Every finding on record at Rose Meadows Health & Rehab Center

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include:Review of the facility policy Abuse Policy-Prevention and Identification, dated 4/17/25, indicated it is the facility's policy to deploy staff on each shift in sufficient numbers and assure staff assigned have knowledge of the individual residents' care needs. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/11/26 included diagnoses of cellulitis (bacterial infection affecting the skin's deep layers) and muscle weakness. Review of Section GG: Functional Abilities indicated that Resident R1 required dependent assistance (two or more helpers) for chair/bed-to-chair transfers.Review of an on-call physician note dated 2/5/26 at 4:12 p.m. indicated, nurse calls to report resident was being assisted back to bed earlier and hit his left leg on the edge of the bed and caused a laceration. Per nurse measurements are 6cmx 0.5x0.25. Some bleeding earlier but not currently bleeding.Review of a progress note dated 2/5/26 at 6:03 p.m. indicated, CNA alerted this nurse that resident was bleeding from left lateral leg. Upon inspection this nurse observed a 6cmx0.5cmx0.0cm laceration to the left lateral lower leg. This resident stated, 'My leg got dragged on the side of the bed when being transferred from my wheelchair to bed'.Review of facility submitted information on 2/5/26, indicated on 2/5/26 at 4:00 p.m., [Resident R1] reported that when was being transferred from his wheelchair to his bed by CNA [nurse aid], when his left leg hit the bed and he sustained a cut. Resident was assessed by the RN (registered nurse) and telehealth was completed. First aide provided to the resident per MD (medical doctor) order. Area was cleansed and Steri strips applied and area covered with dry dressing.Review of an employee statement via phone by NA Employee E1, dated 2/5/26 indicated, transferred the resident from the wheelchair to the bed without another employee.Review of Resident R1's plan of care for ADLs (activities of daily living) Functional Status / Rehabilitation Potential, not initiated until 2/6/26, indicated that the resident will have staff assist of two with all transfers for safety. The plan of care did not indicate assist of two prior to 2/6/26.Review of the facility's plan of correction included:-Wound will be monitored for signs/symptoms of infection. -Nursing care plan updated to include any new orders. -Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs. -All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments. -All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries. Review of facility provided education information and on-going quality assurance measures revealed facility staff received education on accident prevention, falls, and reviewing ADL information in the computerized charting system, as well as ongoing monitors to prevent future accidents and improve systems. This education was completed on 2/17/26 and was in compliance as of that date.During an interview on 2/19/26 at approximately 11:15 a.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of the observations and staff interviews, it was determined that the facility failed to maintain an effective pest control program in the Main Kitchen. Findings include:During observations on 10/18/25, between 8:30 a.m. and 10:00 a.m. the following was observed: -One live cockroach on the wall of the food service hallway. -Two dead cockroaches in the food service staff restroom. -Four live cockroaches under the range in the food service preparation area. -Food waste debris and dead cockroaches behind food services counters. -Cockroach waste on the wall in the food cart storage area. During an interview on 10/18/25, at approximately 9:00 a.m. the Food Service Director confirmed there has been an ongoing issue with pest control in the main kitchen and described the actions taken by the facility (deep-cleaning of the kitchen, pressure washing the food service carts, weekly pest control vendor maintenance, and facility maintenance staff spraying food-service safe pest control solutions daily). During an interview on 10/18/25, at approximately 11:30 a.m. the Director of Nursing confirmed the facility failed to maintain an effective pest control program in the Main Kitchen. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 207.2 Administrator's responsibility.

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for three of six residents (Residents R5, R66, R102).Findings include: Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 9/25/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of a physician's orders dated 9/19/25, indicated Resident R5 was to receive gabapentin (a medication that can be used to treat neuropathy) 1200 mg (milligrams) three times per day. Review of a physician's orders dated 9/19/25, indicated Resident R5 was to receive omeprazole (a medication to reduce stomach acid) 20 mg daily. Review of a physician's orders dated 9/20/25, indicated Resident R5 was to receive a combination medication of lisinopril (medication to lower blood pressure) 20 mg and hydrochlorothiazide (medication to reduce fluid in the body) 12.5 mg daily. Review of a physician's orders dated 9/20/25, indicated Resident R5 was to receive duloxetine (a medication that can be used to treat depression or neuropathy) 30 mg daily. Review of a physician's orders dated 9/20/25, indicated Resident R5 was to receive apixaban (a medication to prevent blood clots) 30 mg daily. Review of a physician's orders dated 9/20/25, indicated Resident R5 was to receive carvedilol (a medication that can be used to treat high blood pressure) 30 mg daily. Review of a progress note dated 9/18/25, at 8:52 p.m. indicated Resident R5 was oriented to the facility. Review of Resident R5's Medication Administration Record (MAR) for September 2025, indicated: 9/19/25: Gabapentin, hour of sleep dose documented as 9 (9 is code for order Other/See Nurse Notes). Review of the associated progress note dated 9/20/25, at 12:08 a.m. indicated, pending delivery.9/20/25: Gabapentin, morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 10:28 a.m. indicated, pending delivery.9/20/25: Gabapentin, afternoon dose documented as 9. Review of the associated progress note dated 9/20/25, at 3:12 p.m. indicated, pending delivery.9/20/25: Omeprazole, early morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 6:29 a.m. indicated, pending pharmacy delivery.9/20/25: Lisinopril/Hydrochlorothiazide, morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 10:28 a.m. indicated, CRNP aware, awaiting delivery from RX, new admit.9/20/25: Duloxetine, morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 10:28 a.m. indicated, CRNP aware, awaiting delivery from RX, new admit.9/20/25: Apixaban, morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 10:28 a.m. indicated, CRNP aware, awaiting delivery from RX, new admit.9/20/25: Carvedilol, morning dose documented as 9. Review of the associated progress note dated 9/20/25, at 10:28 a.m. indicated, CRNP aware, awaiting delivery from RX, new admit. Review of the facility provided inventory for the automated medication dispensing machine included gabapentin, omeprazole, lisinopril, hydrochlorothiazide, duloxetine, apixaban, and carvedilol. Review of the clinical record indicated Resident R66 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of high blood pressure and diabetes. Review of a physician's orders dated 10/30/25, and reordered 10/31/25, indicated Resident R66 was to receive insulin aspart (an injectable medication to treat high blood sugar) 12 units four times a day (9:00 a.m., 1:00 p.m., 5:15 p.m., and 9:00 p.m.). Review of a progress note dated 10/30/25, at 7:44 p.m. indicated Resident R66 arrived at the facility at 1:45 p.m. on 10/30/25. Review of Resident R66's MAR for October 2025, indicated: 10/30/25: Insulin aspart, 9:00 p.m. dose documented as 9. Review of the associated progress note dated 10/30/25, at 10:06 p.m. indicated, pending delivery. Review of the facility provided inventory for the automated medication dispensing machine included insulin aspart. Review of the clinical record indicated Resident R102 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation and anxiety disorder. Review of a physician's orders dated 10/24/25, indicated Resident R102 was to receive buspirone (a medication to treat depression and anxiety) twice daily. Review of a physician's orders dated 10/24/25, indicated Resident R102 was to receive apixaban twice daily. Review of a progress note dated 10/24/25, at 2:30 p.m. indicated Resident R102 arrived at the facility at 2:15 p.m. on 10/24/25. Review of Resident R102's MAR for October 2025, indicated: 10/24/25: buspirone, hour of sleep dose documented as 5. Review of the associated progress note dated 10/25/25, at 12:21 a.m. indicated, awaiting medications, CRNP aware. 10/24/25: apixaban, hour of sleep dose documented as 5 (5 is code for order Hold/See Nurse Note). Review of the associated progress note dated 10/25/25, at 12:22 a.m. indicated, awaiting medications, CRNP aware. Review of the facility provided inventory for the automated medication dispensing machine included apixaban and buspirone. During an interview on 12/3/25, at 5:10 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement procedures to ensure availability of prescribed medications for three of six residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for one of five residents reviewed (Resident R38). Findings include:The Centers for Disease Control define diabetes as Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body ' s cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dL). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias, and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable level of CBG ' s. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it is untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage, and non-healing wounds. Review of the facility policy Notification of Changes in Resident Condition and Treatment Changes reviewed 4/17/25, indicates the medical practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. Review of the clinical record revealed Resident R38 was admitted to the facility on [DATE] with diagnoses that included diabetes, atherosclerotic heart disease (the buildup of fats and cholesterol substances in and on the artery walls), and hyperlipidemia (having too many fats, like cholesterol and triglycerides in your blood). Review of the Minimum Data Set (MDS- a mandated assessment of a resident 's abilities and care needs) dated 9/24/25, indicated diagnoses remain current. Review of Resident R38' s physician orders revealed the following orders:-On 7/3/25, Apidra SoloStar (a fast-acting insulin that starts to work about 15 minutes after injection, peaks about 1 hour, keeps working for 2-4 hours) administer before meals (8 am, 12 pm, 4 pm). If >340, notify the physician. -On 10/2/25, the CBG was noted as 342, no recheck documented.-On 10/7/25, the CBG was noted as 353, no recheck documented.-On 11/16/25, the CBG was noted as 384, no recheck documented.-On 11/17/25, the CBG was noted as 406, no recheck documented. Review of Resident R38' s eMAR (computerized charting) and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. During an interview on 12/3/25, at 5:10 p.m. the Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition and failed to document an assessment or interventions used related to abnormal blood glucose levels for Resident R38. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.29 (d) Resident Rights.28 Pa. Code 211.10 (c)(d) Resident Care Policies.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of two residents reviewed (Resident R37).Findings include: Review of the facility policy, Trauma Informed Care dated 4/17/25, indicated that Each resident will be screened for a history of trauma upon admission. If trauma is identified, triggers of past trauma will be discussed and identified during the assessment process. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/22/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), anxiety, and PTSD. Review of the facility diagnosis list indicated that the diagnosis of PTSD was added on 7/25/25. Review of Resident R37's care plan for [Resident R37] has a diagnosis of PTSD not initiated until 11/25/25, included one intervention of Encourage slow / deep breathing exercise, reassuring conversation with pleasant topics. During an interview on 12/3/25, at approximately 5:10 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder for one of two residents reviewed. 28 Pa Code 201.24(e)(4) admission Policy.28 Pa Code 211.12(a)(d)(3)(5) Nursing Services.28 Pa. Code 211.16(a) Social Services.

Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of five residents (Resident R66). Findings include: Review of facility policy Medication Administration dated 4/17/25, indicated that medications are administered only as prescribed by the provider. Review of Resident R66's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R66's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 11/6/25, included diagnoses of type 2 diabetes (disease where the body either doesn't make enough insulin or doesn't use it properly) and encephalopathy (disease that alters brain function, causing altered mental state). Review of a physician's order dated 10/31/25, indicated for Resident R66 to receive 12 units of insulin aspart subcutaneously four times a day for blood sugars <140. Review of Resident R66's medication audit report from 11/1/25, through 11/30/25 revealed the following related to the administration of insulin aspart:11/3/25: 9:00 p.m. dose administered with blood sugar of 110.11/4/25: 11:45 a.m. dose administered with blood sugar of 70.11/13/25: 7:45 a.m. dose administered with blood sugar of 125; 5:15 p.m. dose administered with blood sugar of 139; and 9:00 p.m. dose administered with blood sugar of 110.11/22/25: 5:15 p.m. dose administered with blood sugar of 138 and 9:00 p.m. dose administered with blood sugar of 138.11/23/25: 7:45 a.m. dose administered with blood sugar of 127.11/2/25: 9:00 p.m. dose administered with blood sugar of 90. During an interview on 12/3/25, at approximately 5:00 p.m. the Director of Nursing confirmed that the orders for insulin aspart were specifically administered outside of the parameters set in the physician order. During an interview on 12/3/25, at approximately 5:10 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents were free from significant medication errors for one of five residents. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c) Resident care policies.28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization (Resident R1 and R4).Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Review of facility Bed Hold Policy dated 4/17/25, indicated, Prior to transfer and at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy and addresses information explaining the return of the residents to the most available bed. Review of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/29/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interfere with daily life) and metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain). Review of Section C: Cognitive Patterns indicated severe cognitive impairment. Review of a progress note dated 7/18/25, at 4:50 a.m. indicated that Resident R1 was ordered to be sent to the hospital. Further review of Resident R1's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of a progress note dated 8/21/25, at 6:28 p.m. indicated that Resident R1 was ordered to be sent to the hospital. Further review of Resident R1's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of a progress note dated 9/23/25, at 8:38 p.m. indicated that Resident R1 was ordered to be sent to the hospital. Further review of Resident R1's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R4 had severe cognitive impairment. Review of a progress note dated 10/6/25, at 2:08 a.m. indicated Resident R4 was ordered to be sent to the hospital. Further review of Resident R4's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. During an interview on 12/3/25, at approximately 5:10 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a left humerus (upper arm) fracture for one of six residents reviewed (Resident R1). This was identified as harm for past non-compliance.Findings include:Review of facility document entitled, Abuse, Neglect, and Misappropriation dated 4/17/25, indicated neglect is the failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of Resident R1's admission record indicated she was admitted to the facility on [DATE] and readmitted on [DATE].Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 6/30/25, included diagnoses of hemiplegia of left side (paralysis or weakness on one side of the body), diabetes and a history of falls.Review of the MDS dated [DATE], Section GG: Functional Abilities, Section GG0170 indicated Resident R1was dependent on staff for bed to chair transfer.Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance - hemiplegia affecting left side dated 6/18/24, requires resident to have an assist of two for transfers and lying to sitting on the side of the bed requires an assist of two helpers.Review of Resident R1's Kardex (Listing of ADLs, continence levels, and behaviors, which generates directly from the resident care plan) utilized by nurse aide staff dated 9/30/25, indicated that Resident R1 as requiring 2 or more helpers for bed to chair transfers and lying to sitting on the side of the bed, and two persons and a mechanical lift.Review of progress note dated 9/30/25, at 4:00 p.m. indicated Resident R1 had fallen out of bed and complained of left shoulder pain. Left shoulder x-ray was ordered and the resident was given Tylenol for pain to the left shoulder.Review of facility incident report dated 9/30/25, indicated CNA was attempting to transfer resident and she slid out of bed.Review of an x-ray report dated 10/1/25, indicated Resident R1 sustained a fracture to the left humerus.Review of CNA Employee E1's statement written on 9/30/25 indicated I sat resident up at the edge of the bed waiting for help, and the force of sitting her up made her slide forward and she hit her shoulder on something while sliding and she ended up on the floor.A review of CNA Employee E1's personnel file indicated a hire date of 9/10/25, and employee E1 received competencies in the ability to confirm appropriate transfer methods per the plan of care, assisting with transfers, and transferring residents safely.Review of the facility submitted report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/1/25 indicated Employee E1 attempted to transfer Resident R1 without an assist of 2 persons as required and was terminated.During an interview on 10/23/25, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect that resulted in actual harm for one of six residents which resulted in actual harm of a fractured left humerus to Resident R1.On 10/3/25, the facility-initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately.This plan included the following:-Immediate termination of NA Employee E1.-Facility completed a full house audit to ensure correct transfer statuses were documented for each resident.-Education was provided on 10/3/25, to all nursing staff on abuse and neglect.-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes.During interviews on 10/22/25 from 1:10 p.m. to 2:45 p.m., revealed the following:CNA Employee E2 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E3 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E4 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E6 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E7 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E8 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E9 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E11 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E13 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E12 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E13 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E14 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E15 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E16 confirmed the use of orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E20 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E21 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.During interviews on 10/22/25, (CNA Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, and E12), confirmed they received point of care training on 10/3/25, for bed mobility and safe transfers.The facility has demonstrated compliance with the regulations since 10/16/25.During an interview on 10/23/25, at 4:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.20(b)(1) Staff Development.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.11(d) Resident care plan.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and documents, clinical record review and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in the actual harm of a left humerus (upper arm) fracture for one of six residents (Resident R1). This was identified as past noncompliance.Findings include:Review of facility policy, Incidents/Accidents dated 4/17/25, indicated It is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees by minimizing possible exposure to safety hazards to the extent applicable. The facility is to ensure that residents are handled and transferred safely.Review of facility policy, Routine Resident Care dated 4/17/25, indicated It is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs. The facility will provide routine daily care by a certified nursing assistant (CNA) with training in rehabilitation/restorative care including maintaining proper body position and alignment and assisting with transfers. Review of clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 6/30/25, included diagnoses of hemiplegia of left side (paralysis or weakness on one side of the body), diabetes and a history of falls.Review of the MDS dated [DATE], Section GG: Functional Abilities, Section GG0170 indicated Resident R1was dependent on staff for bed to chair transfer.Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance - hemiplegia affecting left side dated 6/18/24, requires resident to have an assist of two for transfers and lying to sitting on the side of the bed requires an assist of two helpers.Review of progress note dated 9/30/25, at 4:00 p.m. indicated Resident R1 had fallen out of bed and complained of left shoulder pain. Left shoulder x-ray was ordered and the resident was given Tylenol for pain to the left shoulder.Review of facility incident report dated 9/30/25, indicated CNA was attempting to transfer resident and she slid out of bed.Review of an x-ray report dated 10/1/25, indicated Resident R1 sustained a fracture to the left humerus.Review of CNA Employee E1's statement written on 9/30/25 indicated I sat resident up at the edge of the bed waiting for help, and the force of sitting her up made her slide forward and she hit her shoulder on something while sliding and she ended up on the floor.A review of CNA Employee E1's personnel file indicated a hire date of 9/10/25, and employee E1 received competencies in the ability to confirm appropriate transfer methods per the plan of care, assisting with transfers, and transferring residents safely.Review of the facility submitted report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/1/25, indicated Employee E1 attempted to transfer Resident R1 without an assist of 2 persons as required and was terminated.During interviews on 10/22/25 from 1:10 p.m. to 2:45 p.m., revealed the following:CNA Employee E2 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E3 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E4 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E6 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E7 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E8 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E9 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E11 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E13 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.CNA Employee E12 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E13 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E14 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E15 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E16 confirmed the use of orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E20 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E21 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/3/25.During interviews on 10/22/25, (CNA Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, and E12), confirmed they received point of care training on 10/3/25, for bed mobility and safe transfers.During review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility failed to protect residents from neglect for one of six residents (Resident R1). The facility has demonstrated compliance with the regulations since 10/16/25During an interview on 10/23/25, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a left humerus (upper arm) fracture for one of six residents (Resident R1). This was identified as past noncompliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)( e)(1) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (c )(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on review of facility policies, facility provided documents, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for two of three residents reviewed (Resident R190 and R400). Findings include: Review of the facility policy Abuse, Neglect and Misappropriation dated 4/18/24, with a previous review date of 8/21/23, indicated that the facility will provide resident centered care and prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property. Neglect is identified as the failure of the facility or it's employees to provide care or services to a resident that is necessary to avid physical harm, pain, mental anguish or emotional distress. Review of the facility provided documentation dated 8/27/24, indicated that Resident 190's room mate, Resident R119 had stated that Resident R 190 had not been provided care from Nurse Aide Employee E2 on 8/26/24, during the 7:00 a.m., through 3:00 p.m shift. Review of statements obtained during the investigation, Resident R119 was interviewed on 8/26/24 at 4:00 p.m., and stated that she did not believe her room mate received care on the 7-3 shift. Statements from other residents were not provided. The facility investigation indicated they were unable to determine whether the neglect had actually occurred. The investigation indicated that staff were re- educated on abuse. The documentation related to the training did not include Nurse Aide Employee E2. Review of the clinical record indicated that Resident R190 had been admitted to the facility on [DATE], with diagnoses which included encephalopathy, dementia, bacteriuria(bacteria in urine), heart failure, and heart disease. A MDS dated [DATE], indicated the diagnoses remained current. Resident R190 was in isolation due to positive COVID. Review of the facility Documentation Survey Report (the electronic clinical document indicating care provided or the resident) dated August 2024 did not include documentation indicating care had been provided on 8/26/24, until approximately 9:00 p.m., including ADL care, incontinence care, and a bath/ shower. Review of the facility provided documentation dated 10/14/24, indicated that Resident R400 reported to social services that Licensed Practical Nurse (LPN) Employee E9 had stretched out her hand causing discomfort when looking for a pill in her hand. Review of the statement written and signed by Resident R400 stated on 10/13/24, LPN Employee E9 was asked if Resident R400's pills were in her food, LPN Employee E9 responded that they have to watch her take her pills. LPN Employee E9 handed her the cup and then after Resident R400 took the meds in the cup, LPN Employee E9 stretched out Resident R400's pointer finger and thumb of her right hand and when Resident R400 said stop, it was painful , it went on as Resident R400 swallowed her pills. Review of the statement from LPN Employee E9 indicated she asked Resident R400 to open her hand and found Bupropion pill and picked up the pill and put it in Resident R400's mouth and watched her swallow it. Review of the clinical record indicated Resident R400 was admitted to the facility on [DATE], with diagnoses which included Diabetes, lung disease, acute pancreatitis, kidney failure, falls and depression. Resident R400 had been found in her apartment by the apartment manager unresponsive. Review of he clinical record indicated that on 10/22/24, Resident R400 was discharged back to her apartment with ACCESS transport to be followed by AHN Home health. During an interview on 11/14/24, at 9:45 a.m., the Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for two of three residents reviewed (Resident R190 and R400). 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate and/or report potential abuse and/or neglect for four of five residents (Resident R4, R13, R57 and R116). Findings include: Review of the facility policy Abuse, Neglect and Misappropriation, dated 4/18/24, with a previous review date of 8/21/23, indicated that the facility will provide resident centered care and the intent of the facility is to prevent the abuse, mistreatment or neglect of residents. The accurate and timely identification of any event which would place our residents at risk for potential abuse is the primary concern. Each occurrence of resident incident, bruise, etc., will be identified and reported to the supervisor and investigated immediately. In the event a situation is identified as abuse, neglect, etc., an investigation by the executive leadership will follow. Review of a grievance placed by Resident R4's mother dated 10/28/24, indicated that Resident R4 was sent to an appointment not appropriately dressed and with a bib on. Review of the facility action form dated 10/29/24, indicated that an investigation identified staff had not freshened up Resident R4 before leaving for the appointment. Review of a grievance placed by Resident R13's daughter dated 9/20/24, indicated that Resident R13 was not provided care on 9/17/24. Review of the facility action form dated 9/23/24, indicated that the assigned nurse aide (NA) was caring for another resident and that Resident R13 was provided care by another NA. Review of a grievance placed by Resident R57 dated 6/22/24, indicated staff would not get him out of bed because they had no lift pad. Review of the facility action form dated 6/26/24, indicated that the facility has plenty of lift pads and staff were re-educated in regards to checking laundry other units and in central supply. Review of a grievance placed by Resident R57 dated 8/7/24, indicated resident identified poor customer service. The facility did not indicate what poor service was identified. Review of he facility action form dated 8/7/24, indicated that the facility verbally discussed poor customer service with staff and Relias training was available. Review of a grievance placed by Resident R116 dated 10/21/24, indicated that he had asked his aide to put him into bed about 2:00 p.m., the NA stated she would, but never returned. Review of the facility action form dated 10/21/24, indicated his NA went on break and the nurse put him back into bed. Not his assigned NA. Review of Resident R116's MDS dated [DATE], indicated he was a transfer of two with the hoyer lift. Review of Resident R116's plan of care indicated Resident R116 is a transfer of two with a total lift. During an interview on 11//13/24, at 1:58 p.m., the DON confirmed that the facility failed to identify and/or investigate and/or report potential abuse and/or neglect for four of five residents (Resident R4, R13, R57 and R116). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management. 28 Pa. Code: 211. 10(d) Resident care policies. 28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for three of six residents reviewed (Residents R6, R20, and R72), and failed to document results accurately in blood glucose summary and medication administration record for three of five residents (Residents R52, R69, and R91). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Blood Glucose Point of Care Testing reviewed 4/18/24, indicated the importance of ongoing glucose monitoring is necessary to detect extremes of high and low blood glucose levels to evaluate the effectiveness of the treatment plan. Review of the facility policy Notification of Change in Condition reviewed 4/18/24, revealed the facility is required to have processed in place for notifications of acute changes such as cardio/respiratory failure, choking, and poor glycemic control, falls, onset of delirium, and falls with head injuries or fractures. The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. Review of the facility policy Clinical Documentation Standards reviewed 4/18/24, indicated nurses will follow basic standard of practice for documentation including, but not limited to providing a timely and accurate account of resident information in the medical record. Document accurately and truthfully to the best of his/her knowledge. Document the status of the resident including changes. Review of the clinical record revealed Resident R6 was readmitted to the facility on [DATE], with diagnoses that included diabetes, heart failure (progressive heart disease that affects pumping action of the heart muscles), and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/23/24, indicated the diagnoses remain current. Review of a physician order dated 2/13/24, revealed hypoglycemia protocol - able to swallow: follow 15/15 rule. Give 15 grams of fast acting carbohydrate for blood sugar less that 70. May repeat in 15 minutes. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 7/2/24, at 7:34 a.m. CBG was noted to be 60. On 10/31/24, at 7:48 a.m. CBG was noted to be 60. Review of the care plan dated 7/21/22, included administer insulin per medical provider;s orders. Observe for effectiveness and side effects. Report abnormal findings to medical provider. Observe for signs and symptoms of hypoglycemia. Obtain blood sugars per orders. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow physician's orders, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R20 was readmitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of a physician's order dated 5/20/24, indicated to monitor for signs and symptoms of hypo/hyperglycemia. Review of the clinical record eMAR revealed that the resident's CBG's were as follows: On 11/2/24, at 8:42 a.m. CBG was noted to be 64. Review of the care plan dated 3/28/23, included administer medications per medical provider;s orders. Observe for effectiveness and side effects. Report abnormal findings to medical provider. Observe for signs and symptoms of hypoglycemia. Obtain blood sugars per orders. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow physician's orders, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record revealed Resident R72 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia, and repeated falls. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of a physician's order dated 8/30/24, indicated to inject Novolog insulin (fast-acting) per sliding scale before meals. If blood sugar is 341 - 999, inject six units, call MD. Further review of a physician's order dated 9/2/24, indicated to monitor for signs and symptoms of hypo/hyperglycemia. Review of the clinical record eMAR revealed that the resident's CBG's were as follows: On 10/16/24, at 4:25 p.m. CBG was noted to be 359. Review of the care plan dated 3/18/21, included administer medications per medical provider;s orders. Observe for effectiveness and side effects. Report abnormal findings to medical provider. Observe for signs and symptoms of hyperglycemia. Obtain blood sugars per orders. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow physician's orders, and the physician was not notified of abnormal results on the above listed dates. During an interview on 11/13/24, at 12:34 p.m. Licensed Practical Nurse (LPN) Employee E6 stated for blood sugars below 60, they would give juice and snacks, call the doctor, and recheck the blood sugar per doctor's orders. If blood sugar was elevated, they would check the physician's orders for sliding scale parameters. Follow the orders, recheck the blood glucose in 20 minutes and document in the nurses notes. During an interview on 11/13/24, at 12:37 p.m. LPN Employee E3 stated any blood sugar under 70, they would for sure call the doctor, give juice and snack, assess the resident and recheck the blood sugar in 45 minutes. If the blood glucose was elevated, usually around 350 - 400, they would check the physician orders for sliding scale parameters. Call the doctor, and document in the eMAR. During an interview on 11/13/24, at 12:42 p.m. LPN Employee E7 stated anything below 70 or above 400, they would call the doctor. They would follow the received orders and document in the eMAR and nurses notes. During an interview on 11/13/24, at 12:46 p.m. Registered Nurse (RN) Employee E8 stated if blood sugar was between 70-80, they would give juice or snack. They would assess the resident. If blood sugar was greater than 400, they would check the orders for parameters, and call the doctor. They would document in the nurses notes. During an interview on 11/15/24, at 11:00 a.m. the Director of Nursing confirmed the facility failed to document hypo-/hyperglycemic episodes, failed to follow physician orders, and failed to notify the MD of changes in condition for Residents R6, R20, and R72. Review of the clinical record revealed Resident R52 was admitted to the facility on [DATE], with diagnoses that included diabetes, bilateral below knee amputations, chronic kidney disease(The kidneys filter waste and excess fluid from the blood, as the kidneys fail they no longer filter waste). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 10/4/24, revealed Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin, 3 units with meals, if blood sugar less than 120 to hold and notify physician. Review of the clinical record eMAR revealed that the resident's CBG's were as follows: On 11/1/24, at 8:01 a.m. CBG was noted to be 81. On 11/12/24, at 7:56 a.m. CBG was noted to be 90. On 11/13/24, at 7:36 a.m. CBG was noted to be 92. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 9/8/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Review of the clinical record revealed Resident R69 was admitted to the facility on [DATE], with diagnoses that included diabetes, obesity, and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 10/26/23, revealed Novolog insulin sliding scale with result less than 130 to be held. A physician order dated 8/19/22, revealed an order for blood sugars to be checked in early AM every day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 11/13/24, No results documented for AM glucose or insulin dosage On 11/3/24, 10:57 p.m. CBG was noted to be 6.0 On 11/2/24, 2:51 a.m. CBG was noted to be 62. On 8/30/24, 6:38 a.m. CBG was noted to be 68. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 9/27/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Review of the clinical record revealed Resident R91 was admitted to the facility on [DATE], with diagnoses that included diabetes, dysphagia (difficulty swallowing), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 2/13/24, indicated to inject Aspart insulin (fast acting insulin) as per sliding scale with blood sugar results between 70-140 insulin to be held. On 11/13/24 Insulin Aspart inject 4 units subcutaneously with meals for DM hold if blood sugar less than 120 or skipping meals. Review of the clinical record electronic Medication Administration Record (eMAR) and blood glucose summary(BGS) revealed that the resident's CBG's were inconsistent and documented as follows: On 11/9/24, at 11:13 a.m. CBG was noted to be 82 in BGS summary and 106 in eMAR. On 11/9/24, at 9:47 p.m. CBG was noted to be 74 in BGS summary and 174 in eMAR. On 11/10/24, at 8:17 a.m. CBG was noted to be 115 in BGS summary and 137 in eMAR. On 11/10/24, at 12:05 p.m. CBG was noted to be 115 in BGS summary and 143 in eMAR. On 11/11/24, at 11:01 a.m. CBG was noted to be 90 in BGS summary and 171 in eMAR. On 11/13/24 there is no documentation of a BGS in either the summary or eMAR or that insulin was given. Review of Resident's eMAR and clinical progress notes indicated the resident received insulin for documented blood sugar results and as per order with no interventions required. Review of the care plan dated 9/3/24, included diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, monitor/document/report to MD as needed signs and symptoms of hypo-/hyperglycemia. During an interview on 11/13/24, at approximately 8:50 a.m. Licensed Practical Nurse (LPN) Employee E5 stated for residents without diabetic parameters they would notify the doctor for blood glucose levels under 70, assess if unresponsive give Glucagon (medicine to increase blood sugar), if responsive give glucose gel, or over 400, give insulin per order, call doctor and document in progress notes. LPN Employee E5 stated that if order for insulin states to hold insulin for levels less than 120 would hold the insulin, document that it was not given and notify the physician. During an interview on 11/14/24, at 11:30 a.m. the Director of Nursing (DON) confirmed the facility failed to provide timely and complete communication to a physician when there was a change in condition. The DON confirmed the facility failed to recognize, assist and document the treatment of complications commonly associated with diabetes. Documentation should reflect the carefully assessed diabetic resident for vital signs, skin (color, temperature, dryness, sweating, irritation or abrasions), percentage of meals consumed, mood changes, pain, restlessness, numbness/tingling, results of any fingerstick, interventions to stabilize the blood glucose levels and response, notification of physician of unstable or significant variances from base line per physician order. The DON confirmed that documentation should be checked for accuracy in results so that no confusion will occur in the administration of medication. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, manufacturers recommendations,resident interviews, clinical records, and staff interviews, it was determined that the facility failed to make certain medications were administered as ordered by the physician for two of five residents (Residents R52 and R69) and failed to make certain that residents are free of significant medication errors for two of three residents observed (Resident R301, and R24.) Findings include: A review of facility policy Medication Administration dated 8/21/23, and 4/18/24, indicated facility staff should comply with facility policy to provide guidance of general medication administration to be provided by personnel recognized as legally able to administer medications only as prescribed by the provider. Observe the five rights in giving medication: (i) the right resident, (ii) the right time, (iii) the right medicine, (iv) the right dose, (v) the right route. A review of the manufacturers guideline for glargine insulin (Lantus - long-acting type of insulin that works slowly, over about 24 hours) Solostar prefilled pen, November 2000, specified to perform a safety test before each injection. Select a dose of two units, hold the pen with the needle pointing upwards, gently tap the reservoir to remove air bubbles, press the injection button all the way in and check if insulin comes out of the needle tip. A review of the manufacturers guideline for a fast-acting insulin (Novolog/Humalog - starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for two to four hours) Flextouch prefilled pen indicated priming the pen by turning the dose selector to select two units, hold the pen with the tip facing upwards, gently tap the top of the reservoir to remove air bubbles, press the dose button until the dose counter returns to zero, a drop of insulin should be seen at the needle tip. A review of the clinical record indicated that Resident R52 was admitted to the facility on [DATE], with diagnoses that included diabetes, bilateral below knee amputations, chronic kidney disease (The kidneys filter waste and excess fluid from the blood, as the kidneys fail they no longer filter waste). A review of a physician order dated 10/4/24, indicated to check blood sugar (BS) before meals and give Lispro flex pen (short-acting insulin) inject 3 units subcutaneously with meals, hold if blood sugar is less than 120. A review of the medication administration record (MAR) dated November 2024 indicated that Resident R52 received insulin on 11/1/24, 11/12/24, and 11/13/24 against order to hold if blood sugar is less than 120. A review of the clinical record, blood glucose summary, showed that on 11/1/24 at 8:01 a.m., BS was 81, 11/12/24 at 7:56 a.m , BS was 90, and on 11/13/24 at 7:36 a.m , BS was 92. A review of the clinical record indicated that Resident R69 was admitted to the facility on [DATE], with diagnoses that included diabetes, obesity, dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of a physician order dated 8/19/22, indicated to check BS early AM every day. On 10/26/23 an order for Novolog insulin (short-acting insulin) to be given per sliding scale, if BS result less than 130 to hold. A review of the MAR dated November 2024, indicated that Resident R69 did not have a documented result on 11/13/24, or that insulin was given as ordered. A review of the clinical record indicated that Resident R69 blood sugar summary showed a result on 11/13/24, at 8:20 a.m to be 80, which was not carried over to the eMAR and no documentation was made to hold the insulin. During an interview on 11/14/24 at 11:30 a.m., the Director of Nursing confirmed the above findings and that the facility failed to make certain medications were administered as ordered by the physician for Residents R52 and R69. A review of a clinical record indicated Resident R301 was admitted to the facility on [DATE], with diagnoses that included diabetes, repeated falls, and muscle weakness. A review of a physician orders dated 11/6/24, indicated to inject insulin Lispro (fast-acting) per sliding scale. If blood glucose was between 141 - 180, give two units of insulin. Further review of a physician order dated 11/6/24, indicated to inject insulin glargine 18 units one time a day. During an observation on 11/13/24, at 8:42 a.m. of Resident R301's medication administration Licensed Practical Nurse (LPN) Employee E4 indicated Resident R301's blood sugar was 158. LPN Employee E4 set the Lispro insulin pen to two units and set the glargine insulin pen to 18 units, failed to prime either insulin pen and administered the medications. A review of a clinical record indicated Resident R24 was readmitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. A review of a physician order dated 9/2/24, indicated to inject insulin Aspart (short-acting) per sliding scale before meals. If blood glucose was between 181 - 220, give four units of insulin. During an observation on 11/13/24, at 12:18 p.m. of Resident R24's medication administration LPN Employee E3 indicated Resident R24 ' s blood sugar was 182, set the insulin pen to four units of insulin, failed to prime the pen, and administered the medication. During an interview on 11/13/24, at 12:40 p.m. LPN Employee E3 confirmed she failed to prime the insulin pen prior to administering the medication. During an interview on 11/13/24, at 1:15 p.m. the Director of Nursing confirmed that facility failed to administer the correct dose of insulin by failing to prime the insulin pen needle for Residents R301, and R24. 28 Pa. Code 211.12 (c)(1)(3) Nursing Services. 28 Pa. Code 201.29 (j) Resident rights. 28 Pa Code: 201.18 (b)(1)(3) Management. 28 Pa Code: 211.10 (d) Resident care policies.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change. Findings include: Review of the facility policy Skin Care & Wound Management Overview reviewed 4/18/24, indicated each resident is evaluated upon admission and weekly thereafter for changes in skin condition. Application of treatment protocols based on clinical best practice standards for promoting wound healing. Review of the facility policy Infection Control Program reviewed 4/18/24, indicated residents have a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. Policies, procedures, and aseptic practices are followed by employees in performing procedures and in disinfection of equipment. During an observation on 9/19/24, at 1:30 p.m. with Licensed Practical Nurse (LPN) Employee E1 the following occurred during a dressing change: -supplies gathered, scissors removed from treatment cart, scissors were not cleansed -table cleansed with wipe, allowed to dry, and towel placed as barrier, supplies placed on barrier -ABHS (alcohol-based hand sanitizer) used, gloves donned -scissors used to cut tape to size, initials/date wrote on tape , scissors again ot cleansed prior to use -soiled gloves removed, ABHS used, clean gloved donned LEFT LEG wounds: -soiled dressing removed with scissors, these were again not cleansed prior to use. -drape placed under leg -soiled gloves removed, ABHS used, clean gloves donned -wounds cleansed with wound cleanser spray, dried with gauze 4x4's -Vaseline dressing opened and cut to size with scissors that remained uncleaned -dressing placed on wounds -ABD pad placed over wound, wrapped with cling gauze -gauze cut with scissors, same scissors, not cleansed -cling gauze secured with dated/initialed tape -gloves removed, ABHS used, clean gloves donned RIGHT LEG wounds: -scissors used to removed soiled dressing, same scissors used, remained not cleansed -towel placed under right leg -cleansed with wound cleanser spray, dried with gauze 4x4 -soiled gloves removed, ABHS used, clean gloves donned -scissors used to cut Vaseline dressing to wound sizes, same scissors remained not cleansed -ABD pad cut in half with scissors and placed over dressings. scissors continue to remain uncleaned -wrapped with cling gauze, gauze cut to shorten with the continued use of uncleaned scissors -tape placed to secure SACRAL wound: -soiled gloves removed, ABHS used, clean gloves donned -cleansed with wound spray and dried with gauze 4x4's -hydrophilic wound dressing cream placed on gloved hand and wiped onto buttocks -soiled gloves removed, ABHS used, clean gloves donned -zinc oxide ointment placed on ABD pad and placed on buttocks -soiled supplies gathered in bag and placed in soiled utility -hands washed with soap. During an interview on 11/14/24, at 2:15 p.m. LPN Employee E1 confirmed she failed to cleanse the scissors in between soiled and clean items. During an interview on 11/14/24, at 2:25 p.m. the Director of Nursing confirmed the facility failed to prevent cross contamination during a dressing change, 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, resident interviews, clinical record reviews, family interview, and staff interviews it was determined the facility failed to ensure the resident's right to voice grievances and to act promptly in the resolution of grievances for two of two residents (Resident R55 and Resident R163). Findings include: A review of the facility policy Resident Grievance last reviewed 6/26/23, indicated a grievance is an official statement of a complaint over something believed to be wrong or unfair. Complaint is defined as knowledge someone believes they have been wronged or treated unfairly. The policy indicated the facility will provide resident centered care that meets psychosocial, physical, and emotional needs and concerns of the residents. The grievance official will complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Official. The grievance review will be completed in a reasonable time frame. Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the date the grievance was received, a summary of the statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident(s) concerns, a statement as to whether the grievance was confirmed or not, whether any corrective action was or will be taken, and the date the written decision was issued. Residents will be notified, and the grievance official will meet with the resident and inform the resident of the investigation and how the resident's grievance will be resolved. A copy of the written grievance decision will be provided to the resident, upon request. The facility's Social Service Director (SSD) is the Grievance Offical, SSD/Grievance Official Employee E10. Review of Resident R55's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD - chronic lung disease that leads to difficulty in breathing, shortness of breath and wheezing), diabetes, asthma, chronic kidney disease and major depression-single episode (an individual experiencing only one major depressive episode in their lifetime, with no history of previous depressive episodes.) Review of Resident R55's current physician orders dated 1/19/24, included Mirtazapine for depression and Venlafaxine for depression. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of needs) dated 12/7/23, indicated the diagnoses remained current. The Brief Interview for Mental Status (BIMS - a screening tool to determine cognition) recorded a score of 15, indicating the resident is cognitively intact. Review of Resident R55's care plan dated 11/20/23, addressed care needs relating to depression with interventions of psychological counseling, suicidal ideations resulting from the loss of her husband with interventions of behavioral health counseling, and anxiety with interventions of behavioral health counseling. Review of Resident R55's psychological consultant note dated 1/10/24, documented while she was out [at] hospital, apparently some items were stolen from her room, including a necklace that had great sentimental value as it was a gift from her husband almost [AGE] years ago. Discussed her frustration in efforts to discuss this issue with nursing and administrative staff. During an interview on 1/17/24, at 1:45 p.m. Resident R55 disclosed her diamond solitaire necklace went missing when she was being transferred to the hospital in early January, 2024. Resident R55 stated she had reported the missing item to several staff members and has not heard any developments from an investigation for the lost item from any staff. During an interview on 1/18/24, at 4:19 p.m. Resident Family RF1 informed that Resident R55 was transferred to the hospital on 12/28/23. Resident Family RF1 reported meeting Resident R55 at the hospital and the only jewelry items the resident had on were a silver bracelet and a watch and was not wearing a 16 gold chain with diamond solitaire pendant. Resident R55 returned from the hospital to the facility late in the evening on 1/6/24. Resident Family RF1 visited the the resident on 1/7/24 and reported the resident's room was a mess. Resident Family RF1 spoke with Registered Nurse Unit Manager (RNUM) Employee E9 about the missing necklace. Resident Family RF1 reported phoning the Emergency Medical Service that transported Resident R55 to the hospital, and they reported the only jewelry the resident had on was a watch and silver bracelet. Resident Family RF1 informed the resident did not have the dexterity to remove the necklace herself and the necklace was sentimental as it was given to Resident R55 by her late husband. Resident Family RF1 ask RNUM Employee E9 if she could investigate the loss further. Resident Family RF1 also spoke to SSD/Grievance Official Employee E10 and Social Worker (SW) Employee E11 and told Resident Family RF1 to file a police report. During an interview on 1/18/24, at 4:33 p.m. SSD/Grievance Official Employee E10 and SW Employee E11 confirmed a grievance form was not filed on behalf of Resident R55 for the missing necklace. During an interview on 1/18/24, at 5:25 p.m. RNUM Employee E9 confirmed seeing Resident R55 wearing the necklace in the facility and that Resident R55 did not have the dexterity to remove the necklace. RNUM Employee E9 reported she placed a call to the hospital about the necklace, and the hospital had no knowledge of it. RNUM Employee E9 also reported the missing necklace to SW Employee E11. Review of Resident R163's record indicated the resident was admitted to the facility on [DATE]. Diagnoses included compression fracture of vertebrae (small bones of the backbone) with surgical aftercare, diabetes, cirrhosis of the liver, pressure ulcer of the sacral region (above the tailbone region), muscle weakness and difficulty in walking. Review of Resident R163's current physician orders dated 1/19/24, included pressure reducing/relieving mattress, physical therapy, occupational therapy, Hoyer lift (a device used to transfer persons with serious mobility issues) for all transfers, and wound care. Review of Resident R163's MDS dated [DATE], indicated the diagnoses remained current. The BIMS recorded a score of 15, indicating the resident was cognitively intact. Review of Resident R163's care plan dated 12/22/23, addressed a self care deficit with interventions to include a Hoyer lift for transfers, and compression fracture of the vertebrae with interventions to include assistance with activites of daily living (ADLs - bathing/showering, dressing, eating, mobility, and personal hygiene and grooming). Review of Resident R163's record indicated they had a room change on 11/10/23. During an interview on 1/16/24, at 1:30 p.m. Resident R163 reported their green blanket had been missing since their room change in November, 2023. The resident informed they told everyone about it - nursing staff and social workers, and has not heard any developments from an investigation for the lost item from any staff. During an interview on 1/18/24, at 5:58 p.m. SSD/Grievance Official Employee E10 confirmed a grievance form was not filed on behalf of Resident R163 for the missing green blanket. During an interview on 1/18/24, at 6:00 p.m. the SSD/Grievance Official Employee E10 confirmed the facility failed to ensure the resident right to voice grievances and the facility failed to act promptly in the resolution of grievances. 28 Pa. Code: 201.29(i)(j) Resident Rights. 28 Pa. Code: 201.18(e)(4) Management.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for six of eight residents reviewed (Residents R34, R69, R70, R97, R106 and R134). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Blood Glucose Point of Care Testing reviewed 6/26/23, indicated the facility would provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the resident. Step G of the procedure indicated to record the results and contact the provider per physician ' s orders if out of range. Review of the facility policy Notification of Change in Condition reviewed 6/26/23, indicated the facility must inform the resident, consult with the resident's physician and the resident's representative when there is a change requiring such notification. The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. Review of the clinical record indicated Resident R34 was readmitted to the facility on [DATE], with diagnoses that included diabetes, cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), and high blood pressure. Review of Resident R34's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/12/23, indicated the diagnoses remain current. Review of a physician orders dated 8/24/23 and 11/18/23, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, if less than 70, notify doctor, if greater that 400, notify doctor. Further review of physician orders dated 10/11/23, indicated to give Glucose gel 40% by mouth if blood sugar less than 70 recheck blood sugar every 15 minutes and repeat is blood sugar remains less than 70. Hypoglycemia Protocol: Continue to check glucose every 15 minutes until blood sugar is over 80. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 1/12/24, at 6:28 p.m. CBG was noted to be 44. On 12/29/23, at 9:05 p.m. CBG was noted to be 487. On 11/9/23, at 12:52 p.m. CBG was noted to be 410. Review of Resident R34's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow facility protocol, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan revised 2/2/23, indicated to administer medications as ordered by physician, report abnormal findings to medical provider. Observe for signs of hyperglycemia and hypoglycemia. Obtain blood sugars per orders, report abnormal findings to medical provider. Review of a clinical record indicated Resident R69 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and sepsis (infection of the blood stream). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 10/24/23, indicated to inject Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale with meals. If blood sugar is 0-70 initiate hypoglycemia protocol and call doctor. If blood sugar over 450 give 14 units and call doctor. A physician order dated 11/22/23 and 11/29/23, indicated to inject Novolog insulin per sliding scale; notify doctor is less than 70 or greater than 340. Review of Resident R69's eMAR revealed that the resident's CBG's were as follows: On 12/11/23, at 6:04 p.m. CBG was noted to be 62. On 11/15/23, at 5:48 a.m. CBG was noted to be 405. On 11/13/23, at 12:42 p.m. CBG was noted to be 437. On 11/10/23, at 1:28 p.m. CBG was noted to be 419. On 11/3/23, at 6:00 a.m. CBG was noted to be 430. A review of Resident R69's eMAR and clinical progress notes indicated the resident was not assessed for hypo/hyperglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R69's care plan dated 1/14/23, indicated to administer insulin injections per orders. Observe for signs and symptoms of hypo/hyperglycemia. Obtain blood sugars per orders. Review of the clinical record indicated Resident R70 was readmitted to the facility on [DATE], with diagnoses that included diabetes, heart failure (progressive heart disease that affects pumping action of the heart muscles), and difficulty in walking. Review of Resident R70's MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 3/7/23, indicated to inject Novolog insulin per sliding scale. If less than 70 initiate hypoglycemia protocol and call doctor, and if blood sugar is 401-600 inject 20 units and call doctor. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 10/12/23, at 6:25 a.m. CBG was noted to be 417. On 10/8/23, at 12:38 p.m. CBG was noted to be 414. On 10/4/23, at 4:30 p.m. CBG was noted to be 471. On 10/3/23, at 11:45 p.m. CBG was noted to be 404. Review of Resident R70's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/9/21, indicated observe for signs and symptoms of hyper/hypoglycemia. Administer medications per medical provider's orders. Report abnormal findings to medical provider. Obtain blood sugars per orders. Review of the clinical record indicated Resident R97 was admitted to the facility on [DATE], with diagnoses that included diabetes, muscle weakness, and high blood pressure. Review of Resident R97's MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 10/25/23, indicated to inject Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale before meals. If blood sugar is over 400 give 20 units and notify doctor. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 11/13/23, at 12:47 p.m. CBG was noted to be 477. Review of a progress note dated 11/13/23, at 12:47 p.m. revealed the Licensed Practical Nurse (LPN) gave 16 units. Review of Resident R97's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates and failed to follow the physician ' s order. Review of the care plan dated 11/2/23, indicated to observe for signs and symptoms of hyper-/hypoglycemia. Administer insulin injections per orders. Administer medication per medical provider's order. Obtain blood sugars per orders. Review of the clinical record indicated Resident R106 was readmitted to the facility on [DATE], with diagnoses that included diabetes, anxiety, and high blood pressure. Review of Resident R106's MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 12/28/23, indicated to inject Novolog insulin per sliding scale. If blood sugar less than 70 notify doctor, and if greater than 400, give 20 units and notify the doctor. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 1/5/24, at 10:12 p.m. CBG was noted to be 403. On 9/17/23, at 12:43 p.m. CBG was noted to be 69. Review of Resident R106's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow physician's order, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R134 was readmitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and muscle weakness. Review of Resident R70's MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 10/11/23, indicated to give one tube of glucose gel, recheck blood sugar every 15 minutes and repeat treatment is blood sugar remains under 70. Administer 1 mg glucagon as needed for blood sugar less than 70. Call provider after first dose. A physician order dated 9/11/23, indicated to inject Lantus (long-acting type of insulin that works slowly, over about 24 hours) 18 units in the evening. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 11/23/23, at 8:37 a.m. CBG was noted to be 62. On 10/11/23, at 12:52 p.m. CBG was noted to be 45. On 10/11/23, a t 12:05 p.m. CBG was noted to be 45. On 10/11/23, at 8:35 a.m. CBG was noted to be 63. Review of Resident R134's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/9/21, indicated observe for signs and symptoms of hyper/hypoglycemia. Administer medications per medical provider's orders. Report abnormal findings to medical provider. Obtain blood sugars per orders. During an interview on 1/17/24, at 1:50 p.m. LPN Employee E8 stated for blood sugar under 70, they would notify the doctor and provide a snack. If the blood sugar was over 200, they would check the orders for parameters, and call the doctor accordingly. During an interview on 1/17/24, at 1:53 p.m. LPN Employee E7 stated for blood sugars over 400, they would check the parameters, call the provider or on-call service. If the blood sugar was less than 70 they would offer a snack, call the doctor, and recheck in one hour. During an interview on 1/17/24, at 2:00 p.m. LPN Employee E6 stated for blood sugars over 300, they would check the orders for parameters, give the ordered insulin, and call the doctor or on-call service. If the blood sugar was less than 70, they would check the orders, tell the supervisor. During an interview on 1/17/24, at 2:08 p.m. LPN Employee E5 stated for blood sugars less than 70 she would give juice. notify the supervisor and recheck in two hours. For blood sugars over 230, she would call the doctor to get orders, notify the supervisor, and recheck in one to two hours. During an interview on 1/17/24, at 2:10 a.m. LPN Employee E4 stated for blood sugars under 70 she would give juice, recheck in 10-15 minutes, and call the doctor. For blood glucose over 300 without ordered parameters, she would call the doctor, monitor the resident, and document in the progress notes. During an interview on 1/17/24, at 10:20 a.m. LPN Employee E3 stated for blood sugars less than 70, she would call the provider to get orders for glucose gel and monitor the resident for signs and symptoms of hypoglycemia. If the blood sugar was over 400, she would call the provider, recheck in 30 minutes, notify the supervisor and Director of Nursing, and document in the progress notes. During an interview on 1/18/24, at 3:00 p.m. the Director of Nursing (DON) confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R34, R69, R70, R97, R106, and R134. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for food borne illness during trayline service in the Main kitchen. Findings include: During tray line observation on 1/16/24, from 11:30 a.m. through 12:00 p.m. the following was observed: During trayline service Dietary Cook Employee E1 left trayline to obtain a sandwich from the refrigerator with gloves, returned to the tray line and placed cheese on hamburgers, left trayline and obtained buns and opened buns from plastic wrapping and placed buns on plate and placed lettuce and tomatoes on buns, with no handwashing and glove change between tasks. During an interview on 1/16/24, at 12:00 p.m. Dietary Manager Employee E2 confirmed that the facility failed to maintain practices to prevent the potential for food borne illness in the Main kitchen. 28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy, observation and staff interviews, it was determined the facility failed to provide privacy and confidentiality of resident health information on one of two electronic health records systems (B2 Unit). Findings include: Review of facility policy titled Routine Resident Care last reviewed 6/23/23, informed licensed staff will include the following services based upon their scope of practice, but not limited to, maintain confidentiality of resident information at all times. During an observation on 1/16/24, at 12:34 p.m. the electronic health record system on the medication cart on the B2 Unit was open and displayed confidential resident information. During an interview on 1/16/24, at 12:36 p.m. Graduate Practical Nurse Employee E12 confirmed the electronic health record system on the medication cart on the B2 Unit was open and displayed confidential resident information. During an interview on 1/17/24, at 12:00 p.m. Registered Nurse Unit Manager Employee E9 confirmed the facility failed to facility failed to provide privacy and confidentiality of resident health information. 28 Pa. Code: 211.5(b) Clinical records. 28 Pa. Code: 201.29(j) Resident rights.

Based on a review of facility policy, resident record review, and staff interview, it was determined the facility failed to review and revise a resident care plan to reflect current status and needs for one of eight residents (Resident R47). Findings include: Review of facility policy titled Plan of Care Overview last reviewed 6/23/23, informed the purpose of this policy the Plan of Care, also Care Plan, is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. The facility will provide an Registered Nurse assessment of the resident as an on-going, periodic review that provides the foundation for resident focused care and the care planning process. The facility will review care plans quarterly and/or with significant changes of care. Review of Resident R47's record indicated the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, dementia, schizophrenia (a serious mental disorder in which a person interprets reality abnormally), cognitive communication deficit (difficulty in thinking and use of language), dysphagia (difficulty in swallowing liquids and food), depression, and has a need for personal care. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of needs) dated 11/20/23, indicated the diagnoses remained current. Review of Resident R47's current physician orders dated 12/1/23, included staff to feed meals effective 12/17/23, and a dysphagia pureed texture meal effective 12/18/23. Review of Resident R47's care plan dated 12/30/23, addressed nutritional problem with the intervention of staff to provide assistance with meals, and an activities of daily living deficit with the intervention of staff to assist with meals. Review of Resident R47's meal ticket for the lunch meal on 1/17/24, included Staff Feed and a pureed meal of roast pork, bread, brown gravy, green beans, mashed potatoes, and lemon cake. During an observation on 1/17/24 at 12:40 p.m. through 12:59 p.m. Resident R47 had their lunch meal, uncovered and on the tray table in front of them. Staff were not present to feed the resident. The resident was observed multiple times attempting to put their finger in the food and placing their finger to their lips. During an interview on 1/17/24, at 4:40 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E13 informed order reports are reviewed every morning and care plans are updated accordingly. During an interview on 1/17/24, at 4:45 p.m. the Registered Nurse Assessment Coordinator confirmed the facility failed to review and revise a resident care plan to reflect current status and needs. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policy, resident record reviews, resident interviews, observations, and staff interviews, it was determined the facility failed to ensure that a resident who is unable to carry out activities of daily living in eating receives the necessary services to maintain good nutrition for one of four residents (Resident R47). Findings Include: Review of facility policy titled Routine Resident Care last reviewed 6/23/23, informed it is the policy of this facility to provide resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and to provide routine daily care by a certified nursing assistant including but not limited to maintaining adequate fluid and nutritional intake. Review of Resident R47's record indicated the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, dementia, schizophrenia (a serious mental disorder in which a person interprets reality abnormally), cognitive communication deficit (difficulty in thinking and use of language), dysphagia (difficulty in swallowing liquids and food), depression, and has a need for personal care. Review of Resident R47's Minimum Data Set (MDS - a periodic assessment of needs) dated 11/20/23, indicated the diagnoses remained current. The Brief Inventory for Mental Status (BIMS - a test to determine cognitive ability) recorded a score of 06, indicating the resident had a severe cognitive impairment. Review of Resident R47's current physician orders dated 12/1/23, included staff feed effective 12/17/23, and a dysphagia pureed texture meal effective 12/18/23. Review of Resident R47's care plan dated 12/30/23, addressed nutritional problem with the intervention of staff to provide assistance with meals, and an activities of daily living deficit with the intervention of staff to assist with meals. Review of Resident R47's meal ticket for the lunch meal on 1/17/24, included Staff Feed and a pureed meal of roast pork, bread, brown gravy, green beans, mashed potatoes, and lemon cake. During an observation on 1/17/24, at 12:40 p.m. through 12:59 p.m. Resident R47 had their lunch meal, uncovered and on the tray table in front of them. The resident could be seen multiple times attempting to put their finger in the food and placing their finger to their lips. During an interview on 1/17/24, at 1:00 p.m. Registered Nurse (RN) Unit Manager Employee E9 confirmed the lunch meal arrived on the unit at 12:30 p.m. RN Unit Manager Employee E9 also confirmed the meal ticket stated Staff Feed and approximately two bites of mashed potatoes and lemon cake was consumed. RN Employee E9 commented the resident doesn't eat much, and the Nursing Assistant assigned to Resident R47 was busy feeding another resident. During an interview on 1/17/24, at 1:00 p.m. the RN Unit Manager Employee E9 confirmed the facility failed to ensure that a resident who is unable to carry out activities of daily living in eating receives the necessary services to maintain good nutrition. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility provided policies and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to protect residents from staff-initiated abuse and/or neglect. This failure resulted in a staff member physically abusing a resident and multiple staff neglecting care of 18 of 184 residents reviewed. This failure created an Immediate Jeopardy situation for 18 of 184 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was defined as the failure of the facility, its employees or services providers to roved goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 8/3/23, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C: Cognitive Patterns revealed Resident R1 to be severely cognitively impaired. Review of Section D: Behavior indicated that Resident R1 is known to have behavioral symptoms. Review of Resident R1 ' s care plan for behavior problems initiated 10/21/22, included the intervention for staff to approach and speak in a calm manner. Review of a progress note written by Registered Nurse (RN) Employee E12 dated 9/13/23, at 6:56 p.m. indicated Was informed of an incident at 5:30 of an incident by the Unit Manager (Employee E22), that there was an incident involving RN Employee E1 and Resident R1. RN Employee E1 was sent home, 911 was called at 5:50 p.m. Review of facility submitted information dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of an employee statement written by RN Employee E1 dated 9/13/23, indicated This RN was at nurse's station trying to get the two residents apart from one another. We (staff) had been trying this for a length of time and the two were not moving/separating. I was telling them to go to their rooms or the dining room and Resident R1 grabbed the pen from my hand and threw it at me. I then went from behind the desk to get them to move. The NA thought I was going to harm the resident, but I was attempting to get her to move from the nurse's station. I did mumble under my breath and called her a bitch. Resident was never touched or harmed. Staff continued to work to get them apart. They then moved to the dining room. NA Employee E2 went downstairs to find supervisor. I did tell NA Employee E2 my supervisor was (the Director of Nursing). NA Employee E2 did not contact (the DON), however she did tell Licensed Practical Nurse Employee E15 that she recorded the abuse stated on her phone. She was also recording other staff while in the dining rooom that were addressing the two residents. Review of an undated employee statement written by NA Employee E2 indicated While sitting at the nurse's station I began to hear Resident R1 become upset about being alone with Resident R54. The Unit Manager (UM - RN Employee E1) began to explain why she couldn't and Resident R1 started getting more frustrated, the UM became angry and started to yell back in a mean tense. At this moment I became concerned, and recorded for my resident's safety as well as myself. The UM called the resident a little bitch and charged towards (Resident R1) as if she wanted to hit her. At this moment I stepped in between and let the UM know she was out of line and to remember she was on a dementia unit. I also stated that she needed to apologize to the resident. I asked her if she had another supervisor present, and I went to speak with him. I felt unsafe for my resident, the UM apologized but that shouldn't have occurred. I understand recording is not permitted, but needed to be able to support my statement. Review of an employee statement written by NA Employee E3 dated 9/13/23, indicated I was the one-on-one with Resident R54 when issue happened. I was standing between Resident R1 and Resident R54. Resident R1 was not listening (to) me and (NA Employee E4) both kept redirecting Resident R1 to go back to dining room and sit down she was not easily redirected at all. RN Employee E1(UM) heard us having a hard time came out her office to redirect Resident R1. Resident R1 then grabbed her pen out of her and hit RN Employee E1(UM) in the face with it. Yes, RN Employee E1(UM) did call her a little bitch but it wasn't loud she kinda muttered it. She was a little angry at the situation but we know she would never put her hand on any resident. RN Employee E1 (UM) also wanted NA Employee E2 to come talk in her office and she wouldn't go. NA Employee E2 started scolding RN Employee E1(UM) like she was a child. Review of an employee statement written by NA Employee E4 dated 9/13/23, indicated NA Employee E3 was standing in between Resident R54 and Resident R1 trying to get her to go into the dining room. Resident R1 kept getting angrier and we kept trying to redirect her. RN Employee E1 (UM) came over and told her to go to her room or go sit in the dining room. Resident R1 grabbed the pen out of RN Employee E1's (UM) hand and threw it at her and hit her in the face. RN Employee E1(UM) came from behind the desk. NA Employee E2 stared scolding RN Employee E1(UM) like she was a little child. RN Employee E1 (UM) asked her to go into her office and talk but she wouldn't go. NA Employee E2 was being very unprofessional. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and a seizure disorder. Review of Section C revealed Resident R2 to be cognitively intact. Review of Section H - Bladder and Bowel revealed that Resident R2 is occasionally incontinent. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section C revealed Resident R3 to be cognitively intact. Review of Section G: Activities of Daily Living (ADL) Assistance indicated Resident R3 required staff assistance for bed mobility, toilet use, and personal hygiene. Resident R3 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R3 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and an anoxic brain injury (injury to the brain caused by a complete lack of oxygen). The facility diagnosis list included Review of Section C revealed Resident R4 to be moderately cognitively impaired. Review of Section G: indicated Resident R4 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R4 is always incontinent of bladder and bowel. Review of Resident R4 ' s care plan initiated 12/21/21, and revised on 9/21/23, revealed that he has impaired cognitive function, and the care plan for incontinence revised on 11/15/22, revealed that Resident R4 should be checked for incontinence and for his brief to be changed as needed. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Section C revealed Resident R5's BIMS score to be 12, moderately cognitively impaired. Review of Section G: indicated Resident R5 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R5 is frequently incontinent of bladder and bowel. Review of Resident R5 ' s care plan initiated 7/26/23, revealed that she has impaired cognitive function, and the assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression) and a seizure disorder. Review of Section C revealed Resident R6 to be moderately cognitively impaired. Review of Section G indicated Resident R6 required staff assistance for bed mobility, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R6 is always incontinent of bladder and bowel. Resident R6 ' s care plan for ADL assistance initiated 5/17/23, indicated Resident R6 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Review of Resident R6 ' s care plan for incontinence initiated 7/19/21, revealed that Resident R6 should be checked for incontinence and that briefs should be changed as needed. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain) and diabetes. Review of Section C revealed Resident R7 to be moderately cognitively impaired. Review of Section G indicated Resident R7 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R7 has a urinary catheter and is always incontinent of bowel. Resident R7 ' s care plan for bowel incontinence initiated 7/13/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. Review of the clinical record indicated Resident R8 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of a seizure disorder and history of a stroke. Review of Section C revealed Resident R8 to be moderately cognitively impaired. Review of Section G indicated Resident R8 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R8 is always incontinent of bladder and bowel. Resident R8 ' s care plan for ADL assistance initiated 2/21/23, revealed Resident R8 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R8 ' s care plan for bowel incontinence initiated 2/28/23, indicated for staff to provide assistance as needed, and to provide peri-care (cleaning the genitalia and surrounding area) after each incontinent episode. Review of the clinical record indicated Resident R9 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoporosis (condition when the bones become brittle and fragile). Review of Section C revealed Resident R9 to be severely cognitively impaired. Review of Section G indicated Resident R9 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R9 was frequently incontinent of bladder and bowel. Resident R9 ' s care plan for ADL assistance initiated 5/12/23, revealed Resident R9 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R9 ' s care plan for bladder incontinence initiated 5/22/23, revealed staff should check resident for incontinence. Wash, rinse, and dry perineum. Change clothes as needed after incontinent episodes. Change briefs as needed. Review of the clinical record indicated Resident R10 was admitted to the facility 10/10/19. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C revealed Resident R10 to be severely cognitively impaired. Review of Section G indicated Resident R10 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R10 is frequently incontinent of bladder and bowel. Resident R ' s care plan for ADL assistance initiated 7/1/21, revised 1/30/23, revealed that staff should observe and anticipate Resident R10 ' s needs: food, thirst, body positioning, pain, and toileting needs. Resident R10 ' s care plan for bowel incontinence initiated 8/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R10 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R10 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R11 was admitted to the facility 3/10/23. Review of the MDS dated [DATE], included diagnoses of COPD and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Section C revealed Resident R11 to be moderately cognitively impaired. Review of Section G indicated Resident R11 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R11 is always incontinent of bladder and bowel. Resident R11 ' s care plan for ADL assistance initiated 6/15/23, revealed Resident R11 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R11 ' s care plan for bowel incontinence initiated 3/21/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R12 was admitted to the facility 5/31/23. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R12 to be cognitively intact. Review of Section G indicated Resident R12 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R12 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 6/1/23, revealed Resident R12 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R12 ' s care plan for bowel incontinence initiated 6/5/23, revealed that staff should provide peri-care after each incontinence episode. Resident R12 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R12 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of the clinical record indicated Resident R13 was admitted to the facility 1/14/23. Review of the MDS dated [DATE], included diagnoses of chronic kidney disease (gradual loss of kidney function) and dementia. Review of Section C revealed Resident R13 to be severely cognitively impaired. Review of Section G indicated Resident R13 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R13 is frequently incontinent of bladder and bowel. Resident R12 ' s care plan for ADL assistance initiated 1/16/23, revealed Resident R13 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R13 ' s care plan for frequent bowel incontinence initiated 1/23/23, revealed that staff should provide peri-care after each incontinence episode. Resident R11 ' s care plan for bladder incontinence initiated 3/21/23, staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode Review of the clinical record indicated Resident R14 was admitted to the facility 11/22/22. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle weakness. Review of Section C revealed Resident R14 to be moderately cognitively impaired. Review of Section G indicated Resident R14 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R14 is always incontinent of bladder and bowel. Resident R14 ' s care plan for history of a cerebral vascular accident (CVA, stroke) initiated 12/5/22, revealed staff should assist with ADL and provide passive range of motion with care. Resident R14 ' s care plan for bowel incontinence initiated 12/5/22, revealed that staff should provide peri-care after each incontinence episode. Resident R14 ' s care plan for bladder incontinence initiated 8/5/22, staff should check Resident R14 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility staffing information indicated that NA Employee E5 was responsible for ADL care for Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14. Review of a report dated 10/2/23, indicated the local police were dispatched to the facility and they had been called by the facility to report neglect. The Director of Nursing (DON) provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients (Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) that were named in the allegation. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E6, this nurse expressed concerns with the nursing supervisor throughout the shift. This NA (NA Employee E5) was missing for over 30 minutes. The call lights were going off. The nursing supervisor made an announcement. The NA sat at the nursing station. This nurse encouraged this NA to change the resident. The NA kept disappearing. The NA was asked to do walking rounds. The NA was late. The residents were complete [sic]. NA Employee E5 told this nurse she could not get residents up because of it by six hoyers. Review of an employee statement written by RN Employee E7 indicated that the B-1 unit 3:00 pm to 11:00 p.m. aide and the assigned nurse for 7:00 a.m. to 7:00 p.m. reported NA Employee E5 who worked that none of the residents were changed and all the residents were soaked, and their briefs were torn due to excess voiding. 3:00 pm to 11:00 p.m. aide had to change every bed also. Review of an employee statement written by LPN Employee E8 indicated .had (list of room numbers) on the 3:00 p.m. to 11:00 p.m. shift .whoever was the 7:00 a.m. to 3:00 p.m. daylight aid did not do no last rounds at all. Resident R4 was laying in his own BM (bowel movement) it was everywhere from his head to feet covered in his own BM. Resident R5 was wet with old urine ring stains in the sheets. Resident R6 was soaking wet in urine. Resident R7 was sitting wet in urine. Resident R9 was soaking wet in urine. Resident R11 was soaking wet, also Resident R12. Everyone total bed changes with old urine rings on the sheet. Review of an employee statement written by NA Employee E5: I didn't get some up because one of them refused. It was only three people and a busy day so I couldn't get help with Hoyer for all six people. For the people I didn't change in the afternoon I got a really bad pain in my knee from slipping in the shower room the previous day. It got so bad to the point I couldn't move but I tried my best to finish up it just got unbearable, and I didn't want to go home and leave only two aides on the floor. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide care to her unit (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14). NA Employee E5 confirmed she did not previously inform facility staff of her injury on 10/1/23, that she stated prevented her from providing care. NA Employee E5 confirmed she did not inform facility management or a charge nurse on 10/2/23, that she was unable to provide care, and that multiple of her residents were left in soiled briefs, clothing, and linen. The facility failed to remove this aide from the schedule until further investigations were completed putting these residents at risk for continued neglect. Review of the clinical record indicated Resident R15 was admitted to the facility 7/3/23. Review of the MDS dated [DATE], included diagnoses of obstructive uropathy (condition where the flow of urine is blocked), reduced mobility, and the need for assistance with personal care Review of Section C revealed Resident R15 to be cognitively intact. Review of Section G indicated Resident R15 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R15 has a urinary catheter and is always frequently of bowel. Resident R15 ' s care plan for ADL assistance initiated 7/5/23, revealed that Resident R15 is extensive to total assistance with toileting and that Resident R15 ' s assistance required with ADLs may fluctuate based on time-of-day, mood, pain, or fatigue. Resident R15 ' s care plan for bowel incontinence initiated 7/5/23, revealed that staff should provide peri-care after each incontinence episode. Review of facility submitted information dated 10/3/23, indicated that on 10/3/23, Resident R15 stated that the NA on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of a progress note dated 10/4/23, at 12:34 p.m. indicated Resident assessed with LPN Employee E23, resident was incontinent of BM, cleaned, new brief applied. Resident's peri/ buttocks are excoriated, bright red, multiple wounds present. No new wounds were noted. Review of a transcribed employee statement to the DON from NA Employee E9 on 10/4/23, indicated, Took care of Resident R15 last night every time you clean her up, she is in pain. I was not being rough with her on the way out she offered me candy. Am I being rough with her, no I am not. Review of an employee statement written by NA Employee E10 dated 10/4/23, indicated Resident R15 called me into the room at 11:30 p.m. and asked to be changed because the aide before (NA Employee E9) didn't clean her well enough. While I was helping her, Resident R15 began to tell me what NA Employee E9 did to her. Resident R15 called NA Employee E9 into the room the first time because Resident R15 needed a blanket and Employee E9 obliged her. About five minutes later Resident R5 put her call light on again because she moved her bowels and asked to be changed and Resident R15 stated that NA Employee E9 screamed at her and while she (NA Employee E9) was attempting to clean her up, scrubbed Resident R15's vagina so roughly that she hurt hours after the fact. Resident R15 waited until 11:30 p.m. to put on the call bell again because she wanted to make sure that NA Employee E9 wasn't in the facility. Review of an employee statement written by LPN Employee E24 dated 10/4/23, indicated NA Employee E10 made this nurse aware at 11:30 p.m. that resident wanted to speak to me. Resident told this nurse that NA Employee E9 on 3:00 p.m. - 11:00 p.m. had yelled at her because she had to call her back into the room after an incontinent episode. She stated that NA Employee E9 was very rough with doing her incontinence care. She stated her vagina was still burning and sore hours after incident. Resident had waited to report this incident until after 11:00 p.m. when she knew NA had left. She staed that she had never been treated so roughly. She said that she had called the main number of the facility but was not able to get anyone to give me the message that she needed me to help. NA Employee E10 provided incontinence care at this time. Resident positioned for comfort. RN Supervisor made aware of incident. During an interview on 11/9/23, at 11:00 a.m. Resident R15 described the incident. It was about nine (9:00 p.m.) I asked NA Employee E9 to cover me with a blanket. Right after, I needed to be changed. She yelled and screamed at me, she hurt me when she was changing me. After that the man aide (NA Employee E10) took good care of me and cleaned me up. When asked if she felt scared, Resident R15 responded, Oh, yeah. It was an assault. Definitely was. When she stuck her hand in between my legs so hard, I was hurting for a couple days. It was painful what she did to me. Seemed like she was ready to kill me. It was really nasty. Review of the clinical record indicated Resident R16 was admitted to the facility 12/14/21. Review of the MDS dated [DATE], included dementia and high blood pressure. Review of Section C revealed Resident R16 to be severely cognitively impaired. Review of Section G indicated Resident R16 required staff assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of Section H indicated that Resident R16 is always incontinent of bladder and bowel. Resident R16 ' s care plan for bowel incontinence initiated 12/27/21, revealed that staff should provide peri-care after each incontinence episode. Resident R16 ' s care plan for bladder incontinence initiated 12/27/21, staff should check Resident R16 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. Review of a progress note written by RN Employee E12 dated 10/5/23, at 5:55 p.m. indicated Resident had urine-soaked bed, resident sound asleep, no injuries noted. Resident and resident's bed changed. Review of an employee statement written by LPN Employee E25 on 10/5/23, indicated Nurse aides reported that when patient (Resident R16) one wing to the other, he was noted with a round ring, wet fitted sheet with dry brief. Review of an employee statement written by NA Employee E26 on 10/5/23, indicated Resident R16 came downstairs after being upstairs for a few days and his bed was dirty with a big dirty ring around the butt area and the brief was dry. Review of an employee statement written by NA Employee E11 on 10/5/23, indicated I never got the chance to wash and change Resident R16 yet because I had showers to do this morning. I'm always on the back of (unit) everyday and it's heavy and don't nobody want to work back so I'm stuck working back there every day. I was going to change and wash him after lunch before he went downstairs. Review of the clinical record indicated Resident R17 was admitted to the facility 6/3/22. Review of the MDS dated [DATE], included psychotic disorder (mental disorder characterized by a disconnection from reality) and intellectual disabilities. Review of Section C revealed Resident R17 to be severely cognitively impaired. Review of Section G indicated Resident R17 required staff assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Section H indicated that Resident R17 is always incontinent of bladder and bowel. Resident R17 ' s care plan for bladder incontinence initiated 6/15/22, revealed staff should check Resident R11 for incontinence. Wash, rinse, and dry perineum. Change clothing after each incontinent episode. Review of facility submitted information dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident R17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E14 was responsible for Resident R17's care on 10/10/23, evening shift, Review of an employee statement written by NA Employee E14 on 10/10/23, at 11:30 p.m. indicated Resident is consistently overly saturated. Date, timed, and initial briefs for 10/10/23, at 6:30 a.m. when resident was changed on last rounds. Came in tonight to resident stating My pee-pee hurts and asked to change him he complied. Pulled the same brief off that I put on. Let the nurse know, went and got supervisor, advised her of it. Supervisor did ask me why I was dating briefs, to cause problems. I stated no, it's because residents are being abused and neglected. Supervisor escalated to DON. Review of an employee statement written by NA Employee E5 on 10/11/23, indicated Resident R17 did not get changed because he was already irritated and screaming and yelling when I asked him, he started to scream and yell more and left unit. Review of an employee statement written by LPN Employee E27 on 10/11/23, indicated Around 8:30 p.m. NA Employee E28 approached this nurse and said that resident was refusing to be changed and put in bed and was barricading himself inside the dining room. Resident was in the dining room at the end of shift. Review of behavior charting completed by NA Employees E5 and E13 both documented that Resident R17 had not displayed behaviors on 10/10/23. Review of a progress note written by RN Employee E12 dated 10/11/23, at 6:01 p.m. indicated Resident assessed post complaint from previous shift. Peri area is reddened with two open areas, right groin and left lower groin area. Resident also has reddened areas under breast folds, red and yeast like. Resident's thighs and lower legs are also reddened. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not provide incontinence care to Resident R17 on 10/10/23. When asked the reason why, she stated that Resident R17 had been displaying behaviors that day. NA Employee E5 confirmed that she had documented Resident R17 as having no behaviors, as this level of behavior was his normal. NA Employee E5 was unable to explain why, if this level of behavior is normal, he is able to be provided incontinence care on other days. Review of the clinical record indicated Resident R18 was originally admitted to the facility on [DATE], and read

Based on review of facility provided policies and documentation, provided reports, clinical records, and resident and staff interviews, it was determined that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy Abuse, Neglect, & Misappropriation, reviewed 6/6/23, revealed that it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. The policy further stated the facility will provide education and training upon hire, annually, and as needed for retraining. Education and training in-services documentation of attendance will be maintained. Review of a facility submitted report dated 9/14/23, indicated that on 9/13/23, Nurse Aide (NA) Employee E2 reported that RN Employee E1 had called Resident R1 a bitch and moved around the desk towards the resident. NA Employee E2 stepped between the resident and the nurse. No physical contact occurred between the nurse and the resident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property completed 9/19/23, indicated verbal abuse was substantiated. Review of facility provided education sign-in sheets dated 9/21/23, 63 staff members of the 200 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a provided report dated 10/2/23, indicated the local police were dispatched to the facility, after the facility had called to report an allegation of abuse/neglect. The Director of Nursing (DON) was noted to have provided provided the officer with four sworn statements dated 10/1/23. The DON also provided a list of highlighted patients. These statements alleged neglect of Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 by Nurse Aide (NA) Employee E5. A facility submitted report and a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property were not completed. Review of a facility submitted report dated 10/4/23, indicated that on 10/3/23, Resident R15 stated that the NA (NA Employee E9) on the 3:00 p.m. - 11:00 p.m. shift had yelled at her because she had to call her back into the room after an incontinent episode. Resident R15 stated that the NA was very rough with her. Resident stated that her vagina was still burning and sore hours after the incident. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E9 completed 10/4/23, indicated the investigation was ongoing. Review of NA Employee E9's personnel file on 11/4/23, indicated that NA Employee E9 was terminated from employment at the facility, related to substantiated abuse. Review of a facility submitted incident dated 10/5/23, indicated that on 10/5/23, at 2:00 p.m. Resident R16 was moved from one wing of the facility to a different wing. He was noted with a ring of wet urine on the fitted sheet with a dry brief. NA Employee E11 was immediately suspended. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property was not completed. Review of the education provided for the above-mentioned incident on 9/13/23, failed to include reeducation for the alleged perpetrators NA Employee E5 (10/2/23), NA Employee E9 (10/3/23), and NA Employee E11 (10/5/23). Review of facility provided education sign-in sheets dated 10/2/23, through 10/6/23, 64 staff members of the 214 staff current at the time of the education, who remained employed at the facility at the time of the survey, were documented as having received education. Review of a facility submitted incident dated 10/11/23, indicated that on 10/10/23, at 11:30 p.m. NA Employee E14 stated that on 10/10/23, at 6:30 a.m. he had written the date, time, and his initials on Resident 17's brief. When NA Employee E14 came on duty on 10/10/23, at 11:30 p.m. he went to change Resident R17's brief which still had on the date, time, and his initials. Review of facility staffing information indicated that NA Employee E5 was responsible for Resident R17's care on 10/10/23, day shift; NA Employee E13 was responsible for Resident R17's care on 10/10/23, evening shift. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E5 completed 10/11/23, indicated the investigation was ongoing. A Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for NA Employee E13 was not completed. Review of NA Employee E5's personnel record included a corrective action. Employee had a report of neglect (this is the 2nd report of this since the start of employment). The investigation was unsubstantiated but this employee will be brought back to work and will need to complete her Relias (electronic educational program) to 100% and will be retrained by a senior aide. Suspended 10/12/23, and 10/13/23, back to work on 10/16/23. Review of the facility reeducation provided to NA Employee E5 after this second incident (10/2/23, 10/11/23) included: Bathing, urinary drainage bag maintenance, care of indwelling urinary catheter care, skin check, and shaving - electric razor. During an interview with NA Employee E34, responsible retraining NA Employee E5, on 11/5/23, at 5:13 p.m. NA Employee E34 confirmed that she provided hands-on reeducation on how to change a brief, hand-washing, and other hands-on care issues. When asked if she felt NA Employee E5 needed retraining, NA Employee E34 responded, Absolutely needed retraining. Even when I retrained her, she was having a rough time to be involved in the care. Maybe she didn't want to do it, maybe she was uncomfortable. It didn't seem like she cared or was getting it. Further review of facility provided investigation documentation failed to include reeducation on abuse or neglect for NA Employee E5 related to the incident on 10/11/23. During an interview on 11/8/23, at 11:12 a.m. NA Employee E5 confirmed she did not received in-person abuse and neglect retraining based on the 10/2/23, and 10/11/23, incidents. Review of a facility submitted report dated 11/5/23, indicated that on 11/5/23, at 6:00 a.m. Resident R18 was found to have a bedpan underneath her for an unknown amount of time. Evening shift staff stated that a bedpan had been placed under Resident R18 at approximately 7:00 p.m. on 11/4/23. The assigned nurse aide stated that she checked when Resident R18 wasn't sure if there was a bedpan underneath her or that she might be dreaming. The nurse aide put her hand underneath Resident R18's left buttock and between her legs and did not feel a bedpan. The nurse aide didn't completely roll the resident to check. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for LPN Employee E29 initiated 11/5/23, indicated the investigation was ongoing. During an interview on 11/7/23, at 11:00 a.m. the Nursing Home Administrator stated that for the above incidents, facility staff education was completed at 100% due to a text blast that included all facility staff members. The Nursing Home Administrator confirmed that while it could be verified that the education was sent out via text message to all employees, there was no capability or process in place to ensure that the receiving staff member opened, read, or understood the education. On 11/7/23, at 11:04 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed and the Immediate Jeopardy template was provided to facility administration. On 11/7/23, at 5:24 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Ad hoc QAPI (Quality Assurance and Performance Improvement) will be conducted by facility QAPI committee to report allegations of noncompliance during the survey on 11/7/23. -RDO will provide abuse education to facility leadership, including a posttest. Facility leadership will administer same education and posttest to employees and contracted employees of the facility. This will be completed by 11/7/23. -Any employee that is not available to come into the facility will be educated regarding abuse over the phone and will not be permitted to return to the active work schedule until they come into the facility and satisfactorily complete the posttest. -The front desk of the facility will be staffed by facility, leadership around the clock to ensure compliance with education for all employees unable to come to the facility on [DATE]. -Random skin sweeps and abuse questionnaires on five residents five times a week for the next two weeks and weekly for eight weeks of the residents of the facility by the DON/designee. -Random education audits will be conducted by the employees utilizing the same abuse posttest to ensure retention of knowledge. This will be contacted with 10 staff members five times a week for the next two weeks and weekly, eight for eight weeks of the employees of the facility by the DON/designee. -Additional abuse education will be completed monthly for three months to be completed by the DON/designee. Compliance will be monitoring and ensuring completion of this education will be done by the HR manager/designee. -Facility will reach out to (directed in-service provider) regarding the scheduling of a directed in-service for all employees and contracted employees of the facility. This will be scheduled with (directed in-service provider) within the next 30 days. -All abuse training will be certified complete by the HR manager/designee against an active employee/ contracted employee roster, starting at 11/7/233 and ongoing. -All findings regarding the IJ citation reported monthly in the facility's QAPI meeting for the next three months. During observations completed on 11/8/23, between 9:30 a.m. and 4:00 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 11/8/23, between 9:30 a.m. and 4:00 p.m. 25 staff members confirmed they received education on abuse prevention. During staff interviews conducted on 11/9/23, between 9:30 a.m. and 11:30 a.m. 16 staff members confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 11/9/23, at 11:55 a.m. when the action plan implementation was verified. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure abuse and neglect prevention training was completed for all facility staff after substantiated abuse incidents, resulting in an Immediate Jeopardy for 18 of 184 residents. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of nursing job description, facility policy, clinical record, and staff interview, it was determined that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services to maintain safety for two of thirteen residents (Resident R19 and R20), and actual harm resulting increased pain during the provision of nursing care for one of thirteen residents. (Resident R20). Findings include: Review of the facility provided Licensed Practical Nurse (LPN) job description titled, Charge Nurse dated 6/6/23, indicated the LPN/charge nurse must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guideline that pertain to long-term care. Review of the facility policy Colostomy Appliance Bag Change dated 6/26/23, indicated that staff will cleanse surrounding skin area and stoma with mild soap and water - rinse. Review of the facility policy Medication Administration dated 6/26/23, indicated for transdermal patches, Remove old patch and dispose of properly. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 8/21/23, revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Section H - Bladder and Bowel indicated the presence of an ostomy (an artificial opening in an organ of the body, created during an operation). Review of a physician's order dated 8/14/23, indicated for staff to clean Resident R20's ostomy site with soap and water. Review of Resident R20's care plan for alteration in bowel elimination initiated 4/5/23, indicated for staff to cleanse area around stoma/colostomy site with soap and water. pat dry. Apply skin prep non sting. During an interview and observation on 11/4/23, at 1:35 p.m. Resident R20 stated to the surveyor that the nurse was coming to provide colostomy care to him. Surveyor exited the room at 1:36 p.m. when Licensed Practical Nurse (LPN) Employee E20 entered the room. Resident R20 could be heard to be screaming loudly It burns, it burns for the next few minutes. On 11/4/23, at 1:41 p.m. the surveyor reentered the room to observe the care that was causing Resident R20 to scream loudly. Resident R20 was observed to be holding a towel over his stoma site. After about a minute he removed the towel, and LPN Employee E20 said she needed to finish cleaning the stoma. With a spray bottle in her hand, she began to spray directly onto the stoma and the surrounding area. Resident R20 immediately began screaming that it was burning him again. The surveyor asked LPN Employee E20 what she was using to clean the stoma and surrounding area. LPN Employee E20 stated that it was peri-cleaner (perineal cleanser that gently cleans urine, emesis and fecal matter) and displayed the bottle to the surveyor. The surveyor took the bottle from LPN Employee E20's hand. The bottle was labeled Bye-Bye Odor and stated on the front of the bottle ODOR ELIMINATOR, neutralizes odors and freshens the air. The surveyor informed LPN Employee E20 that she had been using air freshener to clean Resident R20's stoma and surrounding skin. During an interview on 11/4/23, at 1:43 p.m. LPN Employee E20 confirmed that she was unaware she was using air freshener rather than peri-cleaner. During an interview on 11/4/23, at 1:49 p.m. the Director of Nursing (DON) confirmed that the facility failed to assure nursing competency in relation to stoma care. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and quadriplegia (paralysis of all four limbs). Review of a physician's order dated 3/24/22, indicated for staff to apply one Nitroglycerin Patch 24 Hour 0.1 MG/HR (medication used to prevent episodes of chest pain in people who have coronary artery disease) transdermally (providing a medication in a form for absorption through the skin) one time a day, and remove per schedule. Review of Resident R19's Medication Administration Record (MAR) for November 2023 indicated the nitroglycerin patch is ordered to be removed at 8:59 a.m. and the new patch applied at 9:00 a.m. Review of a facility reported incident indicated When the medication nurse (LPN Employee E17) was administering (Resident R19's) nitroglycerin patch she noted 1 patch on the right chest wall, and three on the left chest wall. Review of Resident R19's MAR for 11/1/23, through 11/6/23. indicated the nitroglycerin patch was documented as removed prior to administration by LPN Employees E18, E19, and E20. During an interview on 11/9/23, at approximately 12:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to assure that licensed nurses displayed the appropriate competencies and skills sets to provide nursing services to maintain safety for two of thirteen residents, resulting in actual harm of increased pain during the provision of nursing care for one of thirteen residents (Resident R20). 28 Pa. Code: 201.14(1) Responsibility of licensee. 28 Pa. Code: 201.18(a)(3) Management.

Based on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 176 residents (Resident R1). Findings include: Review of facility policy Elopement Prevention reviewed 10/18/22, indicated that elopement is defined as when a resident leaves the premises or a safe area without authorization and/or a supervision and places the resident at harm or risk for injury. Any resident admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise. Review of the clinical face sheet indicated that Resident R1 was admitted on [DATE]. A review of the Minimum Data Set Assessment (MDS-periodic assessment of care needs) dated 4/23/23, included diagnoses of cerebrovascular accident (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain burst), cognitive social or emotional deficit (problems with the ability to think, learn, remember, use judgement, and make decisions and an inability to regulate their responses to certain emotions) and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of medical record revealed a document dated 4/30/18, from the Court of Common Pleas, Orphans ' Court Division, that was entitled Final Order of Court Determining Incapacity and Appointing Plenary Guardian of the Person and/or Estate. This document awarded guardianship to Resident R1's aunt (Resident Representative) based on, but not limited to, the following statement: Resident R1 suffers from vascular cognitive disorder, stemming from a brain aneurysm rupture on May 17, 2017, a condition or disability which totally impairs her capacity to receive and evaluate information effectively and to make and communicate decisions concerning her management of financial affairs or to meet essential requirements to her physical health and safety. Review of Resident R1's medical record revealed a Care Plan initiated 7/1/21, for behavior problems that included removing her roommate's oxygen and throwing it on the floor, approaching other residents with a closed fist, unfastening other resident clothing, collecting other residents' food and drinks from their rooms, taking food out of the nourishment room, trying to smoke in the facility, inappropriate sexual behaviors towards other residents and staff (e.g. smacks staff on the buttocks), and entering other rooms without invitation and will take items. Review of medical record revealed a physician's order dated 1/27/22, that stated Resident R1 may not go out on LOA (leave of absence) with anyone unless approved by guardian. Review of Resident R1's medical record revealed a progress note dated 3/8/22, that stated Resident R1 was noted at bedtime going into patients' rooms, and noted going into resident room bathrooms this shift as well. Patient redirected multiple times. Review of Resident R1's medical record revealed an additional progress note dated 3/23/22, that stated Resident R1 was walking halls, and went into the lounge and was witnessed attempting to open a beg left in there. She was stopped, educated, and redirected. Review of Resident R1's physician orders dated 4/19/22, to apply Wanderguard (a monitoring device worn on the wrist or ankle that alerts staff when a resident leaves a safe area.) Review of Resident R1's care plan initiated 4/20/22, for elopement risk, with goal that Resident R1 will not exit property if unsafe to navigate community. Review of the Wandering Observation Tool, (an assessment meant to determine risk of resident wandering or eloping) for Resident R1, dated 8/23/22, contained the following information: 1) Does resident have a history of wandering and /or a pattern tied to the resident ' s past? Yes 2) Is the resident accepting of current stay/living arrangements? Yes 3) Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? Yes 4) Has the resident expressed anxiety/apprehension to leave the facility, packed personal belongings, pacing with no course of action or direction, or attempted to exit doors? Yes 5) Does the resident have a history of elopement? Yes 6) Does the resident wander without a sense of purpose? (i.e., confused, may enter others ' rooms, and explore other ' s belongings? Yes 7) Does resident have any additional risk factors for elopement or unsafe wandering? No 8) Based on the responses above, is the resident at risk for elopement or unsafe wandering? Yes Based on this evaluation, the resident has been identified as a risk for elopement or unsafe wandering, proceed to care plan. Further review of Resident R1's medical records and subsequent Wandering Observation Tool assessments dated 11/23/22, and 2/24/23, contained similar content, but all concluding with the statement, Based on this evaluation, the resident has been identified as a risk for elopement or unsafe wandering, proceed to care plan. Review of a nurses note for Resident R1 written on 5/4/23, at 6:45 p.m. that stated the following: Resident R1 cut off her Wanderguard on this shift. When asked where she put it, she said I threw it in the trash can. A new Wanderguard was put on her right ankle. Also found a nail cutter in her pocket. This nurse took the nail cutter from her and put it in the nurse cart. Review of a nurses note for Resident R1 written on 5/6/23, at 8:45 p.m. that stated the following: Resident R1 was found on locked down unit by another nurse. Resident was redirected back to her unit and tolerated the redirection well. Review of a nurses note for Resident R1 written on 5/10/23, at 7:59 a.m. notified by another resident that (Resident R1) had entered her room and taken a pop out of her fridge, entered Resident R1's room and resident was seated on her bed with an opened cold Pepsi on her tray table. Resident R1 denied taking it. Advised Resident R1 not to enter anyone's room and not to take items that didn't belong to her. Advised her she is welcome to buy pop from the vending machine or ask her family to provide them for her. Resident shook her head in understanding. Social Services notified. Police arrived spoke to both parties, no charges were filed. Review of an order written on 5/17/23, to discontinue Wanderguard, and elopement risk was removed from Resident R1's care plan. Review of Resident R1's medical record revealed an additional Wandering Observation Tool completed 5/24/23, that contained the following information: 1) Does resident have a history of wandering and /or a pattern tied to the resident ' s past? Yes 2) Is the resident accepting of current stay/living arrangements? Yes 3) Has the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave? No 4) Has the resident expressed anxiety/apprehension to leave the facility, packed personal belongings, pacing with no course of action or direction, or attempted to exit doors? No 5) Does the resident have a history of elopement? No 6) Does the resident wander without a sense of purpose? (i.e., confused, may enter others ' rooms, and explore other ' s belongings? Yes 7) Does resident have any additional risk factors for elopement or unsafe wandering? No 8)Based on the responses above, is the resident at risk for elopement or unsafe wandering? No This assessment did not place Resident R1 at risk for elopement or unsafe wandering. Review of a nurses note written on 5/27/23, at 2:40 a.m., that stated the following: Resident R1 returned to [NAME] Health Center at 0225 (2:25 a.m.) this morning. Stated that she is unharmed and feeling okay. VS (vital signs) obtained, and WNL (within normal limits). HS (bedtime) medications were given on arrival. Will continue to monitor. Review of medical record revealed an additional note written on 5/27/23, at 3:59 a.m., stated that following: Resident R1 was brought back to the facility by two [NAME] police officers at about 0225 (2:25 a.m.), ambulatory, escorted back to her room by this nurse. Alert and oriented times three. Not in any distress. Denied any pain. Stated she had a bus pass, walked through the front entrance, and walked to the bus stop where she entered a bus. Family notified of resident's return to the facility. During an interview on 5/31/23, at 10:54 a.m., Resident Representative, Resident Family RF1, recounted the above events and stated that she received a phone call on 5/26/23 at approximately 6:30 p.m. from the Nursing Home Administrator (NHA) informing her that Resident R1 was unable to be located and her whereabouts were unknown. Resident Family RF1 stated that she was told that the police had not yet been notified and she advised that this should be done as the resident has a bus pass. Resident Family RF1 stated that she called the police and that her family conducted a search of their own. Resident R1's son was able locate Resident R1 unaccompanied on 5/27/23, at approximately 1:30 a.m. walking in downtown Pittsburgh (approximately eight miles and 24 minutes by car from the facility). Resident R1's son then took her back to his house. Resident Family RF1 explained that police retrieved Resident R1 at 2:04 a.m. and transported her back to the facility. When Resident Family RF1 was asked if Resident R1 had a history of elopement she stated Yes. At her last facility. She used the code to get out of the door and she said she did it because 'my son needed me . Resident Family RF1 stated that resident often expresses interest in trying to get to her house and car, however she hasn't owned either in many years. During an interview on 5/31/23, at 11:15 a.m., Resident R1 ' s roommate, Resident R2, stated that she was aware of the elopement and had last seen Resident R1 at approximately 2:00 p.m. that day. Resident R2 stated that she (Resident R1) has an alarm but takes it off. She is an escape risk. During an interview on 5/31/23, at 2:35 p.m., Regional Director of Clinical Operations Employee E1 stated that the Corporate Director of Behavioral Programming, Employee E2, had reviewed Resident R1's chart and provided documentation that stated, repeated sexual demands or behaviors may be a person's way of expressing they need intimacy- also maybe an attempt to be freed from a restrained environment. Therefore, the decision was made to discontinue Resident R1's Wanderguard. During an interview on 5/31/23, at 3:04 p.m., Social Worker Employee E3, stated I agree that she (Resident R1) would need supervision with taking a bus and going out of the facility. During an interview on 5/31/23, at 3:24 p.m., Nurse Aide (NA) Employee E4 was asked how she would identify any resident that would be at risk for elopement and NA Employee E4 replied that they have Wanderguards and are in an Elopement Book at the front desk. NA Employee E4 also stated that she was working the evening that Resident R1 was returned to the facility by the police, and she had asked Resident R1 why she had left the building and that Resident R1 replied that she was 'going to Clairton to get my car and see my son.' NA Employee E4 also stated that Resident R1 walks all around the building and that I don't think she can make that decision to be able to leave the building unattended. During an interview on 5/31/23, at 3:26 p.m. NA Employee E5 was asked how she monitors residents at risk for elopement and stated, they have Wanderguards, but that Resident R1's was taken off and that she tries to keep an eye on her, but she walks all over so it's hard. NA Employee E5 stated that she asked Resident R1 where she went the evening of the elopement and Resident R1 stated that she was ' trying to get to Clairton but got on the wrong bus.' NA Employee E5 added that she shouldn't have been out that late. During an interview on 5/31/23, at 3:30 p. m. Resident R1 was asked if the above interviews were accurate, and she said yes. When Resident R1 was asked what kind of car she owned she had stated I don't know. During an observation on 5/31/23, at 3:36 p.m., State Agency noted that no receptionist was at the front desk and attempted to exit out of the front door. However, the door was secured, and egress was not successful. During an interview on 5/31/23, at 3:40 p.m. Receptionist Employee E6 explained that someone is at the front desk from 6:00 a.m. until 8:30 p.m. and that no one can enter or exit the facility without being buzzed in by staff. Receptionist Employee E6 explained she has a button under her desk that once pressed, opens the doors and after 8:30 p.m. she puts a lock box over the button so that it cannot be accessed. Receptionist Employee E6 explained that after she leaves at 8:30 p.m. it is then nursing staff's responsibility to let people in and out of the building. She further explained that there is a keypad at the front door that requires a code. Once the correct code is entered the doors will open. Receptionist Employee E6 also displayed the Elopement Book which is utilized to help her identify residents that have been deemed an elopement risk. The Elopement Book contains Face Sheets of residents that reside on the locked unit and of two people that have Wanderguards. The Face sheet contains a small black and white photo of the resident in the upper left-hand corner of the page. Receptionist Employee E6 stated that Resident R1 was no longer in the book because she no longer had a Wanderguard and does not reside in the locked unit. Receptionist Employee E6 stated she had seen Resident R1 by the front door the day before the elopement and had to redirect her back to her unit. She also stated that she was on duty the evening of the elopement but was unable to explain how resident may have gotten out of the building. Receptionist Employee E6 offered an explanation that Resident R1 may have exited within a larger group of people and was not identified but that it's easy to let them out when they don't have a Wanderguard. On 6/1/23, at 11:29 a.m., the Regional Director of Clinical Operations Employee E1 was made aware that Immediate Jeopardy existed for one of 176 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During an interview on 6/1/23, at 2:25 p.m. the Regional Director of Operations Employee E9 stated that there was a system failure when a Wandering Assessment was done. On 6/1/23, at 4:32 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Possible elopement was identified on 5/26/23, by approximately 6:00 p.m., staff had conducted a full accountability census (head count) of all residents, verifying only one resident was not found. A complete search of property interior and exterior had been engaged without success in findings, with repeated searched each hour through 12:30 a.m. on 5/27/23. -Police were contacted at approximately 7:05 p.m. on 5/26/23, reporting a potential elopement. -Allegheny County Port Authority Bus Line was also contacted. -Resident R1 was returned to the facility on [DATE] at 2:40 a.m. and assessed by nurse for injuries with no adverse findings. -Staff education was implemented on elopement prevention policy and ways to identify residents at risk for elopement. Education was completed on 6/2/23 at 12:00 p.m. -Specific training provided to front desk individual who let Resident R1 out of the front door, to identify potential elopement risk. Education was completed on 5/31/23. -An Interdisciplinary Team Meeting was held on 6/1/23 to review Resident R1's care plan interventions regarding risk for elopement and care plan adjustments were made and Wanderguard was reapplied. Residents: -A review of all current residents wandering assessments were audited for accuracy and any risk factors identified from these assessments will have care plan interventions to reflect these changes. These were completed by 6/2/23, at 8:45 a.m. System Correction: -System change implemented for changing front door code every month to prevent unwanted egress. -Changed system for receptionist for the wander photo book to incorporate only those residents not on the behavior unit. This will include residents that have access to the front door and have been determined to be at-risk for elopement. Monitoring: -Audit all wander assessment by 6/1/23, then three times per week for five weeks, then five times per month for 3 months. -Audit daily nurse notes for signs and symptoms of wandering behavior each business day (five times per week) for five weeks, then three per week for three months. -Five times a week for two weeks for resident elopement risk with appropriate care plan interventions. The Director of Nursing or designee will audit five staff members five times per week for two weeks then two times a week for two weeks for ability to identify residents at increased risk for elopement. -All audits will be referred to Quality Assurance Performance Improvement (QAPI) committee for review of results and continuation as results indicate. During interviews on 6/2/23, from 9:30 a.m. through 11:30 a.m. 19 employees confirmed they had received education on the new facility elopement policy and procedures, which included identification of exit-seeking behaviors, and interventions to reduce risks. During a medical record review on 6/2/23, it was verified that all residents had received updated wandering assessments. During an interview on 6/2/23, at 10:00 a.m., Licensed Practice Nurse (LPN) Employee E7 stated that she was Resident R1's nurse the evening of the elopement and had also completed the Wandering Observation Tool dated 5/24/23 that marked Resident R1 to not be at risk for wandering or elopement. LPN Employee E7 explained that she was unaware of Resident R1's history of elopement and that when she completed the Wandering Observation Tool, she referred to Resident R1's care plan to see if she had been categorized as a risk for elopement and that the care plan did not contain any interventions for wandering or elopement. She further stated that she was aware that Resident R1 no longer had a Wanderguard and this, along with the care plan information led her to mark that Resident R1 was not at risk for wandering or elopement. LPN Employee E7 stated that she was first aware of Resident R1's absence at 6:00 p.m., as Resident R1 usually stops to see her at that time for her medication. LPN Employee E7 then asked other staff if they had seen her, and the last confirmed sighting had been between 5:00 p.m. and 5:30 p.m. LPN Employee explained that she and other staff members began looking for her and attempted to call Resident R1 on her cell phone, however Resident R1 had left her cell phone in her room. LPN Employee E7 stated that she got in her car and drove around the neighborhood to look for Resident R1 but was unsuccessful. LPN Employee E7 had also notified a nursing supervisor. During an interview on 6/2/23, at 1138 a.m., NA Employee E8 stated that she also was present on the evening of the elopement and assisted in her search. NA Employee E8 stated that she was surprised that she (Resident R1) wasn't on a Wanderguard anymore because she does wander. Why would you take it off? She's always gone. The Immediate Jeopardy was lifted on 6/2/23, at 1:08 p.m. when the action plan implementation was verified. During an interview on 6/2/23, at 1:19 p.m. the Nursing Home Administrator and Regional Director of Clinical Operations Employee E1 confirmed that the facility failed to provide adequate supervision for Resident R1 which resulted in an elopement from the facility. This failure created an immediate jeopardy situation for one of 176 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy and clinical records, observation, and staff interviews, it was determined that the facility failed to provide treatment and services, causing actual harm for two of five residents, causing the development of bilateral foot wounds (Resident R2) and the worsening of a pressure ulcer to the hand (Resident R140). Findings include: Review of the facility policy Skin Care and Wound Management last reviewed 2/7/22, with previous review date of 4/5/21, indicated that the facility staff strive to prevent resident skin impairment and promote the healing of existing wounds. All residents upon admission identify areas of skin impairment and pre-existing signs of potential breakdown. Residents receive daily skin care and weekly skin sweeps. Skin is monitored for any changes and areas under skin folds and adaptive equipment are assessed. With any skin concerns care plans are developed, review of appropriate treatments, staff obtain a physician's order for the treatments and monitor it's progress and modify interventions as indicated. Review of clinical record revealed that Resident R2 was readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 4/27/22, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of clinical record for Resident R2 included documentation from consulted Wound Care Certified Registered Nurse Practitioner (CRNP) Employee E13 dated 5/4/22, that indicated that Resident R2 was to have heel boots (a medical device applied to the feet which is used to take pressure off the heels to promote healing and prevention of pressure ulcers). Review of clinical record for Resident R2 revealed documentation dated 5/22/22, from Wound Care CRNP Employee E13, stated new Stage II pressure injury (partial-thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) was identified on left lateral foot. Review of the clinical record for Resident R2 revealed no other documentation from 5/4-5/22/22 to indicate that this area was being monitored or assessed. Review of clinical record for Resident R2 revealed documentation dated 6/22/22, from Wound Care CRNP Employee E13, that indicated a new deep tissue injury was identified on the right heel. This wound did not include any description or measurements. Review of Resident R2's clinical record indicated Resident R2 did not have heel boots in place from 5/4/22, through 8/4/22 which caused Resident R2 to develop pressure ulcers and worsened wounds causing actual harm. During an observation of 8/4/22, at 11:50 a.m., Resident R2 was observed lying in bed with no heel boots present. During an interview on 8/4/22, at 1:40 p.m. with Wound Nurse Employee E8, confirmed that the facility failed to provide heel boots which caused Resident R2 to develop wounds of her bilateral heels; CRNP Employee E13 did not write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R2's plan of care did not include care for heels with elevating or use of heel boots. Review of the clinical record indicated that Resident R140 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial care plan had no care/interventions noted for this problem upon admission. Review of the admission assessment dated [DATE], indicated Resident R140's left hand contracture with the center of her palm bleeding and pus on it from her fingernails digging into it. Review of a progress note dated 2/22/22, indicated the Hospice nurse assessed the resident and the facility Registered Nurse Employee E14 indicated Hospice Registered Nurse (RN) Employee E15 told her Resident R140's left hand has always been like that and no new orders were provided. The clinical record did not contain any initial measurements or full description of this wound. Review of the facility's Wound Care CRNP Employee E13 did not include an assessment of Resident R140's left contracted hand. Review of Resident R140's care plan did not include interventions for the contracted left hand until after evaluated by OT and splint was placed. During an interview on 8/3/22, at 1:25 p.m. including the Director of Nursing (DON), the Regional Director of Clinical Operations (RDC) Employee E7, the Wound Care CRNP Employee E13, the Wound Nurse Employee E8, the RDC Employee E7 stated that Resident R140 was on Hospice, they dictate her care. The facility confirmed that Resident R140 had a delay of service for failure to assess and monitor the wound upon admission which caused worsening to the area. Review of Resident R140's progress notes indicated that on 4/18/22, Registered Nurse Employee E14 identified that Resident R140's left contracted hand had crust and foul-smelling odor. Resident R140 was examined by Nurse Practitioner Employee E16 who indicated it took two staff to open Resident R140's hand, then an open wound was identified with foul odor from nails digging into hand and an antibiotic with a probiotic was started and ordered from 4/18/22, through 5/2/22. A rolled towel was placed in Resident R140's left hand and Occupational Therapy (OT) was notified to assess Resident R140 for a palm guard. Review of the clinical record did not include any skin assessments of Resident R140's left hand until 4/18/22, when Employee E14 identified Resident R140's left hand having an odor. During an observation and interview on 8/4/22, at 8:45 a.m. Licensed Practical Nurse(LPN) Employee E17 entered Resident R140's room and stated she had taken care of Resident R140 since her admission. Resident R140 was in her broda chair, a left palm guard was in place. Licensed Practical Nurse(LPN) Employee E17 stated that she had been caring for Resident R140 since admission and that her left hand had been contracted. LPN Employee E17 stated that she was aware of the nails digging into her left hand and was unsure why OT hadn't been aware of it before it got worse. She stated she thought everyone was aware. During an interview on 8/4/22, at 9:00 a.m., Nurse Aide Employee E30 indicated that she had also taken care of Resident R140 since admission and would try to wash her left hand but it was so tight she couldn't open it. Employee E30 indicated that she thought the nurses were aware. During a phone interview on 8/4/22, at 9:15 a.m., with Registered Nurse Employee E14, she indicated that she had asked the Hospice nurse and alerted the facility staff of Resident R140's contracted hand upon admission but nothing was done until her hand began to smell. During an interview on 8/3/22, at 1:25 p.m., the DON, RDC Employee E7 and Regional Director of Operations Employee E18 confirmed that the facility failed to ensure Resident R140 was provided care and services timely to prevent the development of a skin alteration which caused actual harm by a worsening wound to Resident R140's left hand. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/4/21, 3/22/21, 1/15/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 5/28/19, 4/2/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/4/21, 3/22/21, 1/15/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 201.18(b)(3) Management. Previously cited 6/4/21, 3/22/21, 5/28/19. 28 Pa. Code 201.18(e)(1) Management. Previously 6/4/21, 3/22/21, 1/15/21, 9/22/19, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 211.5(f)(h) Clinical records. Previously 6/4/21, 8/16/19. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/4/21, 3/22/21, 1/15/21, 1/2/21, 9/10/20, 8/16/19. 28 Pa. Code 211.11(c)(d) Resident care plan. Previously cited 6/4/21. 28 Pa. Code 211.12(c) Nursing services. Previously cited 6/4/21, 1/2/21. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 6/4/21, 1/15/21, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/4/21, 3/22/21, 1/15/21, 1/2/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 7/1/19, 5/28/19.

Based on facility documents, observations, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents; failed to ensure that dependent residents received showers for six of 46 residents reviewed (Resident R48, R62, R90, R112, R121 and R173); failed to make certain that seven of 11 residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening (Residents R78, R93, R114, R130, R120, R164, and R183), and failed to prevent pressure ulcer development resulting in actual harm for one of 17 residents reviewed (Resident R117). Additionally, the facility failed to provide feeding assistance as ordered for one of four residents reviewed with weight loss (Resident R48), failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Facility assessment dated [DATE], indicated the facility will have sufficient staff to meet the needs of the residents at any given time. Review of the facility policy Nurse Staffing Information dated 4/5/21, indicated the facility will provide the sufficient number of staff to care for the resident population. Review of the facility policy, Routine Resident Care dated 4/5/21, indicated that the facility will provide personal care including bathing, dressing, eating and hydration, toileting, assisting with ambulation, transfer, and repositioning. During an initial tour and resident interviews of the C wing nursing unit on 5/25/21, at 9:40 a.m. Resident R112 indicated that her brief was wet, she wanted to be changed, and a strong urine odor was detected. During an initial tour and resident interview on 5/27/21, at 9:21 a.m. Resident R114 stated, Are you here to change me? and that her call light sometimes does not get answered for a couple hours. Resident R114 was visibly wet and stated, I haven't been changed since last night. During an observation on 5/25/21, at 9:50 a.m. Resident R173 was noted to have an obviously wet brief and bed sheet, urine odor was detected, and the resident stated no one is coming to change me and I've been laying in urine all day. During an initial tour of the B wing nursing unit on 5/25/21, at 10:00 a.m. Resident R116 indicated the call bell has been on since 7:00 a.m. and no one comes. Resident R116 needed assistance to the bathroom and stated, I sometimes wear a brief because it takes too long for them to come. A review of the clinical record indicated Resident R116 was continent of urine. During an interview on 5/25/21, at 10:15 a.m. Resident R50 indicated it takes hours for the call bell to be answered. Resident 50 stated, I need assistance with eating, and no one comes. Sometimes I lay in my own waste for hours. During a resident interview on 5/25/21, at 10:30 a.m. Resident R84 indicated staff never answer the call bells. Resident R84 stated, I have to wait a very long time to get any assistance at all for anything. During a resident interview on 5/25/21, at 10:45 a.m. Resident R130 indicated that staff do not respond to call bells. Resident R130 stated, I have to wait a long time to get help to go to the bathroom. During a resident interview on 5/25/21, at 10:55 a.m. Resident R136 indicated that there is not enough staff to answer call bells and they never bring water. Resident R136 stated, Even when you ask for water, they don't bring it. I can't wait to get out of here. During a resident interview on 5/25/21, at 11:00 a.m. Resident R120 indicated call bells are not answered timely. Resident R120 stated, I have to wait hours to get out of bed. They never come when you call. During an observation on 5/25/21, at 1:00 p.m. the call light was activated for Resident R80. The lighted monitor at both ends of the hall and facing the nurse station illuminated with the location requesting assistance. Two licensed nurses and one nurse aide were at the nurse's station. During an interview on 5/25/21, at 1:40 p.m. (40 minutes later) with Registered Nurse (RN) charge nurse Employee E42 and Resident R80, the RN Employee E42 confirmed the call bell was not answered timely and the resident indicated that he wanted pulled up in bed. During an observation on 5/25/21, at 1:00 p.m. the call light was activated for Resident R120. The lighted monitor at both ends of the hall and facing the nurse station illuminated with the location requesting assistance. Two licensed nurses were at the nurse's station. During an interview on 5/25/21, at 2:00 p.m. (one hour later) with RN Employee E42 and Resident R120, the RN Employee E42 confirmed the call bell was not answered timely and the resident indicated that he had been waiting to get out of bed. During an observation on 5/25/21, at 1:00 p.m. the call light was activated for Resident R117. The lighted monitor at both ends of the hall and facing the nurse station illuminated with the location requesting assistance. Two licensed nurses were at the nurse's station. During an interview on 5/25/21, at 2:00 p.m. (one hour later) with RN Employee E42 and Resident R117, RN Employee E42 confirmed the call bell was not answered timely and the resident indicated she needed assistance with dialing the telephone. Review of Resident R160's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 5/10/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G Functional Status indicated that Resident R160 is totally dependent on staff for dressing, transfers in and out of bed, and bathing. Review of Resident R160's plan of care updated 4/27/21, indicated she required dependent assist of two with transfers using a mechanical lift, and extensive assistance of one staff member with dressing and bathing. During an interview and observation on 5/25/21, at 10:15 a.m. Resident R160 was in bed without a shirt or gown on, only a sheet covering her. Resident R160 stated, I would love to be wearing a top, and I'm not. Resident R160 further stated that she is, stuck in bed forever and I don't get enough showers. Review of the ADL Care Look Back Report (a facility generated monthly report of nurse aide documentation for ADL completion) from 4/1/21 through 5/25/21, indicated no showers were provided for Resident R160. Review of Resident R179's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/25/21, at 2:05 p.m. Resident R179 stated that staff, sometimes never answer call bell, you have to yell for help, I call them on the phone. Resident R179 stated that if she had [CONDITION(S)] treatments, she didn't always get her meals when she came back and was not bathed on those days. Review of Resident R99's admission record indicated she was admitted to the facility on [DATE]. A review of the annual MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G: Functional Status, Question G0120 indicated that Resident R99 was totally dependent on staff for toilet use and Section H: Urinary Continence indicated that Resident R99 was always incontinent of urine. Review of Resident R99's plan of care updated 4/20/21, indicated that she was incontinent of bowel and bladder, and for staff to aid with toileting, provide peri-care after each incontinent episode, and change briefs as needed. During an interview on 5/26/21, at 8:00 a.m. Resident Family RF99 indicated, they are very understaffed, and the facility has had staffing problems before but that he had never seen it this bad. RF99 indicated that he comes in every morning and changes his mother's brief, which are often wet. Review of Resident R47's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/26/21, from 7:45 a.m. until 8:31 a.m. (a period of 46 minutes), the call light signal for Resident R47's room appeared on the announcement screens on the C wing nursing unit. During an interview on 5/26/21, at 8:33 a.m. Resident R47 confirmed that she had been waiting for a response to her call bell, for over a half hour and that they had just answered it. Review of Resident R24's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G Functional Status indicated that Resident R24 was totally dependent on staff for transfers and bathing. During an interview on 5/26/21, at 2:15 p.m. Resident Family RF24 stated that she was aware that they are not giving her mother showers, just bed baths and that she is often in bed at 11:00 a.m. even though the resident family member had asked that they shower her and get her up, they don't have enough help. Review of the Shower Assignment Sheet indicated that Resident R24 was to have showers on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift. Review of Resident R114's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/27/21, at 9:21 a.m. Resident R114 stated that her call light sometimes does not get answered for a couple hours. The resident specifically stated she waited for incontinent care and to get out of bed. Resident has been and has a history of incontinence. Additionally, Resident R114 stated staffing difficulties are more on the weekends. Review of Resident R27's admission record indicated she was admitted to the facility on [DATE]. A review of the annual MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/27/21, at 9:56 a.m. Resident R27 stated that her call light does not get answered timely, and she often must look for a nurse for assistance. The resident expanded stating that she would need help to get to the bathroom and have incontinent periods two to three times a week when she couldn't make it on her own. Review of Resident R64's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C: Cognitive Status indicated that Resident R64 had no cognitive impairments and Section G Functional Status indicated that Resident R64 requires staff assistance for transfers, toilet use, and bathing. During an interview on 5/28/21, at 12:47 p.m. Resident R64 stated, I put my call light on one night because my roommate was vomiting and had to get into her wheelchair to go to the desk because no one came. Resident R64 also indicated that showers were not being given because, you need two people to use the lift and they don't have enough staff. Review of Resident R117's admission record indicated she was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G Functional Status indicated that Resident R117 requires assistance for bathing. A review of Resident R117's plan of care dated 4/15/21, indicated she required physical assistance with bathing. During a family interview on 5/31/21, at 1:37 p.m. Resident R117's daughter stated that she is concerned that her mother is not being, bathed or even wiped down. Daughter stated that on a previous visit a nurse aide had told her that she would be in the room in ten minutes to assist Resident R117 to the restroom but after two hours her daughter assisted her mother herself. Resident R117's son-in-law stated that he has brought up his concerns to the Nursing Home Administrator (NHA), twice previously. During an interview on 5/26/21, at 9:36 a.m. Nurse Aide (NA) Employee E31 stated that she often does not have time to shower people, that sometimes there is only one aide for two floors, and that she would not be able to get any residents who require an assist of two out of bed on this day due to there not being staff available to assist her. Review of the facility provided deployment sheet for 5/26/21, indicated NA Employee E31 was assigned to the first floor. Per the deployment sheet, the census for that unit was 89 residents, with four nurse aides assigned, averaging 22 to 23 residents per nurse aide. The facility policy entitled Routine Resident Care dated 4/5/21, indicated that licensed staff will include the following services: monitoring and assessment of resident needs, routine care is provided by Nurse Aides assisting or provides for personal care such as bathing, dressing, eating and hydration and toileting. Review of the clinical face sheet indicated that Resident R62 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 5/19/21, indicated that Resident R62 was totally dependent on staff for toileting, bathing, and personal hygiene. Review of Resident R62's Care Plan dated 4/21/21, indicated that she needed extensive assistance for personal hygiene and bathing. Review of the Shower Assignment Sheet indicated that Resident R62 was to be showered on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift. Review of nurse aide documentation on 6/2/21, revealed that Resident R62 had received bed baths but no showers during the past 30 days. During an observation on 5/25/21, at 9:40 a.m., Resident R62 was noted to have greasy hair and body odors. Review of the clinical face sheet indicated that Resident R48 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident R48 was totally dependent on staff for bathing and personal hygiene. Review of Resident R48's Care Plan dated 6/1/21, indicated that he needed extensive assistance for personal hygiene and bathing. Review of the Shower Assignment Sheet indicated that Resident R48 was to be showered on Monday and Thursday on the 11:00 p.m. to 7:00 a.m. shift. Review of nurse aide documentation revealed that Resident R48 had received bed baths but no showers during the past 30 days. During an observation on 5/25/21 at 10:10 a.m., Resident R48 was noted to be unshaven, hair was not groomed, and had body odor. Review of the clinical face sheet indicated that Resident R173 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident R173 was totally dependent on staff for toileting and bathing and extensive assistance required for personal hygiene. Review of Resident R173's Care Plan dated 5/27/21, indicated that he needed extensive assistance for personal hygiene and was totally dependent for bathing. Review of the Shower Assignment Sheet indicated that Resident R173 was to be showered on Monday and Thursday on the 7:00 a.m. to 3:00 p.m. shift. Review of nurse aide documentation revealed that Resident R173 had received bed baths but no showers during the past 30 days. During an observation on 5/25/21, at 10:00 a.m. Resident 173 was noted to have poor hygiene, body odor, and was unshaven. Review of the clinical face sheet indicated that Resident R112 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident R112 was totally dependent on staff for toileting, bathing, and personal hygiene. Review of Resident R112's Care Plan dated 5/17/21, indicated that she needed extensive assistance for personal hygiene and is totally dependent for bathing. Review of the Shower Assignment Sheet indicated that Resident R112 was to be showered on Monday and Thursday on the 7:00 a.m. to 3:00 p.m. shift. Review of nurse aide documentation revealed that Resident R112 had received bed baths but no showers during the past 30 days. Review of the clinical face sheet indicated that Resident R121 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident R121 was totally dependent on staff for toileting, bathing, and personal hygiene. Review of the Shower Assignment Sheet indicated that Resident R121 was to be showered on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift. Review of nurse aide documentation revealed that Resident R121 had not received bed baths or showers during the past 30 days. Review of the clinical face sheet indicated that Resident R90 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], indicated that Resident R90 was totally dependent on staff for toileting, bathing, and personal hygiene. Review of the Shower Assignment Sheet indicated that Resident R90 was to be showered on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift. Review of nurse aide documentation revealed that Resident R90 had received bed baths but no showers during the past 30 days. During an interview on 6/2/21, at 1:30 p.m., the C/D Wing Unit Manager Employee E3 confirmed that showers were not always being done due to nursing staffing issues. A review of the facility policy Resident Weight dated 4/5/21, indicated that weight loss concerns will be discussed at weekly clinical meetings. A review of the facility policy Routine Resident Care dated 4/5/21, indicated that routine care by Nurse Aides includes assisting with personal care for eating and hydration. A review of the clinical face sheet indicated that Resident R48 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy Skin and Wound Management reviewed 4/5/21, indicated the facility strives to prevent skin impairment and promote the healing of existing wounds. The facility will implement interventions to prevent and treat potential skin integrity issues. Each resident is evaluated upon admission and weekly thereafter for changes in skin condition. The facility will obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated 3/12/21, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Wound Evaluation and Management Summary dated 4/7/21, indicated a Stage 3 (full thickness tissue loss, fat may be visible) to the right ischium (hip) measuring 7.0 cm (centimeters) (length) X 7.0 cm (width) X 0.2 cm (depth). A review of a physician order dated 4/8/21, indicated to cleanse the right hip with NSS (normal saline solution) apply leptospermum honey (medical grade honey used in wound healing) and calcium alginate (an absorbent wound dressing that maintains a moist environment for healing) cover with gauze border dressing (an adhesive dressing cover) once daily and as needed. A review of the TAR dated April 2021, indicated the dressing to the right hip was not completed on 4/11, 4/12, and 4/21/21. A review of a physician order dated 4/29/21, indicated to cleanse the right hip with Dakin's half strength solution (an antiseptic solution used to clean wounds) pack with Dakin's soaked gauze and cover with ABD (abdominal) pad (an absorbent dressing cover) two times a day and as needed. A review of the TAR dated May 2021, indicated the dressing to the right hip was not completed on 5/5/, 5/7, 5/11, and 5/23/21. A review of the, Wound Evaluation sheet dated 5/26/21, indicated the wound to the right hip was worsening. A review of the clinical record indicated that Resident R93 was admitted to the facility on [DATE], and the quarterly MDS dated [DATE], revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], 5/2/21 and 5/25/21, Section G0110-Activities of Daily Living revealed that the resident requires the extensive assistance of one person for these tasks which includes dressing and personal hygiene. A review of the Skin Grid Pressure Report dated 5/18/21, revealed a non-stageable area to the left second toe measuring 4 cm by 2.5 cm by 0.2 cm with 100% slough/eschar (yellow moist tissue/dry, black collection of dead tissue). The area was noted after removing the resident's shoes and revealing that the resident was not wearing any socks. A review of a wound consult and X-ray of 5/19/21, indicated [CONDITION(S)] (an infection under the skin) and [MEDICATION(S)] (an antibiotic) was ordered for ten days. Treatment ordered to area was [MEDICATION(S)] (works to bring fluid from deeper tissue to promote the removal of dead tissue) and cover area with a dry dressing every day on the daylight shift. An observation on 5/25/21, at 10:35 a.m. of Resident R93's left foot, revealed a dressing dated 5/21/21. ADON Employee E16 was present for the observation and confirmed that the facility failed to ensure pressure ulcers were monitored, assessed, and received the necessary services to prevent ulcers from worsening. There was no explanation as to why the dressing was not done. On 5/26/21, the wound measured 0.7 cm by 0.96 cm by 0.2 cm with 50% granulation tissue and 50% slough/eschar. A review of the clinical record indicated that Resident R114 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current MDS, dated [DATE], confirmed the above diagnoses. A review of a physician order dated 4/5/2021, indicated off-loading boots (therapeutic shoes designed to provide pressure redistribution for patients at risk for diabetic foot conditions such as neuropathic ulcers) while in bed. A review of the care plan, updated 2/12/2021, indicated the resident should use an appropriate offloading mattress (a mattress to redistribute a patient's weight so to relieve pressure points). Observations on 5/26/21, 5/27/21, 5/28/21, 6/1/21, 6/2/21, and 6/3/21, revealed that Resident R114 was not wearing off-loading boots while in bed. During an interview on 6/1/21, with Registered Nurse (RN), Employee E34 confirmed that Resident R114 should have off-loading boots on, and they were not in place. RN Employee E34 was unable to give a reason why boots were off. A review of the clinical record indicated Resident R120 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Wound Evaluation and Management Summary dated 5/20/21, indicated that Resident R120 had a Stage 3 pressure ulcer to the right posterior thigh measuring 7.4 cm X 3.68 cm X 0 cm that developed on 3/30/21. A review of physician order dated 2/4/21, indicated to use a low air loss mattress (specialty mattress to prevent pressure ulcer development). An observation on 5/28/21, at 12:25 p.m. revealed that Resident R120's bed did not have a low air loss mattress applied. During an interview on 5/28/21, at 12:35 p.m. Licensed Practical Nurse (LPN), Employee E20 confirmed that Resident R120's bed did not have a low air mattress. During an interview on 5/28/21, at 1:10 p.m. the Director of Nursing (DON) confirmed that the facility staff failed to follow physician orders for a low air loss mattress to prevent further skin breakdown. A review of the clinical record indicated Resident R130 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a nurse progress noted dated 5/13/21, indicated Resident R130 had 2 open areas to the left leg measuring 1.4 cm X 3.5 cm X 0.0 cm. A review of the Wound Evaluation sheet dated 5/19/21, indicated the left lower leg with Stage 3 pressure ulcer measuring 2.1 cm X 1.78 cm X 0.10 cm. A review of a physician order dated 5/1/21, indicated weekly skin evaluations were to be done by a licensed nurse. A review of the TAR dated May 2021, indicated the scheduled weekly skin evaluation was not completed for the week of 5/1/21 through 5/7/21. A review of a physician order dated 5/14/21, indicated to cleanse the left BKA with NSS, apply hydrogel (a dressing to keep the wound moist), ABD pad and wrap with Kerlix (woven gauze dressing) once daily and as needed. A review of the TAR dated May 2021, indicated the dressing to the left BKA was not completed 5/15/21 through 5/19/21 a total of 5 days. A review of a physician order dated 5/20/21, indicated cleanse left BKA with NSS, apply [MEDICATION(S)] and calcium alginate, cover with ABD, and wrap with Kerlix once daily and as needed. A review of the TAR dated May 2021, indicated the dressing to the left BKA was not completed 5/20/21 through 5/31/21, a total of 12 days. A review of the clinical record indicated Resident R164 was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section G: Activities of Daily Living (ADL) Assistance indicated that Resident R164 required extensive assistance for bed mobility. Review of Section M: Skin Conditions indicated that Resident R164 was at risk for pressure ulcer development but had no current pressure ulcers at the time of assessment. A review of the Admission Observation Tool (a screening tool utilized during readmission after a hospitalization ) completed by RN Employee E34 on 1/12/21, at 10:28 p.m. indicated that Resident R164 had no current skin conditions. A review of the Braden Observation Tool (a screening tool to assess she vulnerability to pressure ulcer development) dated 2/3/21, indicated that Resident R164 was at low risk of pressure ulcer development. A review of the plan of care updated 3/19/21, indicated the resident required the assistance of two staff to reposition and turn in bed. A review of a physician order dated 2/14/21, indicated pressure relieving boots to both feet at all times, while in bed. During observations on 5/30/21, at 2:55 p.m. on 5/31/21, at 12:45 p.m. and on 6/1/21, at 11:48 a.m. Resident R164 was in bed without pressure relieving boots on. A review of the Initial Wound Evaluation dated, 2/24/21 indicated Resident R164 had an unstageable pressure wound to the right heel measuring 1.5 cm x 3.0 cm x UTD (unable to determine) cm, with a developed date of 2/13/21, and a unstageable pressure wound (a full thickness skin, muscle loss with slough/eschar present in the base of the pressure ulcer, preventing you to see the depth of the ulcer) with necrosis (dead tissue) to the left heel measuring 2.5 cm x 4.0 cm x UTD cm, with a developed date of 2/13/21. A review of the Wound Evaluation dated 5/26/21, indicated a right heel pressure wound measuring 1.98 cm x 2.00 cm x 0.00 cm. A review of a physician order dated 4/16/21, through 5/19/21, indicated to cleanse the left heel with normal saline, pat dry, apply leptopspermum honey, and border gauze daily. From 5/20/21 through 5/26/21, the order changed to cleanse with normal saline, pat dry, apply leptospermum honey, pack with packing strips. Cover with border gauze daily. A review of a physician order dated 4/29/21 through 5/26/21, indicated to apply skin prep to discolored area daily. A review of the May 2021, TAR indicated the left heel dressing change was not completed on 5/13/21, 5/15/21, 5/19/21, 5/20/21, 5/21/21, 5/22/21, and 5/27/21, and the left medial heel dressing change was not completed on 5/13/21, 5/20/21, and 5/21/21. During an interview on 6/3/21, at 1:30 p.m. the DON confirmed the above findings and Resident R164 was readmitted without wounds, and the facility failed to identify a new pressure wound, and to apply pressure relieving boots as ordered by the physician. A review of the clinical record indicated Resident R183 was admitted to

Based on a review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to make certain that seven of 11 residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening (Residents R78, R93, R114, R130, R120, R164, and R183) and failed to prevent pressure ulcer development resulting in actual harm for one of 17 residents reviewed (Resident R117). Findings include: A review of the facility policy, Skin and Wound Management reviewed 4/5/21, indicated the facility strives to prevent skin impairment and promote the healing of existing wounds. The facility will implement interventions to prevent and treat potential skin integrity issues. Each resident is evaluated upon admission and weekly thereafter for changes in skin condition. The facility will obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 3/12/21, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Wound Evaluation and Management Summary dated 4/7/21, indicated a Stage 3 (full thickness tissue loss, fat may be visible) to the right ischium (hip) measuring 7.0 cm (centimeters) (length) X 7.0 cm (width) X 0.2 cm (depth). A review of a physician order dated 4/8/21, indicated to cleanse the right hip with NSS (normal saline solution), apply leptospermum honey (medical grade honey used in wound healing), and calcium alginate (an absorbent wound dressing that maintains a moist environment for healing) cover with gauze border dressing (an adhesive dressing cover) once daily and as needed. A review of the TAR dated April 2021, indicated the dressing to the right hip was not completed on 4/11, 4/12, and 4/21/21. A review of a physician order dated 4/29/21, indicated to cleanse the right hip with Dakin's half strength solution (an antiseptic solution used to clean wounds) pack with Dakin's soaked gauze and cover with ABD (abdominal) pad (an absorbent dressing cover) two times a day and as needed. A review of the TAR dated May 2021, indicated the dressing to the right hip was not completed on 5/5, 5/7, 5/11, and 5/23/21. A review of the Wound Evaluation sheet dated 5/26/21, indicated the wound to the right hip was worsening. A review of the clinical record indicated that Resident R93 was admitted to the facility on [DATE], and the quarterly MDS dated [DATE], revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], 5/2/21, and 5/25/21, Section G0110-Activities of Daily Living revealed that the resident requires the extensive assistance of one person for these tasks which includes dressing and personal hygiene. A review of the Skin Grid Pressure Report dated 5/18/21, revealed a non-stageable area to the left second toe measuring 4 cm by 2.5 cm by 0.2 cm with 100% slough/eschar (yellow moist tissue/dry, black collection of dead tissue). The area was noted after removing the resident's shoes and revealing that the resident was not wearing any socks. A review of a wound consult and X-ray of 5/19/21, indicated [CONDITION(S)] (an infection under the skin) and [MEDICATION(S)] (an antibiotic) was ordered for ten days. Treatment ordered to area was [MEDICATION(S)] (works to bring fluid from deeper tissue to promote the removal of dead tissue) and cover area with a dry dressing every day on the daylight shift. An observation on 5/25/21, at 10:35 a.m. of Resident R93's left foot, revealed a dressing dated 5/21/21. ADON Employee E16 was present for the observation and confirmed that the facility failed to ensure pressure ulcers were monitored, assessed, and received the necessary services to prevent ulcers from worsening. There was no explanation as to why the dressing was not done. On 5/26/21, the wound measured 0.7 cm by 0.96 cm by 0.2 cm with 50% granulation tissue and 50% slough/eschar. A review of the clinical record indicated that Resident R114 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current MDS, dated [DATE], confirmed the above diagnoses. A review of a physician order dated 4/5/21, indicated off-loading boots (therapeutic shoes designed to provide pressure redistribution for patients at risk for diabetic foot conditions such as neuropathic ulcers) while in bed. A review of the care plan, updated 2/12/21, indicated the resident should use an appropriate offloading mattress (a mattress to redistribute a patient's weight so to relieve pressure points). Observations on 5/26/21, 5/27/21, 5/28/21, 6/1/21, 6/2/21, and 6/3/21, revealed that Resident R114 was not wearing off-loading boots while in bed. During an interview on 6/1/21, with Registered Nurse (RN), Employee E34 confirmed that Resident R114 should have off-loading boots on and they were not in place. RN Employee E34 was unable to give a reason why boots were off. A review of the clinical record indicated Resident R120 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Wound Evaluation and Management Summary dated 5/20/21, indicated that Resident R120 had a Stage 3 pressure ulcer to the right posterior thigh measuring 7.4 cm X 3.68 cm X 0 cm that developed on 3/30/21. A review of physician order dated 2/4/21, indicated to use a low air loss mattress (specialty mattress to prevent pressure ulcer development). An observation on 5/28/21, at 12:25 p.m. revealed that Resident R120's bed did not have a low air loss mattress applied. During an interview on 5/28/21, at 12:35 p.m. Licensed Practical Nurse (LPN), Employee E20 confirmed that Resident R120's bed did not have a low air mattress. During an interview on 5/28/21, at 1:10 p.m. the Director of Nursing (DON) confirmed that the facility staff failed to follow physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record indicated Resident R130 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a nurse progress noted dated 5/13/21, indicated Resident R130 had 2 open areas to the left leg measuring 1.4 cm X 3.5 cm X 0.0 cm. A review of the Wound Evaluation sheet dated 5/19/21, indicated the left lower leg with Stage 3 pressure ulcer measuring 2.1 cm X 1.78 cm X 0.10 cm. A review of a physician order dated 5/1/21, indicated weekly skin evaluations to be done by a licensed nurse. A review of the TAR dated May 2021, indicated the scheduled weekly skin evaluation was not completed for the week of 5/1/21 through 5/7/21. A review of a physician order dated 5/14/21, indicated to cleanse the left BKA with NSS, apply hydrogel (a dressing to keep the wound moist), ABD pad and wrap with Kerlix (woven gauze dressing) once daily and as needed. A review of the TAR dated May 2021, indicated the dressing to the left BKA was not completed 5/15/21 through 5/19/21, a total of 5 days. A review of a physician order dated 5/20/21, indicated cleanse left BKA with NSS, apply [MEDICATION(S)] and calcium alginate, cover with ABD, and wrap with Kerlix once daily and as needed. A review of the TAR dated May 2021, indicated the dressing to the left BKA was not completed 5/20/21 through 5/31/21, a total of 12 days. A review of the clinical record indicated Resident R164 was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section G: Activities of Daily Living (ADL) Assistance indicated that Resident R164 required extensive assistance for bed mobility. Review of Section M: Skin Conditions indicated that Resident R164 was at risk for pressure ulcer development but had no current pressure ulcers at the time of assessment. A review of the Admission Observation Tool (a screening tool utilized during readmission after a hospitalization ) completed by RN Employee E34 on 1/12/21, at 10:28 p.m. indicated that Resident R164 had no current skin conditions. A review of the Braden Observation Tool (a screening tool to assess she vulnerability to pressure ulcer development) dated 2/3/21, indicated that Resident R164 was at low risk of pressure ulcer development. A review of the plan of care updated 3/19/21, indicated the resident required the assistance of two staff to reposition and turn in bed. A review of a physician order dated 2/14/21, indicated pressure relieving boots to both feet at all times, while in bed. During observations on 5/30/21, at 2:55 p.m. on 5/31/21, at 12:45 p.m. and on 6/1/21, at 11:48 a.m. Resident R164 was in bed without pressure relieving boots on. A review of the Initial Wound Evaluation dated 2/24/21, indicated Resident R164 had an unstageable pressure wound to the right heel measuring 1.5 cm x 3.0 cm x UTD (unable to determine) cm, with a developed date of 2/13/21, and a unstageable pressure wound (a full thickness skin, muscle loss with slough/eschar present in the base of the pressure ulcer, preventing you to see the depth of the ulcer) with necrosis (dead tissue) to the left heel measuring 2.5 cm x 4.0 cm x UTD cm, with a developed date of 2/13/21. A review of the Wound Evaluation dated 5/26/21, indicated a right heel pressure wound measuring 1.98 cm x 2.00 cm x 0.00 cm. A review of a physician order dated 4/16/21 through 5/19/21, indicated to cleanse the left heel with normal saline, pat dry, apply leptopspermum honey, and border gauze daily. From 5/20/21 through 5/26/21, the order changed to cleanse with normal saline, pat dry, apply leptospermum honey, pack with packing strips. Cover with border gauze daily. A review of a physician order dated 4/29/21 through 5/26/21, indicated to apply skin prep to discolored area daily. A review of the May 2021, TAR indicated the left heel dressing change was not completed on 5/13/21, 5/15/21, 5/19/21, 5/20/21, 5/21/21, 5/22/21, and 5/27/21, and the left medial heel dressing change was not completed on 5/13/21, 5/20/21, and 5/21/21. During an interview on 6/3/21, at 1:30 p.m. the DON confirmed the above findings and Resident R164 was readmitted without wounds, and the facility failed to identify a new pressure wound, and to apply pressure relieving boots as ordered by the physician. A review of the clinical record indicated Resident R183 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 5/19/21, indicated wedge and foam cushion for off-loading and specialty bed, and ensure turning protocol. A review of Resident R183's care plan, updated on 5/26/21, indicated the resident should use the provided appropriate offloading mattress. During observations on 5/26/21, 5/27/21, 5/28/21, 6/1/21, 6/2/21, and 6/3/21 revealed no specialty bed was in place. An interview on 6/2/21, with Maintenance Supervisor Employee E37, confirmed that the facility had ordered and received the mattresses, but none has been deployed to Resident R183's room. During an interview with the DON on 6/2/21, it was confirmed that Resident R183 did not have a specialty mattress. A review of the clinical record indicated Resident R117 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a clinical admission evaluation progress note dated 4/8/21, indicated a pre-existing diabetic ulcer (open wounds or sores usually found on the bottom of the feet) to the ball of the right foot. A review of the, Initial Wound Evaluation and Management Summary, dated 4/14/21, indicated a post-surgical wound of the right plantar (ball of foot) and did not include a wound to the right heel. A review of a nurse progress note dated 4/14/21, indicated a Stage 3 pressure ulcer to the right heel measuring 1.5 cm X 1.5 cm X 0.25 cm. six days after the resident was admitted to the facility. A review of a nurse progress note dated 4/20/21, indicated the right heel wound was not present on admission. A review of a Wound Evaluation sheet dated 4/21/21, indicated a Stage 3 pressure ulcer to the right heel acquired in the facility on 4/15/21, 6 days after Resident R117 was admitted to the facility. A review of a physician order dated 4/19/21, indicated to apply [MEDICATION(S)] and border gauze to the right heel daily. A review of the TAR dated April 2021, indicated the dressing to the right heel was not completed on 4/22/21. A review of a physician order dated 4/23/21, indicated to cleanse the right heel with NSS, apply [MEDICATION(S)] and border gauze daily. A review of the TAR dated April and May 2021, indicated the dressing to the right heel was not completed on 4/27/21, 5/13/21, 5/14/21, and 5/19/21. A review of the Wound Evaluation sheet dated 5/19/21, indicated the wound to the right heel was worsening. A review of a physician order dated 5/19/21, indicated to cleanse the right heel with NSS, apply Iodosorb (an iodine infused wound dressing to absorb fluids and remove pus and debris) and wrap with Kerlix daily. During an interview on 5/26/21 at 10:00 a.m., Certified Registered Nurse Practitioner (CRNP) wound consultant Employee E8 confirmed the above findings and voiced concerns with treatments completed as ordered. A review of the TAR dated May 2021, indicated the dressing to the right heel was not completed on 5/22, 5/24, and 5/26/21. A review of the Wound Evaluation sheet dated 5/26/21, indicated the wound to the right heel was worsening and had progressed to a Stage 4 pressure ulcer (full thickness loss with exposed bone, tendon, or muscle). During an interview on 5/26/21, at 10:00 a.m. CRNP wound consultant Employee E8 confirmed the above findings and that Resident R117 developed a Stage 3 pressure ulcer to the right heel first identified on 5/14/21, six days after the resident was admitted to the facility. During an interview on 6/4/21, at 3:00 p.m. the DON confirmed the above findings and that the facility failed to make certain that residents with pressure ulcers were monitored, assessed, and received the necessary services to prevent new ulcers from developing or worsening for residents R78, R93, R114, R120, R130, R164, and R183 and prevent actual harm of pressure ulcer development for Resident R117. Refer to F725. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/22/21, 1/15/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 5/28/19, 4/2/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/22/21, 1/15/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 201.18(b)(3) Management. Previously cited 3/22/21, 5/28/19. 28 Pa. Code 201.18(e)(1) Management. Previously 3/22/21, 1/15/21, 9/22/19, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 211.5(f)(h) Clinical records. Previously 8/16/19. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/22/21, 1/15/21, 1/2/21, 9/10/20, 8/16/19. 28 Pa. Code 211.11(c)(d) Resident care plan. 28 Pa. Code 211.12(c) Nursing services. Previously cited 1/2/21. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/15/21, 8/16/19, 7/11/19, 5/28/19. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/22/21, 1/15/21, 1/2/21, 9/10/20, 9/22/19, 8/16/19, 7/11/19, 7/1/19, 5/28/19.

Based on review of clinical records, facility policy, an incident report and staff interview, it was determined that the facility failed to provide safe transport of a resident in a wheelchair which resulted in actual harm for one of 7 residents reviewed (Resident R1). Findings include: The facility policy entitled, Positioning in Chair, dated 6/16/16, indicated to maintain correct body alignment when seated in a wheelchair, support the feet by placing them on footplates or adaptive cushions and devices are placed as described in the resident care plan. Review of the Admission Record indicated that Resident R1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated 5/11/16, indicated that Resident R1 had moderately impaired cognition and was totally dependent on staff for locomotion. Review of the physician's orders [REDACTED]. Review of the Activity of Daily Living care plan for Resident R1 on 10/18/16, failed to reveal that the bilateral wheelchair leg rests had been included in the care plan documentation. Review of the facility's incident report dated 9/19/16, at 1:29 p.m. indicated that when Resident R1 was being propelled in a wheelchair holding her legs up, Resident R1 dropped the right foot to the floor, the right ankle rolled and a popping sound was heard. Review of the witness statement dated 9/19/16, at 1:30 p.m. indicated that Nurse Aide (NA), Employee E1, got Resident R1 out of bed and into the wheelchair and pushed the resident out of the resident's room and down the hall to eat lunch in the lounge. NA Employee E1 also stated that Resident R1 was asked if she wanted her leg rests on and she said no. Employee E1 indicated that when they were close to the nurses' station, the resident started complaining that his/her foot was stuck under the chair. Employee E1 stopped the wheelchair and got the resident's foot out from under the chair. Resident R1 complained of pain to the right foot. Review of a nurse progress note dated 9/19/16, at 1:31 p.m. indicated that Resident R1's physician was notified and an order received to obtain an X-ray of the right foot and ankle. Review of a nurse progress note dated 9/19/16, indicated that the X-ray results showed a fracture of the right tibia (the bone in the lower leg that connects the knee to the ankle) and that Resident R1 was transferred to the hospital as per physician order [REDACTED]. Review of the hospital emergency department evaluation dated 9/19/16, at 8:53 p.m. indicated that the resident's chief complaint was right lower leg pain. The emergency department evaluation indicated that Resident R1 was in a wheelchair at the nursing facility when the right foot slipped and was caught under the wheelchair. Results of an X-ray taken at the hospital on [DATE], revealed that Resident R1 had a spiral fracture (a type of fracture that is caused by a twisting force) of the tibia. Review of the, physician progress notes [REDACTED]. Patient sent out, came back with splint. During an interview on 10/18/16, at 3:00 p.m. the Occupational Therapist Department Director, Employee E4, confirmed that Resident R1 had been issued leg rests for his/her wheelchair in July 2016, for positioning while seated in a wheelchair in order to achieve optimum positioning. During an interview on 10/21/16, at 2:09 p.m. the Director of Nursing confirmed that the staff failed to safely transport Resident R1 which resulted in harm to resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/5/16, 6/9/16, 6/2/16, 10/16/15. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/5/16, 7/3/16, 6/9/16, 10/16/15. 28 Pa. Code 201.29(d) Resident rights. Previously cited 7/13/16, 10/16/15. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/5/16, 7/13/16, 6/2/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/5/16, 7/13/16, 6/9/16, 6/2/16, 5/17/16, 3/31/16, 2/29/16,1/25/16, 10/16/15.

Based on a review of an Event Report submitted to the State Survey Agency, clinical records, facility policy, manufacturer guidelines, facility incident reports, a medical examiner report, and staff interviews, it was determined that the facility failed to identify the accident hazard created by having a bed alarm cord wrapped around the bed enabling bars resulting in a fatal accident for one of 26 residents (Closed Record Resident CR1). Findings include: Review of the Manufacturer Guidelines for the Medline Quick-Alert Disposable Bed Sensor Pad, Model #MDT8130B1, indicated that the pad may become damaged when used on a dynamic mattress (air, water, etc.). Additionally, due to the possibility of strangulation, all cords should be routed away from the throat and when securing the system, take up any extra slack in the cord that may become tangled with a patient, bed, or chair. Failure to do so may result in patient injury. Review of the Operator's Manual for the Med-Aire 8 "Alternating Pressure Mattress Replacement System" with low air loss, Item # , indicates to only use attachments recommended by the manufacturer. The facility has no policies for bed alarms or low beds. During an interview on 7/10/13 at 9:45 a.m., Acting Director of Nursing Employee E7, confirmed that manufacturer guidelines are used as policy for this equipment. Resident R1 was admitted to the facility on [DATE]. The Minimum Data Set assessment(MDS - periodic assessment of care needs) dated 6/21/13, includes [DIAGNOSES REDACTED]. Resident CR1's MDS also indicated that extensive assistance of two was needed for bed mobility and there is limitation on both sides of the upper and lower extremities. The care plan updated 6/27/13, includes a deficit in Activities of Daily Living (ADL's) due to limited range of motion and the need for two persons for bed mobility. During multiple interviews on 7/9/13, from 10:00 a.m. through 2:00 p.m., Nursing Aides (NA) Employees E12 and E13, Licensed Practical Nurse (LPN) Employee E6, Hospice Employees E14 and E15, and Medical Director Employee E16, all confirmed that Resident R1 was unable to self-propel and could not move independently in bed. A physician order [REDACTED]. A physician order [REDACTED]. Resident CR1 received the equipment as ordered and the facility placed the resident on the mattress with the alarm despite manufacturer directions. A nurse's note on 7/7/13 at 5:30 a.m., indicated that Resident CR1 was found lying on the left side of the bed with his/her head and neck against the pressure alarm cord, face down with saliva coming from his/her mouth, dentures were on the floor, and a noticeable mark on his/her neck from the cord. Review of Witness Statements dated 7/7/13 and 7/8/13, from LPN Employee E8, Registered Nurse (RN) Employee E9, RN Employee E10, and LPN Employee E11, indicated that Resident R1 had a cord wound around the enable side rail bars (small type of side rail attached to the bed as a means of support to facilitate turning and repositioning in bed) and that extra slack from the cord was into/around Resident CR1's neck. Review of the Medical Examiner's Report from an autopsy performed on 7/8/13, concluded that the cause of death was asphyxiation due to ligature compression of the neck from a cord connected to an alert device. During an interview on 7/11/13 at 2:00 p.m., the Nursing Home Administrator confirmed that cords of any type should not be wrapped around or tied to bed assist bars due to posing an accident hazard. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 8/24/12, 9/16/11. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 9/16/11. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 8/24/12, 9/16/11.