy and agreed to give up the vaping device, which was found hidden in her underwear.A review of the facility policy titled Comprehensive Care Planning, last reviewed April 15, 2025, indicated the facility will develop a comprehensive, person-centered plan for each resident that includes measurable objectives to meet the resident ' s physical, psychosocial, and functional needs. A review of the facility policy titled Smoking Policy-Residents, last reviewed April 15, 2025, documented that electronic cigarettes (e-cigarettes or vapes) are not considered smoking devices with respect to ignition risk but are considered potential hazards due to health effects for the user, second-hand aerosol exposure, nicotine toxicity (overdose of nicotine which can cause nausea, dizziness, and rapid heart rate), and the risk of battery explosion or fire. The policy further stated that residents who wish to use e-cigarettes are to be assessed for their ability to use the device safely and, if appropriate, may do so only with supervision and in designated smoking areas.A review of Resident 1 ' s comprehensive care plan, current as of September 30, 2025, revealed no evidence that the resident ' s known desire and repeated attempts to vape had been assessed or addressed. The care plan lacked interventions to ensure supervision, safety precautions, or psychosocial supports related to vaping behavior, and did not include measurable goals or objectives consistent with the resident ' s expressed preferences and facility policy. The facility failed to ensure that the resident ' s expressed preference and behavior concerning vaping were assessed and incorporated into the person-centered care plan.28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records, select facility policy, observation, and staff and resident interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 19 sampled (Resident 70).Findings include: A review of the facility ' s policy titled Oxygen Administration, last reviewed on July 28, 2025, revealed that the purpose of the policy was to provide guidelines for safe oxygen administration. The policy directed staff to check the oxygen delivery system, including the mask, oxygen tank, and humidifier bottle (also known as humidifier reservoir, the container that holds sterile or distilled water through which oxygen passes to add moisture before being delivered to the resident) to ensure they were in good working order and securely fastened. The policy further required staff to verify that there was an adequate water level in the humidifier bottle so that the water bubbled as oxygen flowed through, and to periodically re-check the water level to ensure proper humidificationA clinical record review revealed that Resident 70 was admitted to the facility on [DATE], with a diagnosis to include respiratory failure (a serious condition that makes it difficult to breathe).A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2025, revealed that Resident 70 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).A physician ' s order dated September 3, 2025, directed that Resident 70 receive oxygen with humidified water at 4.0 liters per minute by nasal cannula. A nasal cannula is a flexible medical tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen to the resident. The order was initiated for the treatment of chronic obstructive pulmonary disease (COPD), a progressive lung disease that causes airflow blockage and makes breathing difficult.During an interview on September 30, 2025, at 10:50 AM, Resident 70 stated that her nose had been very dry because there was no water humidification attached to her oxygen delivery system. The resident reported that she had notified nursing staff about this concern more than a week earlier. Observation of Resident 70 at that time revealed she was in bed receiving oxygen at 4.0 liters per minute via nasal cannula, with no humidifier bottle attached to the oxygen flowmeter.During a follow-up observation on September 30, 2025, at 1:06 PM, Employee 1 (Licensed Practical Nurse) confirmed that Resident 70 had a physician ' s order for oxygen with humidified water at 4.0 liters per minute by nasal cannula. Employee 1 acknowledged that the resident was not receiving humidified oxygen, as the humidifier bottle was not attached to the oxygen delivery system. During an interview on October 1, 2025, at 1:30 PM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure oxygen therapy is administered in accordance with the physician ' s order. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff and residents it was determined the facility failed to ensure that one resident (resident 2) out of 7 residents sampled was free from sexual abuse and resultant psychosocial harm. Findings include: A review of a facility policy entitled Abuse Prevention last reviewed October 2024, revealed abuse, neglect, and/or mistreatment of residents will not be tolerated in any manner. All necessary steps shall be taken to ensure the provision of a safe and secure environment. Residents must not be subjected to abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends, or other individuals. A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die. The disease attacks areas of the brain that help to control intentional movement, as well as other areas) and Dementia (illnesses that affect your thinking, memory, reasoning, personality, mood, and behavior). A review of the resident's Significant Change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 15, 2024, revealed the resident was rarely understood, was severely cognitively impaired, was totally dependent on staff for eating showering, toileting, and dressing, and required maximal assistance with mobility. A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a mental illness that causes extreme mood swings, which can impact a person's energy, thinking, and behavior) and generalized anxiety disorder (a condition that causes excessive and persistent worry that interferes with daily life). A review of Resident 3's admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information) score of 15 (scores of 13-15 equate to intact cognition). A review of Resident 3's clinical record revealed no documented evidence the resident had ever displayed signs of sexually inappropriate behaviors while residing at the facility. Additionally, there was no care plan in place indicating the presence of such behaviors. A review of a facility investigative report dated January 19, 2025, at 1:15 PM revealed Resident 3, a cognitively intact resident was observed by staff performing oral sex on Resident 2, a cognitively impaired resident. A review of the investigative reports and witness statements confirmed that Employee 2 nurse aide (NA) and Employee 3, nurse aide (NA) both witnessed the event and immediately reported to the nurse, Employee 1 registered nurse (RN). When questioned Resident 3 admitted to engaging in the act, stating that Resident 2 had initiated the interaction, although Resident 2, due to her severe cognitive impairment, could not have consented to or initiated sexual behavior. A review of a statement from Resident 3, which did not indicate the date or time it was obtained, revealed that Resident 3 went into Resident 2's room to offer her roommate, some yogurt. Resident 3 stated that Resident 2 was moaning as if she needed a drink. He indicated that he went into the bathroom to get her some water, and upon returning, Resident 2 grabbed his hand and pulled him toward her and started to touch the front of his pants. Resident 3 indicated they began to kiss. Resident 3 stated that Resident 2 had her brief off, so he placed his head between her legs for a few seconds. He stated the staff came in, saw what was happening and he confirmed he immediately got up and left the room. A review of nursing documentation written by Employee 1, RN dated January 19, 2025, at 1:15 PM indicated she was notified by Employee 2 NA that Resident 3 was engaged in inappropriate behavior with Resident 2. When Resident 3 was asked what he was doing, he got up and walked out of the room. Resident 2 was observed lying on her mattress with her incontinence brief removed. When asked if someone hurt her, Resident 2 moaned yes. A body audit was conducted revealing no signs of bruising, marks or bleeding. State police were notified, and an investigation was initiated. Resident 2 was sent to the hospital for a rape kit examination. Resident 3 was separated from this resident and placed on one-to-one observation to ensure residents' safety and provide continuous supervision of this resident. A telephone interview with Employee 2, NA on January 22, 2025, at 1:00 PM revealed she was assigned to Resident 2 on January 19, 2025. Employee 2 stated that she asked Employee 3, NA for assistance with Resident 2's care. When they entered Resident 2's room, the privacy curtain was drawn, and they noticed sneakers sticking out from underneath the curtain. Employee 2 indicated she and Employee 3 then moved around the curtain and observed Resident 3 face positioned between Resident 2's legs. She also noted that Resident 2's brief had been removed and was placed to the side. When asked if Resident 2 would have been capable of removing the brief on her own, Employee 2 responded that she could not. She explained that while Resident 2 had a history of attempting to rip off her brief, the brief tabs were not torn. Instead, the tabs had been carefully undone, and the brief had been intentionally placed to the side. Employee 2 further stated when asked Resident 3 what he was doing, he got up and left the room. She observed that Resident 2 appeared distraught. Employee 2 stated she then helped resident to get dressed and escorted her to the dining room for monitoring. An interview with Employee 3 on January 22, 2025, at 12:12 PM revealed that on January 19, 2025, she had returned from her break when Employee 2 approached her and asked her for assistance with the care. The Resident 2 Employee 3 stated it was approximately 1:00 when they entered the residence room and noticed a pair of sneakers sticking out from under the privacy curtain. She indicated she then walked around the curtain and observed Resident 2 lying on the bed with her brief removed and saw Resident 3's face positioned between Resident 2's legs. Employee 3 stated that she and Employee 2 immediately yelled What are you doing! At that point, Resident 3 got up and walked out of the room. Employee 3 followed Resident 3 out of the room while Employee 2 stayed with Resident 2. Employee 3 immediately reported the incident to Employee 1 RN on duty. Employee 3 further stated she later returned to Resident 2's room and helped her get dressed and assisted her to the dining room. When asked whether Resident 2 would have been able to reach up to pull Resident 3 toward her or grab him, Employee 3 responded no. She explained that Resident 2 requires assistance with. Activities of daily living and would not have the strength to perform such activities. Multiple attempts were made to interview Resident 3 throughout the day on January 22, 2025, however, the resident was asleep during each attempt. A review of legal records indicated, Resident 3 is facing charges of Indecent Assault on a Person with Mental Disabilities, with a preliminary hearing scheduled for February 6, 2025. Resident 2 is cognitively impaired and did not possess the ability to consent to sexual acts with Resident 3. Applying the reasonable person concept, in the case of Resident 2, who is unable to cognizant speak for herself due to severe cognitive impairment, and the assessment of how most people would react to the situation of being sexually abused by Resident 3, Resident 2 would have been negatively affected by Resident 3's actions. An interview with the Nursing Home Administrator on January 22, 2025, at approximately 3:00 PM confirmed that the facility failed to ensure that Resident 2 was free from sexual abuse perpetrated by Resident 3. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records, select facility policy and investigative reports, and staff and resident interviews, it was determined that the facility failed to ensure that one resident out of 25 sampled (Resident 29) was free from physical abuse, perpetrated by another resident, (Resident 2) which resulted in physical injury, a concussion, to the resident victim. Findings include: The facility's Abuse Prevention Policy and Procedure Manual dated as reviewed last by the facility on June 3, 2024, indicated it is the facility policy that abuse, neglect, and/or mistreatment of residents will not be tolerated in any manner. The purpose of the policy indicated all necessary steps shall be taken to ensure the provision of a safe and secure environment. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Examples of physical abuse identified in the facility policy include complaints of physical mistreatment. Residents must not be subject to abuse by anyone, including but not limited to, facility staff, other residents, or other individuals. A clinical record review revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses of severe morbid obesity (abnormal or excessive fat accumulation that presents a health risk) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2024 revealed that Resident 29 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and hemiplegia (paralysis on one side of the body). A review of an annual MDS assessment dated [DATE], revealed that Resident 2 is cognitively intact with a BIMS score of 15. Resident 2's care plan revealed that the resident has alterations in her behavior manifested by physical abuse, verbal abuse, and socially inappropriate behavior related to mood affective disorder and adjustment disorder initiated on August 10, 2022. An incident report dated July 20, 2024, indicated Resident 29 reported to staff that Resident 2 pushed a bedside table, striking Resident 29 in the head. Resident 29 reported that she had her head down at the time near the table. The incident report indicated that Resident 29 was assessed with no visible redness, no edema, and no hematoma, but Resident 29 stated {her head} hurts. A nursing progress note dated July 20, 2024, at 1:53 PM indicated that Resident 2 was involved in an altercation with her roommate. No injuries were reported, and residents should remain separated to avoid further altercations. A progress note dated July 21, 2024, at 6:32 PM revealed that Resident 29 complained of pressure and headache pain. Resident 29 stated that the pain was rated as 9 out of 10 (on a scale of 1-10, with one being the least severe and 10 being the worst). She also stated that she has vertigo and blurred vision. The resident requested to be sent to the emergency department for an evaluation. The entry indicated that the physician wrote an order to send Resident 29 to the emergency department for evaluation and treatment related to headache and vertigo. The hospital after visit summary dated July 21, 2024, indicated that Resident 29 was diagnosed with a concussion without loss of consciousness. The document indicated that Resident 29 should follow up with a primary physician in one to two days and should follow up with an outpatient concussion clinic and schedule a CT head scan without contrast. During her stay, she received acetaminophen 1,000 mg (Tylenol- a pain medication), ketorolac injection 30 mg (Toradol- a nonsteroidal anti-inflammatory pain medication), and oxycodone-acetaminophen 5.0 mg-325 mg (Percocet- an opioid pain medication). A progress note dated July 22, 2024, at 10:46 AM indicated that Resident 29 returned from the emergency department without complaints of dizziness, weakness, or lightheadedness during transfer. The entry noted that the emergency department recommended follow-up with a community provider for an outpatient CT scan without contrast. A physician note dated July 22, 2024, at 3:19 PM indicates that the resident returned from the emergency department this morning with a diagnosis of a concussion. A follow-up appointment for a CT scan of the head was ordered. The note indicated that the resident complained of a 5 out of 10 pain level. During an interview on July 23, 2024, at 11:15 AM, Resident 2 denied being involved in any incident with Resident 29. She explained that Resident 29's room was changed a few days ago. During an interview on July 23, 2024, at 12:15 PM, Resident 29 stated that a few days ago she had an altercation with her roommate, Resident 2. Resident 29 stated that she was bending down near Resident 2's bed when Resident 2 deliberately pushed her bedside table into Resident 29, striking her head. Resident 29 stated that it hurt, and she was very angry and upset about the situation. She explained that she agreed to a room change following the incident. Resident 29 stated that she went to the hospital for an evaluation and she was diagnosed with a concussion based on her symptoms. She stated that she still has a headache. A review of Resident 29's Medication Administration Record for July 2024 revealed the following resident reported levels of headache pain from July 20, 2024, through July 24, 2024: July 20, 2024, at 1:40 PM: a pain level of 4/10 July 21, 2024, at 4:04 PM: a pain level of 4/10 July 22, 2024, at 5:10 PM: a pain level of 3/10 July 24, 2024, at 12:51 PM: a pain level of 3/10 July 24, 2024, at 6:51 PM: a pain level of 3/10 During an interview on July 25, 2024, at approximately 12:45 PM, Employee 12, Registered Nurse Unit Manager (RNM), stated that she investigated the incident between Resident 2 and 29 on July 20, 2024. She explained that both residents were assessed without injury. Employee 12, RNM, stated that Resident 29 agreed to a room change. Employee 12, stated that she contacted the police and wrote an incident report but did not obtain witness statements from residents or staff. Employee 12, also stated that neurological checks were initiated for Resident 29, and on July 21, 2024, Resident 29 was sent to the hospital with complaints of a headache and vertigo. Employee 12, stated that Resident 29 returned to the facility on [DATE], and had a diagnosis of a concussion. During an interview on July 26, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that Resident 29 was sent to the hospital on July 21, 2024, and was diagnosed with a concussion after being struck in the head with the overbed table by her roommate, Resident 2. The NHA confirmed that it is the facility's responsibility to ensure residents are not subjected to abuse by anyone, including other residents. Refer F609, F610 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights

Based on clinical record review and staff interview, it was determined that the facility failed to provide prescribed treatment necessary to manage constipation and promote normal bowel activity to prevent complications, a fecal impaction with resulting pain and discomfort requiring acute care intervention, for one resident out of 29 sampled (Resident 18). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include schizophrenia and anxiety. A quarterly MDS Assesment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) February 9, 2023, revealed that the resident was cognitively intact, required maximum staff assistance with activities of daily living, including toileting, and was always incontinent of bowel. The resident had a physician order dated December 22, 2021, for a bowel regimen that included Milk of Magnesia (MOM - a laxative to relieve occasional constipation) 30 ml by mouth every 72 hours as needed for no bowel movement (BM), Dulcolax suppository (Bisacodyl a stimulant laxative) 10 mg, one rectally as needed after MOM is administered and Fleets enema (rectal enema combination medicine used to treat constipation) 7-19 gms, one application rectally as needed after MOM and Dulcolax if no BM, which was the facility's standing bowel protocol. The resident also had an additional current physicians order initially dated December 23, 2021, for Senna-Docusate Sodium tabs 8.6-50 mg, give one tab by mouth every day (used to treat constipation, Sennosides are stimulant laxatives. Docusate is known as a stool softener. It helps increase the amount of water in the stool, making it softer and easier to pass). According to the resident's May 2023 Medication Administration Record (MAR) Resident 18 received the Senna daily through the month. A review of Resident 18's bowel movement record revealed that she did not have a bowel movement from May 21 2023, through May 27, 2023. A review of a May 2023 MAR (medication administration record) revealed that Resident 18 did not receive any of the physician ordered products prescribed in the bowel regimen (MOM, Dulcolax suppository or Fleets enema) to promote bowel activity between May 21, 2023, and May 27, 2023. A review of nurses notes dated May 24, 2023, at 1:06 P.M. revealed a verbal order was received from the physician assistant to administer MiraLax (a powdered laxative) Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation for 14 Days. A review of the May 2023 MAR indicated that Resident 18 received the Miralax daily from May 25, 2023, through May 31, 2023. There was no documented professional nursing assessment of the resident prior to contacting the physician/physician extender and obtaining a verbal order for Miralax. There was no nursing documentation as to why the physician prescribed bowel regimen was not implemented or if the physician assistant was aware that the existing prescribed regimen had not been followed before providing a verbal order for Miralax. Further review of the resident's bowel record indicated that on May 28, 2023, she had a small BM. The bowel record then revealed that she did not have a bowel movement from May 29, 2023 through June 3, 2023. The resident's corresponding May 2023 and June 2023 MARS revealed that the physician ordered bowel protocol was again not administered as ordered in response to the resident's lack of bowel movements. A nurse's notes dated May 31, 2023 at 1:58 P.M. revealed that per the facility nurse practitioner a KUB (abdominal x-ray) obstruction series was to be completed to rule out constipation/abdominal pain. There was no corresponding documented professional nursing assessment related to any abdominal pain or the resident's constipation prior to obtaining the order from the CRNP for a KUB. The abdominal x-ray was noted as completed on May 31, 2023, at 10:29 P.M. A nurses note dated June 1, 2023, at 1:30 A.M. revealed prior shift reported Abdominal x-ray result, significant rectal constipation. Physician notified, MD order, increase Miralax to twice a day. Positive bowel sounds and resident's abdomen is soft and tender to touch. A nurses note dated June 1, 2023, indicated that the physician assistant reviewed the resident's abdominal x-ray and no new orders were received. A nurses note dated June 2, 2023, t 1:49 P.M. revealed that nursing noted Resident refused to get out of bed this shift, she stated she was not feeling well. No bowel movement noted this shift. Positive bowel sounds in all 4 quads. Receives Miralax and Senna as ordered. MOM given. A review of the resident's June 2023 MAR indicated that staff adminstered a dose of the MOM to the resident on June 2, 2023 at 1:13 PM and a Dulcolax suppository June 3, 2023 at 4:21 A.M. A nurses note dated June 3, 2023 at 12:28 P.M. revealed that Resident 18 assessed with severe abdominal pain. It was noted that the resident had Hypoactive bowel sounds to left upper and upper quadrant; absent on right. Resident crying out when abdomen palpated. Recent abdominal XRay received, with significant rectal constipation, but no evidence of obstruction. Resident with poor intake this shift; did not consume any of her breakfast or lunch trays. Call placed to Physician, Re: above with order to send to ED for further evaluation. A nurses note dated June 3, 2023 at 10:11 P.M. revealed that nursing noted Called ER for follow up report on {Resident 18}. {Resident 18} was disimpacted of a large amount of stool while in ER. A review of hospital documentation dated June 3, 2023 revealed that Resident 18 had a CT scan (computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) CT scan images provide more-detailed information than plain X-rays) of the abdomen. The CT results were noted as A large fecal burden is visualized, particularly in the rectosigmoid colon. The rectum is distended up to 9.2 cm with fecal material, likely related to fecal impaction. The hospital administered lactulose (Lactulose is a non-absorbable sugar used in the treatment of constipation and hepatic encephalopathy-liver problems) 20 grams by mouth and a Sodium phosphate dibasic and sodium phosphate monobasic rectal enema (a combination is a laxative that is used to relieve occasional constipation in adults and children) During an interview June 8, 2023 at 1 P.M., Employee 4 (LPN) confirmed that the facility failed to administer the physician ordered bowel protocol to the resident during extended periods of time without normal bowel activity. The resident developed a large fecal impaction, causing the resident pain and discomfort and requiring transfer to the hospital for intervention to remove the impaction. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.5 (f)(g)(h) Clinical records

Based on a review of clinical records, information submitted by the facility, select resident incident/accident and investigative reports, and staff and resident interviews it was revealed that the facility failed to ensure that one resident was free from physical abuse, which resulted in significant physical harm, broken ribs, and emotional distress for this resident (Resident 74) and failed to implement measures necessary to prevent physical abuse for one resident (Resident 67) out of 20 sampled. Findings include: A review of the facility policy entitled Abuse Protection reviewed by the facility August 2022, revealed it is the policy of the facility for residents to have the right to be free from physical abuse, sexual abuse, misuse of restraints, involuntary seclusion, verbal abuse, mental abuse, neglect, abandonment, misappropriation of property, and self-abuse. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical pain or anguish. A review of the clinical record revealed that Resident 74 was admitted to the facility on [DATE]. The resident's diagnoses included schizoaffective disorder ( a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). A review of Resident 74's Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively intact. A review of a resident incident and accident report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property report form, for investigation of alleged abuse, neglect and misappropriation dated October 17, 2022, at 10:00 AM revealed that on October 16, 2022, Employees 1 and 2 (nurse aides reported to Employee 3 (Registered Nurse) that they found Resident 74 on the floor of the resident's room at approximately 7:30 a.m. Upon Employee 3's observation she noted that the resident was tearful and anxious. Resident 74 stated to Employee 3 she was crawling back to bed and complained of pain to her left arm. Employee 3 observed that the resident's left thigh was reddened. When Employee 3 asked Resident 74 what happened she stated, that Employee 4 (RN) she hit me, I fell on the floor, and she left. It was noted that there was water on the floor by the resident's bed. The physician was notified and on October 16, 2022, at 10:10 a.m. the physician ordered an x-ray of the resident's left shoulder, left elbow, left hand, left rib series and left pelvic area. An employee witness statement written by Employee 1 (nurse aide) October 16, 2022, indicated that on October 16, 2022, at approximately 7:30 a.m. We walked in room to get roommate up for breakfast we found resident {74} on the floor next to her bed. She said to us that the little nurse with short hair from night shift came in tried giving me my meds in the dark and she got mad because she did not turn the light on to see my meds, so she threw the water cup at nurse and nurse hit her causing her to fall and hit her wheelchair and left her on the floor in the dark. Employee 2 (NA) was present, and her witness statement dated October 16, 2022, revealed the exact same statement as Employee 1. A review of a witness statement written by Employee 4 (RN), dated October 18, 2022, revealed that the resident was upset because she was awakened for medication administration. She confirmed that Resident 74 threw water on her, but denied hitting the resident. A review of a witness statement given by Resident 74 on October 17, 2022, revealed that Resident 74 stated when the nurse came in my room it was dark. I could not see to get up and I threw my water on the nurse. When I stood up she pushed me to the floor. When I fell to the floor I was screaming. The resident was unable to recall what time exactly this occurred, only that it was overnight. When asked to further explain what happened when she fell , she stated I fell and hit the back of my head. I hit my roommate's wheelchair. I hope my ribs aren't broken. She laid on the floor and yelled, she further stated that when staff came in they looked her over and had x-rays completed in the facility. A review of an x-ray of the left rib series report dated October 16, 2022, at 2:45 p.m. revealed acute fractures (break in a bone that occurs quickly, rapidly and usually traumatically) involving the left 10th and 11th ribs anterolaterally (situated in front and to one side) in the midaxillary plane (a specific coronal plane that passes through the midline of the body). Upon physician review, it was noted to continue her routine Tramadol (pain medication) and add prn Tylenol for breakthrough pain. Upon further review of the facility report, it was noted that a police investigation into the abuse of Resident 74 was ongoing and was not available for review at the time of survey ending November 4, 2022. The facility's report indicated that Employee 4 was suspended immediately and then terminated from facility employment on October 18, 2022, for abusing Resident 74. A review of the facility's annual abuse training revealed that Employee 4 received this training in September of 2022. The facility failed to ensure that Resident 74 was free from physical abuse resulting in fractured ribs. Interview with the Director of Nursing on November 3, 2022, at approximately 11:00 AM confirmed that Resident 74 had been physically assaulted by a registered nurse during care. Interview with Resident 78 on November 4, 2022 at 11:30 AM revealed that he reported an allegation of staff physical abuse of Resident 67 back in September 2022. Resident 78 stated he reported that he, along with Resident 92 and Resident 46, were in the dining room and witnessed Employee 4 (RN) put Resident 67 in a choke hold. Resident 78 stated that Resident 67 kept trying to stand and Employee 4 became frustrated and got rough with the resident. Resident 78 explained that he reported the incident to nursing staff, but that no one from the facility ever followed up with him about the incident he observed. Interview with Resident 46 on November 4, 2022 at 12:15 PM revealed that she could not clearly recall the incident. Interview with Resident 92 on November 4, 2022 at 12:30 PM confirmed that she did recall the incident and recalled reporting the incident to the facility. Resident 92 stated that she recalls Employee 4 (RN) clothes-lining Resident 67 in the dining room. Resident 92 stated that the employee who was rough with the resident no longer works at the facility. Interview with an Employee 3 (RN) confirmed that Residents 67, 92, and 46 reported the incident on September 26, 2022 and that Resident Concern/Complaint Forms were completed for all three residents. Review of a facility incident report dated September 26, 2022 at 3:00 PM indicated that Resident 67 was forcefully placed in her chair. The location of the incident was the Third-Floor Nursing Unit dining room. Further review of the incident report noted that the incident which occurred on September 24, 2022 at 3:00 PM was reported by Resident 46 on September 26, 2022. Review of the Resident Concern/Complaint Form, which was attached to the incident report indicated that Resident 46 witnessed Employee 4 (RN) pulling Resident 67's head back by the hair and putting the resident in a choke hold. The nursing follow-up (no date) noted the concern was resolved. According to nursing staff's follow-up they conducted interviews with Resident 46 and Resident 67. Resident 67 stated no she didn't choke her, I'm pissed off, I want to go home. Resident 67 has no visible injuries and denied harm. Date discussed was September 26, 2022. No further action was noted to be taken. Resident 67 to continue to follow with psychiatry and provide a safe environment for the resident. Further review of the incident report revealed no documented evidence that Resident 78's Resident Concern/Complaint Form or Resident 92's Resident Concern/Complaint Form was attached to the incident. A written statement by the director of nursing dated September 26, 2022, indicated tha she spoke to Employee 4 on September 26, 2022 upon hearing of the accusations. Employee 4 was reported that she was assisting with Resident 67's increased behaviors and providing one to one intervention with the resident. Employee 4 stated she did guide Resident 67 to sit, but at no time physically or forcefully made the resident sit. Employee 4 was having conversation with Resident 67 the entire time to keep the resident calm and provide as much support as possible. Immediate investigation of accident/incident taken by the director of nursing noted that staff interviews and resident interviews were completed, the Area Agency on Aging was notified. Resident 67 was interviewed and denied the incident. No visible injury was noted. A report was submitted to the State Agency and a PB-22 Form was completed. The police were notified on September 26, 2022 at 4:00 PM. Review of the PB-22 Form concluded no harm was noted and the incident was unfounded. There was no documented evidence that the follow-up interview with Resident 46 included a documented statement by the resident as part of the investigation after the initial allegation was reported by the resident. There was no documented evidence that the facility had thoroughly investigated if there were any other resident witnesses to the incident, which occurred in the dining room which is a resident common area. During interview with the director of nursing (DON) on November 4, 2022 at 1:00 PM, the DON noted that she only recalled a Resident Concern/Complaint Form being submitted for Resident 46. The DON confirmed she was unaware that Resident 78 and Resident 92 had also reported the incident along with Resident 46. The DON confirmed that all allegations of abuse were to be thoroughly investigated by the facility. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.18 (e)(3) Management 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12 (a) Nursing services 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.12 (d)(3) Nursing services

Based on clinical record review, Pa Department of Health reports, PB-22 abuse investigation reports and staff interview, it was determined that the facility failed to conduct prompt clinical nursing assessment of a resident's condition and ensure timely care and treatment for [REDACTED]. Findings include: A review of the clinical record revealed that Resident CR1 was moderately cognitively impaired resident and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment ( MDS - a federally mandated process providing a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.) dated December 22, 2013, revealed that the resident required assistance with her ADLs (Activities of Daily Living). A review of an event report submitted to the State Survey agency along with an abuse investigation (PB#22) dated February 25, 2014, at 2:14 pm revealed that Resident CR1 had been admitted to the hospital February 18, 2014, for lethargy and [MEDICAL CONDITION](stroke) and had returned to the facility on [DATE]. On February 25, 2014, therapy staff at the facility identified that the resident's her left lower leg was externally rotated and shorter than the right. The resident was transferred to the hospital on February 25, 2014, with a [DIAGNOSES REDACTED]. The facility's investigation into the injury determined that Resident CR1 had an unreported fall in the facility at approximately 1 AM on February 23, 2014. Employees 10 and 11, both nurse aides, found Resident CR1 on the floor next to her bed. Employee 10 (nurse aide-NA) left the resident's room and reported to Employee 12 (RN supervisor) that the resident was found "dangling" over the side of the bed. Employee 11 (nurse aide) stayed with the resident and Employee 10 told Employee 11 that the RN, Employee 12 was informed of the resident's fall. However, according to statements Employee 12 (RN) Employee 10 reported told that Resident CR1 was found attempting self transfers and Employee 12 was not aware of a fall. In response to Employee 10's report, Employee 12 obtained a physician order [REDACTED]. A review of nurses notes dated Saturday February 22, 2014 at 5 PM revealed the resident was readmitted to the facility following a hospital stay. A nurses note dated February 23, 2014 at 3:22 AM revealed that a "new order noted, apply bed\chair alarms, [DIAGNOSES REDACTED]. There was no documented event of the circumstances that prompted the the nurse to seek physician's orders [REDACTED]. There was no documented evidence that a nursing assessment was conducted at that time. A nurses note dated Monday February 24, 2014, indicated that Resident CR1 had difficulty maintaining body alignment in the chair. The physician was made aware and an order for [REDACTED]. Review of a Physical Therapy evaluation and treatment document dated February 24, 2014 revealed that upon initial evaluation on February 24, 2014, the resident had impaired range of motion of the left lower extremity and it was weaker than the right. The resident's transfer status was changed at that time to sit to stand transfer ( a mechanical lift where the resident stands with the assistance of the machine). The PT evaluation also indicated that Resident CR1 had pain at a level of 4 on a 0/10 scale in her left lower leg and she grimaced with pain when moved. The PT evaluation noted that the resident was unable to provide the pain description due to cognitive deficits. The pain assessment also noted that the resident's pain limited the resident's functional activities. The clinical impression noted by therapy was that the resident presents with significant decline in functional mobility as a result of acute hospitalization /medical issue. Therapy notified nursing of change in transfer status and nursing notified the physician of the transfer status change. There was no documented evidence that nursing had conducted an assessment of the resident's status related to decreased mobility and increased pain with movement. A nurses note dated February 25, 2014 at 2:14 PM revealed that therapy reported to nursing that Resident CR1's left leg was externally rotated and shortened (signs of a [MEDICAL CONDITION]). Nursing assessed the resident, called the physician and the resident was sent to the hospital with a [DIAGNOSES REDACTED]. There was no documented evidence at the time of the survey that this resident received timely clinical assessments of the resident's status and changes in condition. During an interview October 8, 2014 at 2 PM, the Director of Nursing confirmed that timely assessments of Resident CR1's status and change in condition were not conducted. 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services previously cited 8/8/14

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely implement sufficient interventions to prevent pressure sore development for one resident (Resident CR1) out of 16 resident's sampled. Findings include: A review of the facility's Preventative Measure Guidelines for Braden scale (a tool for Predicting Pressure Ulcer Risk) reviewed October 2014, revealed preventative measures include use pressure reducing devices including heel booties. At risk residents ( a Braden score of 15-18) indicated to protect heels with skin prep ( a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) or offload heels. During an interview October 7, 2014 at 10 am the Director of Nursing stated that the guidelines and the Braden Scale Score is the facility's pressure sore management policy. A review of the clinical record revealed that Resident CR1 was moderately cognitively impaired and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment ( MDS a federally mandated assessment process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems and plan care) dated February 25, 2014, revealed that the resident required maximum assistance with her ADLs (Activities of Daily Living) and was at risk for developing pressure areas. A review of a Braden score dated March 1, 2014, revealed a score of 17 indicating a low risk for pressure sore development. Readmission physician's orders [REDACTED]. Review of an incident report form dated March 5, 2014, at 8 AM revealed a DTI (deep tissue injury) pressure area on the resident's right heel measuring 3 cm x 3 cm (deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin ) with intact skin, deep purple in color. An 8 cm x 7.5 cm intact fluid filled blister, stage II pressure sore was noted on her left heel. The facility determined that these pressure areas were caused by decreased mobility secondary to the resident's recent left [MEDICAL CONDITION]. Physicians orders dated March 5, 2014, were received, after the discovery of Resident CR1's two heel pressure areas, for skin prep to bilateral heels, zero gravity boots ( soft padded boots to offload the heels off the bed or chair, a foot cradle to the bed ( a device at the bottom of the bed to keep sheets off the feet ) and an air mattress to the resident's bed. A review of weekly wound monitoring documentation revealed inconsistent wound staging throughout the progression of healing of the pressure areas. During an interview October 7, 2014 at 11 AM the facility wound nurse confirmed that her wound assessments were not accurate. A review of computer generated nurse aide documentation dated March 1, 2014 through March 5, 2014 indicated that Resident CR1 was turned and repositioned every 1 hour, side to side with the exception of meals. This was the only pressure sore prevention intervention noted prior to the development of the pressure sores on the resident's heels. There was no evidence at the time of the survey that adequate preventative measures to deter pressure sore development were implemented prior to the discovery of the heel pressure areas. During an interview October 6, 2014 at 10 am the Director of Nursing confirmed that adequate interventions were not put into place for this resident who was at risk for pressure sores following the return to the facility following surgery for [REDACTED]. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 8/8/14 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on clinical record and incident Report review and staff interview, it was determined that the facility failed to timely identify the development of pressure sores for two of 16 sampled residents (Residents 31 and 21) identified at risk for pressure sores and failed to implement effective interventions to prevent their development. Findings include: Clinical record review revealed that Resident 31 had [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment (assessment completed at specific intervals to identify car e needs) dated September 27, 2011, indicated that the resident was cognitively impaired, required extensive assistance of two staff for bed mobility and personal hygiene and was at risk for pressure sore development. A nurse's note dated September 27, 2011, at 11:00 p.m., revealed that while nurse aides were rendering care to the resident, a seven centimeter by 4 centimeter red mushy area was noted on the right inner heel. It was also documented in nurse's notes that a 4.5 centimeter by two centimeter dark area was noted in the center of the seven by four centimeter area. A review of the September 27, 2011, Skin Grid and Incident Report timed at 10:15 p.m., indicated that this skin impairment was not present prior to the above date/time and identified pressure as the route cause for this skin impairment. The Skin Grid indicated that the pressure sore was Un-stageable due to visualized eschar (dead tissue) on the pressure sore. Staff statements conducted at the time of the pressure sore identification on September 27, 2011, revealed that heel protectors were ordered by the physician and were to be in place prior to the development of the pressure sore. Staff statements indicated that a possible cause for the Unstageable pressure sore was the fact that the resident was noted to rub his legs on the bed. Based on the staff statements reflecting their knowledge that the resident rubs his legs on the bed, there was no evidence that the facility attempted additional preventative interventions to address the resident's known behavior to prevent potential skin breakdown. Staff statements at the time of the identified pressure sore failed to indicate if the heel protectors remained in place while the resident was moving his legs in bed and if the heel protectors were in place at the time of the identified pressure sore. Interview with Employee 1(LPN) on November 3, 2011, at approximately 10:25 a.m., failed to explain why the pressure sore was found as unstageable with eschar and was not identified prior to September 27, 2011, at a lesser degree of skin impairment. A review of a physician's progress note dated October 7, 2011, indicated that a culture and sensitivity of the right heel was to be obtained. A review of the wound culture results sent to the laboratory on October 7, 2011, revealed that the resident had acquired a [MEDICAL CONDITION]-resistant Staphylococcus aureus infection (MRSA) requiring antibiotic therapy (a drug resistant bacterial infection. A review of a consulting surgeon's evaluation of the resident's right heel pressure sore dated October 20, 2011, revealed that the resident's heel was not properly placed in the heel protector upon the physician's examination. The consultation also indicated that the right heel was necrotic and gangrenous. There was no evidence that staff consistently ensured that the resident's heel was properly positioned to promote adequate healing There was no evidence at the time of the survey that this pressure sore was timely identified by staff or that appropriate interventions to prevent the development of this avoidable pressure sore were effectively implemented. Clinical record review revealed that Resident 21 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment completed June 23, 2011, indicated that the resident was cognitively impaired, required staff assistance for bed mobility, transfers and hygiene, was frequently incontinent of bowel and bladder and was at risk for developing pressure sores. A review of a nurse's note dated July 31, 2011, at 9:30 p.m., revealed that while providing care, a three centimeter by six centimeter open area was found on the resident's left buttock. The review of the July 31, 2011, Incident Report timed at 9:30 p.m., revealed that Resident 21 was incontinent of bowel and was receiving care by staff. During the care, the open area on the buttocks was identified. There was no evidence of impaired skin prior to the identification of this open area. The incident report indicated that the skin impairment was due to the resident's impaired mobility and the resident repositioning self on to his back. Review of the July 2011, scheduled toileting program revealed that the resident was provided incontinence care between 5:00 p.m. and 5:30 p.m. It was documented that the resident was incontinent requiring incontinence care. There was no indication at this time that the resident had any skin impairment or that there were any irregularities noted with the resident ' s skin. The time of the last documented scheduled incontinence care prior to pressure sore development was at 5:30 p.m., and the next documented incontinence care was at 9:30 p.m., (approximately 4 hours) during which an open area was identified. Review of the Weekly Pressure Sore Report dated August 2, 2011, indicated that this open area was assessed to be a Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact blister or serum-filled blister). Interview with Employee 1 on November 3, 10:25 a.m., confirmed that the pressure sore was found as a Stage II and not found at a lesser stage (Stage I - intact skin with non-blanchable redness of a localized area usually over a bony prominence) and size. 483.25(c) Pressure sores Previously cited 5/20/11 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 12/9/10, 5/20/11

Based on review of clinical records and select facility policy, and staff and resident interview, it was determined that the facility failed to timely identify and assess changes in urinary continence and implement prompt individualized measures to prevent a significant decline in bladder function for one of 16 sampled residents (Resident 70). Findings include: A Review of the facility policy for Restorative Bowel and/or Bladder Training and Maintenance Program, reviewed September 1, 2011 revealed that an assessment will be completed for all currently admitted residents who develop an incontinence problem in bowel and/or bladder. When a resident falls under this criteria and is assessed for the need of a restorative bowel and /or bladder program, the staff will complete the following steps: 1. Complete the assessment for bowel and bladder retraining, 2. Make the decision as to the specific and individualized program as indicated by the outcome of the assessment, 3. Implement the restorative program and necessary documentation. Clinical record review revealed that Resident 70 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed her to be moderately, cognitively impaired, requiring the assistance of two staff for toileting and was continent of bladder. A subsequent significant change MDS assessment dated [DATE] revealed that the resident was moderately, cognitively impaired, required the assistance of two staff for toileting and was now frequently incontinent of bladder. A review of the resident's care plan for the problem of self care deficit initiated on July 13, 2011, and last updated October 3, 2011, revealed no interventions for developed and implemented for urinary continence between the decline in bladder function noted on June 2011 and October 2011 MDS assessments. A review of the activities of daily living (ADL) flow record dated April 2011 indicated that Resident 70 was consistently continent of bladder. Upon request, the May 2011 and June 2011 ADL records and corresponding nurses notes were not available at the time of the survey. However, the quarterly MDS assessment dated [DATE] indicated that she was continent of bladder at that time. A review of the ADL record dated July 2011 revealed that Resident 70 was continent of bladder on the 7 AM to 3 PM and the 11 PM to 7 AM shift from July 1, to July 6, 2011, and was incontinent on the 3 PM to 11 PM shift on those days. The record further indicated that she was then completely incontinent from July 8, 2011, to July 31, 2011. A review of the ADL records revealed that Resident 70 was then totally incontinent during the months of August 2011, September 2011 and October 2011. A review of an Assessment for Bowel and Bladder Retraining dated December 22, 2010 indicated that Resident 70 was continent of bladder. The last re-evaluation on this form, was dated February 28, 2011, noting readmission to the facility and a bowel and bladder assessment completed at that time. There were no additional Assessments for Bowel and Bladder Retraining available at the time of the survey. A review of nurses notes dated from June 20, 2011 and July 12, 2011 revealed no documentation that this resident was incontinent of bladder. A nurses note dated July 13, 2011 at 6 AM revealed noted "incontinent of bowel and bladder." Subsequent nursing documentation dated from July 14, 2011 and November 2, 2011 revealed daily notation of bladder incontinence. Resident 70 was hospitalized from August 27 to August 30, 2011. There was no evidence at the time of the survey that a bladder assessment was completed upon re-admission to the facility. Resident 70 had another admission to the hospital from September 26 to October 1, 2011. A Restorative Bowel and/or Bladder Retraining Program (7 day, hourly notation of the resident's urinary continence) dated October 1, 2011 through October 7, 2011 indicated notations of both incontinence and continence and that the resident was assisted to the toilet at times. The final summary dated October 7, 2011 revealed "Bowel and Bladder assessment complete x 1 week. Resident non-compliant with retraining program. Refuses to participate. Prefers to ring call bell when incontinent. And thus uses Bed pan to have bowel movement." A corresponding ADL record dated October 2011 revealed that Resident 70 was incontinent all the time during the month of October 2011. The ADL record for October 2011 and the 7 day bladder diary dated October 1 through 7 2011, did not match and the diary was not completed correctly according to the directions on the form. During an interview November 2, 2011 at 10:30 AM, Employee 2 (nurse aide) stated that Resident 70 is always incontinent of urine. He stated that she wears briefs and is checked by staff for incontinence every 2 hours. He further stated that she has been this way for "months." During an interview November 3, 2011 at 1:30 PM the Director of Nursing confirmed that the facility was unable to locate the clinical record documentation (ADL records & nurses notes) for Resident 70 for the months of May 2011 and June 2011. She further confirmed that no bladder assessment was completed upon return from the hospital on August 30, 2011 and no assessment conducted when it was noted that the resident was having daily episodes of bladder incontinence. She verified that Resident 70 is completely incontinent at this time. 28 Pa. Code 211.12 (a)(d) Resident care policies previously cited 5/20/11 28 Pa. Code 211.5 (c) Clinical record 28 Pa. Code 211.11 (e) Resident care plan 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services previously cited 5/20/11