Every finding on record at Sarah a Todd Memorial Home

Based on clinical record review and staff interview, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 22 residents reviewed (Resident 7).Findings include:Review of Resident 7's clinical record revealed diagnoses that included hemiplegia (paralysis affecting one side of the body) and protein calorie malnutrition (a severe nutritional deficiency from not getting enough protein and energy [calories], leading to muscle loss, weakness, impaired immunity, and organ problems). Review of Resident 7's Hospice Certification and Plan of Care revealed that Hospice care was started on October 3, 2025. Review of Resident 7's Minimum Data Set (MDS) (an assessment tool) revealed that there have not been a Significant Change MDS completed since Resident 7 entered Hospice care on October 3, 2025, when the significant change had occurred.Interview on January 8, 2026, at 11:30 AM, with the Nursing Home Administrator, revealed that the Significant Change MDS should have been completed within the 14-day period after the change in Resident 7's status.28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 22 residents reviewed (Resident 10 and 72).Findings Include:Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years) and dementia (the loss of cognitive functioning that interferes with a person's daily life and activities).Review of Resident 10's clinical record revealed an elopement risk assessment was completed on November 21, 2025, and determined Resident 10 was at risk for elopement.Review of Resident 10's care plan revealed that the Resident was at risk for elopement and had an elopement monitor to right ankle, with an initiation date of November 21, 2025.Review of Resident 10's physician orders revealed an active order for the Resident to have an elopement bracelet, with an initiation date of November 21, 2025.Review of Resident 10's clinical record revealed a nursing progress note written on November 26, 2025, at 9:50 PM, that Resident 10 was displaying exit seeking behaviors by trying to get outdoors, looking for keys, and wandering.Review of Resident 10's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 27, 2025, revealed that Section E0900. Wandering - Presence & Frequency; has the Resident wandered - is marked as 0, indicating the behavior was not exhibited during the look back period.During an interview with the Nursing Home Administrator (NHA) on January 8, 2026, at 10:20 AM, revealed that Resident 10's MDS dated [DATE], was coded inaccurately and should have captured Resident 10's wandering behavior.Review of Resident 72's clinical record revealed diagnoses that included dementia and anxiety (a mental health condition that causes fear, dread, and other symptoms that are out of proportion to the situation).Review of Resident 72's clinical record revealed that the Resident had a fall on October 23, 2025, that resulted in no injury; a fall on November 3, 2025, that resulted in skin tears to the right forearm and elbow; and a fall on December 9, 2025, that resulted in a bruise on top of the Resident's right hand, measuring 6.5 centimeters by 6.5 centimeters.Review of Resident 72's MDS dated [DATE], revealed that Section J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment, A. No Injury was marked as having two are more, and B. Injury was marked as having one.During an interview with the NHA on January 8, 2026, at 10:20 AM, revealed that Resident 72's MDS dated [DATE], was coded inaccurately and should have reflected Resident 72 having two falls with injury and one fall with no injury.28 Pa. Code 211.5(f) Clinical records28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on review of select facility documentation and staff interviews, it was determined that the facility failed to utilize and monitor equipment in accordance with professional standards for food service safety in the main kitchen and one of three dining areas ([NAME] Unit). Findings include: Review of document, titled Dish Machine Temperature Log for the main kitchen from April 2024 to present, read, in part, Minimum wash temperature- 150 degrees F (Fahrenheit unit of measure); minimum rinse temperature 180 degrees F. Action Plan: If temperatures are not within acceptable ranges- Circle temperature and notify supervisor. Supervisor will investigate and make necessary adjustments or call maintenance. Supervisor will make note of action taken. Review of the April 2024 Dish Machine Temperature Log for the main kitchen, revealed wash and rinse cycle temperatures failed to be recorded on April 5, 20, and 21, during breakfast and lunch; and April 15, 26, and 27 during dinner. Further review of the April 2024 Dish Machine Temperature Log for the main kitchen, revealed the wash cycle temperature was below the minimum acceptable temperature on April 2 at lunch. No corrective action was noted. Review of the May 2024 Dish Machine Temperature Log for the main kitchen, revealed wash and rinse cycle temperatures failed to be recorded on May 23 through 25 at dinner. Review of the August 2024 Dish Machine Temperature Log for the main kitchen, revealed wash and rinse cycle temperatures failed to be recorded on August 4 and 18 at breakfast; August 3, 17, 18, and 21 at lunch; and August 1, 3, 4, 17-20, and 22 at dinner. Further review of the August 2024 Dish Machine Temperature Log for the main kitchen, revealed the wash cycle temperature was below the minimum acceptable temperature on August 20, 22-25, and 28-30 at breakfast; August 19, 20, 22-25, 29 and 30 at lunch; and August 24 and 25 at dinner. No corrective action was noted. Review of the September 2024 Dish Machine Temperature Log for the main kitchen, revealed the wash cycle temperature was below the minimum acceptable temperature on September 1-5 at breakfast; September 1-5 and 10 at lunch; and September 2 at dinner. No corrective action was noted. Review of the October 2024 Dish Machine Temperature Log for the main kitchen, revealed wash and rinse cycle temperatures failed to be recorded on October 2, 3, 12, 13, and 15 at breakfast and lunch. Review of documents, titled [NAME] Dish Machine Temperatures, from May 2024 to present, read, in part, If temperatures fall below 145 degrees F for wash and 180 for rinse, notify the director of dining services or kitchen supervisor. Review of the May 2024 [NAME] Unit Dish Machine Temperature Log revealed wash and rinse cycle temperatures failed to be recorded on May 1 at dinner; and a final rinse temperature failed to be recorded on May 23 at dinner. Further review of the May 2024 [NAME] Unit Dish Machine Temperature Log revealed the wash cycle temperature was below the minimum acceptable temperature on May 11, 19, 25, and 26 at breakfast; May 1, 11, 17, 18, 25, 26, 29, and 30 at lunch; and May 2, 11, 22, 25, 26 at dinner. No corrective action was noted. Review of the June 2024 [NAME] Unit Dish Machine Temperature Log revealed wash and rinse cycle temperatures failed to be recorded on June 29 at dinner. Further review of the June 2024 [NAME] Unit Dish Machine Temperature Log revealed the wash cycle temperature was below the minimum acceptable temperature on June 5-7, 11, 14, and 15 at breakfast; June 1, 2, 9, 15, and 17 at lunch; and June 5, 8, 21, and 26 at dinner. No corrective action was noted. Review of the July 2024 [NAME] Unit Dish Machine Temperature Log revealed the wash cycle temperature was below the minimum acceptable temperature on July 7, 16, 21, and 27 at breakfast; July 11, 12, 21, and 31 at lunch; and July 4, 15, 21, 24, 25, and 27-31 at dinner. No corrective action was noted. Review of the August 2024 [NAME] Unit Dish Machine Temperature Log revealed the wash cycle temperature was below the minimum acceptable temperature on August 9 and 15 at breakfast; and August 3-5, 15, 16, 20-24, and 31 at dinner. No corrective action was noted. Further review of the August 2024 [NAME] Unit Dish Machine Temperature Log revealed the rinse cycle temperature was below the minimum acceptable temperature on August 2, 6, 9, 15, 22, and 29 at breakfast; August 5, 9, 15, 16, and 18 at lunch; and August 22 at dinner. No corrective action was noted. Review of the September 2024 [NAME] Unit Dish Machine Temperature Log revealed the wash cycle temperature was below the minimum acceptable temperature on September 21 at breakfast; September 19 at lunch; and September 4, 6, 18, and 20 at dinner. No corrective action was noted. Further review of the September 2024 [NAME] Unit Dish Machine Temperature Log revealed the rinse cycle temperature was below the minimum acceptable temperature on September 11, 21, and 22 breakfast; and September 1, 2, and 4 at lunch; no corrective action was noted. In addition, no wash or rinse temperatures were recorded on September 26 at breakfast, lunch, or dinner. Interview with Employee 3 (Dietary Manager) on December 17, 2024, at 12:23 PM, revealed he provides staff education when temperatures are not recorded, and education to staff in the [NAME] dining area to allow the dish machine to heat up to proper temperature prior to use. During an interview with the Nursing Home Administrator on December 18, 2024, at 1:05 PM, she revealed her expectation for kitchen equipment to be utilized and monitored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(3) Management

Based on observations, clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide medications in a manner that respected the residents' dignity for two of 10 residents observed for medication administration (Residents 23 and 53). Findings include: Review of Facility policy, titled Dignity and Respect in Personal Property (F557), revision date December 2022, revealed the policy statement was, Residents have the right to be treated with respect and dignity . Review of Resident 23's clinical record revealed diagnoses that included dementia with Lewy bodies and diabetes mellitus type II. During medication observations on December 18, 2024, at approximately 9:20 AM, Employee 1 was observed preparing two insulin pens for administration for Resident 23. Employee 1 was observed administering the medication (one in each upper arm), while the Resident was seated in the unit's common area with multiple residents present in the room. Review of Resident 53's clinical record revealed diagnoses of dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). During medication observation on December 18, 2024, at approximately 9:17 AM, Employee 1 was observed preparing and administering Resident 53's insulin injection into Resident 53's left lower abdomen after lifting Resident 53's shirt to access the area. Employee 1 administered the insulin injection in the unit's common area with multiple residents present in the room. During a staff interview on December 19, 2024, at approximately 10:30 AM, Nursing Home Administrator revealed it was the facility's expectation the employees provide injections in the Residents' room to afford privacy and dignity for the residents. 28 Pa code 211.12(d)(1)(5) Nursing Services

Based on observations, staff interview, and manufacturer guidance reviews, it was determined that the facility failed to follow infection control procedures for three of 10 residents observed for medication administration (Residents 18, 23, and 53). Findings include: Review of the manufacturer's usage information for Basaglar Kwipen, Lantus Solostar, Novolog Flexpen, and Insulin Aspart Flexpen (insulins contained in a multidose pen dispensing unit), revealed that directions included swabbing the rubber tip of the pen (area that is punctured by an insulin administering needle) prior to attaching the insulin needle to help prevent infection. During medication administration observation on December 18, 2024, at approximately 9:17 AM, Employee 1 was observed preparing Basaglar Kwikpen for Resident 53. Upon removing the cap of the multi-dose pen dispensing unit, Employee 1 failed to cleanse the rubber tip with an alcohol swab prior to attaching the insulin needle. Employee 1 was subsequently observed injecting the insulin into Resident 53. During medication administration observation on December 18, 2024, at approximately 9:20 AM, Employee 1 was observed preparing Lantus Solostar and Novolog Flexpen for Resident 23. Upon removing the cap of the multi-dose pen dispensing units, Employee 1 failed to cleanse rubber tip of the pens prior to attaching the insulin needles. Employee 1 was subsequently observed injecting the insulin into Resident 23. During medication administration observations on December 18, 2024, at approximately 11:13 AM, Employee 2 was observed preparing Insulin Aspart Flexpen for Resident 18. Upon removing the cap of the multi-dose pen dispensing unit, Employee 2 failed to cleanse the rubber tip of the pen prior to attaching the insulin needle. Employee 2 was subsequently observed injecting the insulin into Resident 18. During a staff interview on December 19, 2024, at approximately 10:30 AM, Nursing Home Administrator revealed it was the facility's expectation that employees cleanse the rubber tips of the insulin pens prior to attaching the insulin needles. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 21 residents reviewed (Resident 86). Findings include: Review of facility policy, titled Procedure: Infection Control: BiPAP [bi-level positive airway pressure which is a type of ventilator used to treat sleep apnea] & CPAP [Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps] Devices, dated May 14, 2013, with a last review date of January 25, 2024, revealed the following, in part: E. The following must be done weekly: 4. Change Ziploc bag weekly that holds mask date and initial (3-11); V. SPECIAL CONSIDERATIONS: A. When the mask is not in use store in clear Ziploc bag (bags to be replaced weekly); and B. Date and initial on bag when changed. Review of Resident 86's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and Parkinson's disease (a long term degenerative disorder of the central nervous system that mainly affects the motor system). Review of Resident 86's physician orders revealed an order for CPAP mask-wash daily with soap and water, air dry, dated July 13, 2023. Observations of Resident 86's room on January 29, 2024, at 10:20 AM and 12:39 PM, revealed their CPAP mask was attached to tubing, which was attached to the machine, laying directly on the nightstand and not bagged. Observation of Resident 86's room on January 30, 2024, at 11:09 AM, revealed their CPAP mask was attached to tubing, which was attached to the machine, bagged in a black bag dated 8/[?] The actual day date was noted be illegible as it had been written over. During an interview with Employee 2 on January 30, 2024, at 11:28 AM, the aforementioned observation was shown. Employee 2 confirmed that the actual date was illegible on the bag in which the CPAP mask was being stored. Employee 2 further indicated that they were not sure of the policy as to when the bag should be changed, but they would look into it. Further review of Resident 86's physician orders revealed no order for the CPAP storage bag to be changed on a weekly basis prior to January 30, 2024. Review of Resident 86's January Medication, Treatment, and Task Administration Record Report or documentation of the CPAP storage bag being changed on a weekly basis prior to January 30, 2024. Observation of Resident 86's room on January 30, 2024, at 11:28 AM, revealed that their CPAP mask was stored in a clear Ziploc bag dated January 30, 2024. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on January 31, 2024, at 10:51 AM, all the aforementioned observations were shared. The ADON indicated that Resident 86 had an order for their mask to be rinsed and air dried daily. It was further discussed that the observations on January 29, 2024, revealed that their CPAP mask was still attached to the tubing and to the machine. In addition, it was again shared that the mask was laying directly on the nightstand with no barrier between the mask and the surface of the nightstand. During a follow-up interview with the NHA and DON on January 31, 2024, at 2:25 PM, the DON confirmed that the CPAP mask should not have been laying directly on the nightstand without a barrier if it was being air dried, and that the storage bag should have been changed weekly. 28 Pa code 211.12(d)(1)(2) Nursing Services

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to implement a care plan intervention which specified a two person assist with transfers, resulting in actual harm, as evidenced by a humeral head fracture (commonly known as the ball of the shoulder's ball-and-socket joint), for one of 24 residents reviewed (Resident 59). Findings Include: Review of Resident 59's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 59's care plan interventions dated January 27, 2021, revealed Resident 59's transfer status to be a stand aid (equipment which normally uses power and a secure belt or sling to raise a patient into a standing position and transfer them very short distances to another seat, toilet or bed) with two assists. Review of facility reported incident as well as facility incident report for Resident 59, revealed that on July 2, 2021, at 8:30 PM Employee 5 was assisting Resident 59 in the bathroom. Employee 5 rang the Resident's call bell for assistance to get Resident 59 off of the toilet via stand lift, as Resident 59 is care planned to be a two assist. Employee 5 did not wait for assistance and proceeded to lift Resident 59 off of the toilet, with the stand aid, in order to clean Resident 59. Resident 59 began yelling loudly. When other staff entered Resident 59's room, Resident 59's left arm was observed to be bent up and backwards in the sling. Resident 59 was yelling out in pain, with her left arm wedged tightly in the sling. Staff had to lift the stand aid in order to place Resident 59 back onto the toilet. Resident 59 complained of left shoulder pain and requested to go to the hospital. Resident 59 was transferred to the hospital and was diagnosed with a left humeral head fracture (commonly known as the ball of the shoulder's ball-and-socket joint). Review of Employee 5's witness statement revealed that on July 2, 2021, at approximately 8:30 PM Employee 5 was in the bathroom cleaning up Resident 59. Employee 5 called for assistance, the response was I will be there in a minute. Employee 5 stated she was told during a prior training to make sure she was ready for transfer. Employee 5 stated the strap on the stand aid was correctly in place and so she lifted Resident 59 up off the toilet just enough to clean her front and back and pull Resident 59's brief up. Employee 5 stated she was then going to put Resident 59 back on the toilet until the second assist came. Employee 5 stated when help arrived, Resident 59 asked to sit and that's when the position of Resident 59's shoulder was discovered. Review of Employee 6's witness statement revealed that when Employee 5 called for help, Employee 6 responded and went to assist Employee 5 with Resident 59's transfer. Employee 6 stated that when she entered the bathroom, Resident 59 was already lifted up off the toilet with the stand aid. Employee 6 noticed Resident 59's left arm was up and back and Employee 6 called for another employee for help. Review of Employee 7's witness statement revealed that when Employee 7 entered the room, she discovered that Employee 5, alone, had lifted Resident 59 off of the toilet to clean her. Employee 7 stated that Resident 59 is a stand aid and should be an assist of two. At that time, Employee 7 noted Resident 59's left arm was bent back and up in the sling. Resident 59 was yelling out in pain. Review of facility's investigation revealed that the facility determined that Employee 5 did not follow Resident 59's care plan for transfers with stand aid and two assists, resulting in Resident 59 suffering a fracture of the humeral head. During an interview with the Nursing Home Administrator and Assistant Director of Nursing on March 8, 2022, at 12:57 PM they stated that the facility investigation determined that the sling was appropriately applied and in place and that Resident 59's fracture occurred due to Employee 5 transferring the Resident alone. They stated the second assist was to help with Resident 59's left side during transfers, as Resident 59 has left sided [CONDITION(S)]. Employee 5 did not follow Resident 59's care planned interventions and transferred Resident 59 independently, instead of with a stand aide with two persons, resulting in a humeral head fracture. 28 Pa. Code 201.8 (b) (1) Management 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code (c) (d) (1) (2) (3) (5) Nursing services

Based on facility policy review, clinical record review, review of facility incident reports, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect which resulted in actual harm, evidenced by a humeral head fracture (commonly known as the ball of the shoulder's ball-and-socket joint), for one of 24 residents reviewed (Resident 59). Findings Include: Review of facility policy titled Freedom From Abuse, Neglect, and Exploitation of Residents and Misappropriation of Resident Property most recently dated January 2021, revealed The resident has the right to be free from verbal, sexual, physical and mental abuse, exploitation, neglect, corporal punishment, involuntary seclusion, mistreatment, and misappropriation of property. Prevention: H. Assure that staff assigned has knowledge of the individual care needs through the care planning process. Definitions: Neglect- the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress; intentionally, knowingly or recklessly causes bodily injury, serious bodily injury or death by failing to provide treatment, care, goods or services necessary to preserve the health, safety, or welfare of a care-dependent person for whom he is responsible to provide care Review of Resident 59's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 59's care plan interventions dated January 27, 2021, revealed Resident 59's transfer status to be a stand aid (equipment which normally uses power and a secure belt or sling to raise a patient into a standing position and transfer them very short distances to another seat, toilet or bed) with two assists. Review of facility reported incident as well as facility incident report for Resident 59, revealed that on July 2, 2021, at 8:30 PM Employee 5 was assisting Resident 59 in the bathroom. Employee 5 rang the Resident's call bell for assistance to get Resident 59 off of the toilet via stand lift, as Resident 59 is care planned to be a two assist. Employee 5 did not wait for assistance and proceeded to lift Resident 59 off of the toilet, with the stand aid, in order to clean Resident 59. Resident 59 began yelling loudly. When other staff entered Resident 59's room, Resident 59's left arm was observed to be bent up and backwards in the sling. Resident 59 was yelling out in pain with her left arm wedged tightly in the sling. Staff had to lift the stand aid in order to place Resident 59 back onto the toilet. Resident 59 complained of left shoulder pain and requested to go to the hospital. Resident 59 was transferred to the hospital and was diagnosed with a left humeral head fracture. Review of Employee 5's witness statement revealed that on July 2, 2021, at approximately 8:30 PM Employee 5 was in the bathroom cleaning up Resident 59. Employee 5 called for assistance, the response was I will be there in a minute. Employee 5 stated she was told during a prior training to make sure she was ready for transfer. Employee 5 stated the strap on the stand aid was correctly in place and so she lifted Resident 59 up off the toilet just enough to clean her front and back and pull Resident 59's brief up. Employee 5 stated she was then going to put Resident 59 back on the toilet until the second assist came. Employee 5 stated when help arrived, Resident 59 asked to sit and that's when the position of Resident 59's shoulder was discovered. Review of Employee 6's witness statement revealed that when Employee 5 called for help, Employee 6 responded and went to assist Employee 5 with Resident 59's transfer. Employee 6 stated that when she entered the bathroom, Resident 59 was already lifted up off the toilet with the stand aid. Employee 6 noticed Resident 59's left arm was up and back and Employee 6 called for another employee for help. Review of Employee 7's witness statement revealed that when Employee 7 entered the room, she discovered that Employee 5, alone, had lifted Resident 59 off of the toilet to clean her. Employee 7 stated that Resident 59 is a stand aid and should be an assist of two. At that time, Employee 7 noted Resident 59's left arm was bent back and up in the sling. Resident 59 was yelling out in pain. Review of facility's investigation revealed that the facility substantiated neglect against Employee 5, as Employee 5 did not follow Resident 59's care plan for transfers with stand aid and two assists, resulting in Resident 59 suffering a fracture of the humeral head. During an interview with the Nursing Home Administrator and Assistant Director of Nursing on March 8, 2022, at 12:57 PM they stated that the facility investigation determined that the sling was appropriately applied and in place and that Resident 59's fracture occurred due to Employee 5 transferring the Resident alone. They stated the second assist was to help with Resident 59's left side during transfers, as Resident 59 has left sided [CONDITION(S)]. The facility failed to ensure that Resident 59 was free from neglect when Employee 5 did not follow Resident 59's care planned interventions and transferred Resident 59 independently instead of with a stand aide with two persons resulting in a humeral head fracture. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that food service equipment was stored in accordance with professional standards of food safety in the main facility kitchen. Findings include: Observation on March 8, 2022, at approximately 12:35 PM revealed plastic domed plate covers stacked and stored under a food preparation table. The domes were stored with the clean underside facing upwards. Dietary staff were observed utilizing these domes while preparing resident meal trays. During an interview with the Dietary Manager at the time of observation, he revealed the expectation that the plate domes should have been stored with the clean underside facing down. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services consistent with professional standards to prevent infection and promote healing for one of two residents reviewed for pressure ulcers (Resident 40). Findings include: Review of Resident 40's clinical record on March 7, 2022, at approximately 12:30 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During wound treatment observations on March 9, 2022, at approximately 1:50 AM, revealed facility Employee 4 performed a treatment dressing change for Resident 40 stage IV pressure ulcer. During the treatment dressing change facility Employee 4 was observed changing gloves between removing the soiled dressing and cleansing the wound and between cleansing the wound and applying the clean dressing. During the observed glove changes facility Employee 4 did not perform hand hygiene. During a staff interview on March 10, 2022 at approximately 10:40 AM, Nursing Home Administrator revealed that staff are expected to perform hand hygiene prior to and after the dressing change per the facility policy titled, Wound Management Program Infection Prevention and Control, (last reviewed January 27, 2022), and also when changing gloves between removing a soiled dressing, cleansing a wound, and applying a clean dressing. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, facility document review and staff interviews, it was determined that the facility failed to ensure care and services were provided in a manner that preserved a resident's dignity and privacy for one of two residents reviewed for pressure ulcers (Resident 40) and one of four residents observed for medication administration (Resident 50). Findings include: Review of Resident 40's clinical record on March 7, 2022, at approximately 12:30 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During wound treatment observations on March 9, 2022, at approximately 1:50 AM, revealed facility Employee 4 entering and preparing the treatment dressing supplies for Resident 40. During preparation, two separate facility staff entered and exited the resident room. Observation of Resident 40 revealed Resident 40 was sitting in a chair at the bedside. During observations of facility Employee 4 removing Resident 40's soiled dressing, cleansing and applying a clean dressing to Resident 40's right ankle wound, it was observed that Resident 40's room door was left open to the unit hallway. During the entirety of the treatment observation, Resident 40's right ankle treatment was visible from the unit hallway. During a staff interview on March 10, 2022, at approximately 10:40 AM, Nursing Home Administrator revealed that it was the facility's expectation that residents are provided privacy during wound dressing changes are performed. Review of facility policy titled, Administration of Medications, last reviewed January 27, 2022, revealed the Policy Statement, included, In accordance with the person centered care and established policies, residents shall receive their medications in the location of their choice. Review of Resident 50's clinical record on March 9, 2022, at approximately 10:00 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During medication observations on March 9, 2022, at approximately 9:32 AM, facility Employee 4 was observed administering Resident 50's medications in the common area of the rehabilitation room. Prior to administration, facility Employee 4 did not ask or confirm if it was ok for the medications to be administered in the common area. During a staff interview on March 10, 2022, at approximately 10:40 AM, Nursing Home Administrator revealed that facility Employee 4 should have asked Resident 50 if she wanted to be provided medications in a private, non-common, area prior to medication administration. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and care to ensure the highest practicable level of well-being for one of four residents reviewed for skin conditions (Resident 71). Findings include: Review of Resident 71's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility skin damage moisture-associated [CONDITION(S)] or excoriation protocol form dated January 29, 2022, revealed that an area of moisture-associated skin damage (MASD) was identified on Resident 71's left inner buttock on that date. Further review of this protocol form, last updated March 8, 2019, revealed instructions to notify the physician if the skin damage deteriorates since last documentation. Review of MASD/Excoriation/Rash Progress Report revealed that Resident 71's area on the left inner buttocks was evaluated on February 26, 2022. The overall progress of healing was documentated as deteriorated. The description of the lesion was noted as flat on February 20, 2022, and excoriated on February 26, 2022. The size of the lesion was noted to be 3.5 cm x 2 cm on February 20, 2022, and 3.6 cm x 1.4 cm on February 26, 2022. The shape of the lesion was noted to be oval on February 20, 2022, and long oval on February 26, 2022. Finally, the color of the lesion was noted to be light pink on February 20, 2022, and pink on February 26, 2022. Further review of this form revealed that Resident 71's area of skin damage was again evaluated on March 4, 2022. At that time, the overall progress of healing was again noted to be deteriorated. Further review of Resident 71's clinical record failed to reveal any evidence that the physician was notified of, or that a practitioner evaluated, Resident 71's area of skin damage after it was first noted to be deteriorated on February 26, 2022. Review of physician communication/order forms revealed that the physician was notified on March 4, 2022, of the deteriorated status of the area of skin damage, and new treatment orders were obtained at that time. During an interview with the Nursing Home Administrator on March 10, 2022, at 9:30 AM she confirmed that nursing documentation showed the skin area to be deteriorated on February 26, 2022, and that there was no evidence that the physician was notified of this change in status. She also revealed the expectation that the physician should have been notified of the change. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure as-needed anti-psychotic drugs were evaluated and renewed every 14 days for one of five resident records reviewed for [MEDICAL CONDITION] medication use (Resident 26). Findings include: Review of Resident 26's clinical record on March 8, 2021, at approximately 1:30 PM, revealed [DIAGNOSES REDACTED]. Review of Resident 26's physician orders [REDACTED]. Review of the clinical record revealed no review of, nor new order for the as-needed antipsychotic medication every 14 days. Review of Resident 26's clinical record on March 19, 2021, at approximately 12:30 PM, revealed a pharmacy recommendation was made on January 27, 2021 which stated, If you believe this resident's (as-needed) order for [MEDICATION NAME] is appropriate beyond 15 days (see CMS regulations below, then follow the instructions below), at the current dose and/or if a reduced dose is appropriate. 1. Please document your rationale and indicate the duration of therapy, if the (as needed order is to continue; in the resident's medical record or below, after first discussing the continued use of this medication with the resident . 2. Please write a New Prescription, if it should continue EVERY 14 days . Review of the pharmacy recommendation revealed that the physician responded on February 1, 2021 and documented, No (change). During an interview on March 11, 2021, at approximately 11:15 AM, Nursing Home Administrator and Director of Nursing revealed it was the facility's expectation that as-needed anti-psychotic medications are reviewed and reordered by the physician every 14 days. 28 Pa. Code 211.2(a) Physician services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, facility policy review and staff interview, it was determined that the facility failed to ensure the resident environment was free from accident hazards for one of 4 resident units observed (Hall 2). Findings include: Review of facility policy titled Administration of Medications, last reviewed January 29, 2021, revealed that section 14 of Policy Interpretation and Implementation, revealed it stated, During routine medication passes, the nurse will secure and lock the medication cart . General observations on March 10, 2021, at approximately 8:50 AM, revealed that the Hall 2 medication cart was located in the hallway between rooms [ROOM NUMBERS]. Observation of the medication cart revealed that the medication cart was unlocked and the medication drawers were accessible. During the observation two residents were observed sitting next to the medication cart on either side approximately 2 to 3 feet from the medication cart. Observations of the Hall 3 at the time revealed that the medication nurse was not visible in the hall. At approximately 8:54 AM, the Director of Nursing and the Assistant Director of Nursing were made aware of the unlocked medication cart at which time the Assistant Director proceeded to the medication cart and locked it. During a staff interview on March 11, 2021, at approximately 11:15 AM, the Nursing Home Administrator and Director of Nursing it was the facility's expectation that medication carts are locked when unattended. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident's care plan was reviewed and revised to reflect the resident's current status for one of 26 residents reviewed (Resident 14). Findings include: Review of Resident 14's clinical record revealed [DIAGNOSES REDACTED].). Observations of Resident 14 on March 9, 2021, at 8:45 AM, and on March 10, 2021, at 12:58 PM revealed resident eating a meal. Present during each observation was an adaptive ladle-type spoon that the resident was using to eat the meal and/or nursing staff was utilizing to assist Resident 14 with the meal. Review of an occupational therapy daily treatment note dated January 5, 2021, revealed, Foods today did not require a spoon, however ladle spoon missing from the unit and not able to be found in the kitchen. Another spoon is to be ordered. Spoon will need to stay and be cleaned on the unit as this spoon is specific to this patient. Review of occupational therapy progress and discharge summary dated January 8, 2021, revealed, The patient performs self feeding using scoop dish and ladle spoon with min (minimal) (25% assist) assistance. Review of Resident 14's current care plan revealed a concern with an activity of daily living deficit due to [MEDICAL CONDITION], muscle weakness and cognitive impairment with an intervention to provide adaptive equipment. Review of Resident 14's care profile revealed that the ladle spoon was not noted among the adaptive equipment that is to be provided to Resident 14 during meals. During an interview with the Registered Nurse Assessment Coordinator (RNAC) on March 10, 2021, at 11:20 AM, he confirmed that Resident 14 is provided with a ladle spoon and that this should have been added to Resident 14's care plan/care profile. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on staff interviews, record reviews, and review of facility documents, the facility failed to follow the Centers for Disease Control and Prevention (CDC) recommended practices regarding routine screening of all admitted residents for signs and symptoms of COVID-19 for 2 of two residents with a previously confirmed COVID infection (Residents 1 and 2). Findings include: According to CDC guidelines for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings at cdc.gov, CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. These additional practices include . Re-evaluate admitted patients for signs and symptoms of COVID-19. While screening should be performed upon entry to the facility, it should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate). A review of the facility's policy titled COVID-19 Testing Strategies for Residents dated July 14, 2020, revealed implementation of the policy included Baseline screening to keep COVID-19 ([DIAGNOSES REDACTED]-CoV-2) out of the facility. Actively screen all residents in the facility for fever and COVID-19 symptoms at least twice daily. Additionally, review of facility policy revealed, Testing should not replace existing infection prevention and control interventions. Testing should be implemented in addition to existing infection prevention and control measures, including visitor restriction, cessation of communal dining and group activities, monitoring all HCP (Health Care Personnel) . and residents for signs and symptoms of COVID-19, and universal masking as source control. Record review for Resident 1 revealed COVID positive test results were received for this resident on July 20, 2020. Review of nursing progress notes dated July 28, 2020, on an alert charting form to rule out respiratory infection (tracking form used to document vitals as well as potential respiratory infection signs and symptoms) revealed, This A/C (alert charting) is DC'd (discontinued) per MD (doctor). Review of Resident 1's Medication, Treatment, and Task Administration Record Report for July 2020 revealed orders to monitor temperature, pulse ox (measures oxygen saturation levels in the blood), shortness of breath and cough every 12 hours. This order was effective June 26, 2020, and was discontinued on July 20, 2020 (date COVID positive results were received). Futher review of the report revealed an order to monitor full set of vitals and cough every shift for positive COVID. This order was effective July 20, 2020, and was discontinued July 27, 2020. An additional order was present to monitor full set of vitals and cough every shift for positive COVID. This order was effective July 27, 2020, and was discontinued on July 28, 2020. Review of the report failed to reveal any orders for additional monitoring for potential COVID signs or symptoms beyond this date. Record review for Resident 2 revealed COVID positive test results were received for this resident on July 20, 2020. Review of nursing progress notes dated August 2, 2020, on an alert charting form to rule out respiratory infection revealed, Res (resident) COVID results - (negative) d/c (discontinue) A/C (alert charting). Review of Resident 2's Medication, Treatment and Task Administration Record Report for July 2020 revealed orders to monitor temperature, pulse ox, shortness of breath and cough every 12 hours. This order was effective June 26, 2020, and was discontinued on July 21, 2020. Futher review of the report revealed an order to monitor full set of vitals and cough every shift for positive COVID. This order was effective July 20, 2020, and was discontinued July 27, 2020. An additional order was present to monitor full set of vitals and cough every shift for positive COVID. This order was effective July 27, 2020, and was discontinued on July 28, 2020. A third order was present to monitor full set of vitals and cough every shift for positive COVID effective July 28, 2020 and was discontinued on August 2, 2020. Review of the report failed to reveal any orders for additional monitoring for potential COVID signs or symptoms beyond this date. Email correspondence received from the Nursing Home Administrator on August 6, 2020, at 11:07 AM, in response to inquiry about ongoing monitoring for potential COVID-related signs and symptoms for residents who had previously tested positive for COVID revealed, We have not received any guidance on reinfection and have not heard of this as a possibility in any of the PA HAN (Health Alert Network) documents. We were following the guidance based on not re-testing positive residents or HCP and to test all previously negative residents. Any changes noted to the residents' physical and/or mental baseline would be reported and an assessment would be completed as we would for any other potential issue. During a phone interview with the Nursing Home Administrator (NHA) on August 6, 2020, at 3:37 PM, she revealed that since they have not seen literature that reinfection is possible, a decision was made to discontinue twice daily screening for previously COVID positive residents, but to err on the side of caution, the facility has put this back into practice as of this date. 28 PA. Code 211.10(d) Resident care policies. 28 PA. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to ensure services are provided in accordance with each resident's written plan of care for one of three residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 2's care plan, dated (MONTH) 3, 2019-present, revealed Transfers: Stand-aid lift and 2 assist. Left arm sling must be removed before all transfers. One CNA must guide her left arm during the transfers. Review of Resident 2's facility form titled Incident/Accident Report dated (MONTH) 10, 2020, revealed that Nurse Aide (NA) 1 finished giving Resident 2 a shower and was lifting the Resident with the stand aid by herself, when Resident 2 began sliding out of the harness onto the left side. NA 1 lowered Resident 2 to the floor. During an interview with the Director of Nursing on (MONTH) 10, 2020, at 10:45 AM she confirmed that NA 1 was not following Resident 2's care plan at the time of the incident. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records and facility grievance forms, as well as staff interviews, it was determined that the facility failed to thoroughly investigate the grievance of a resident's legal representative for one of five residents reviewed (Resident 2). Findings include: Review of the facility's policy titled, Grievances/Complaints-Investigating, last reviewed (MONTH) 2019, revealed that the investigation of grievances will include, among other things, the resident's account of the incident and the employee's account of the incident. A complaint/grievance form submitted by Resident 2's legal representative, dated (MONTH) 18, 2019, revealed that the resident had been left in the bathroom on (MONTH) 16, 2019, during the day and felt light-headed, she rang for assistance and no one came for over 30 minutes. Additionally, the grievance states that on one occasion, the resident woke up at night and a male caregiver was sitting in her room and this frightened her. Review of the facility's investigation, completed (MONTH) 6, 2019, revealed that neither the staff assigned to resident on (MONTH) 16, 2019 nor the male caregiver, Nurse Aide (NA) 1, who had been identified in the grievance, were interviewed to determine if the allegations made by resident's family member were true. An interview with the Director of Nursing on (MONTH) 28, 2019, at 2:15 p.m. confirmed that she had not interviewed the staff in regard to the grievance but had interviewed the resident, who had no concern at the time, and therefore, the DON didn't think it necessary to do so. 28 Pa. Code 201.29(i) Resident rights.

Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by an elopement risk by residents for one of five residents reviewed (Resident 4) who removed a window screen, opened the window and eloped from the secured unit resulting in potential risk for injury to the resident. Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. Resident 4 was admitted to the facility on (MONTH) 9, 2019. Review of the Admission Assessment (a tool used to evaluate various care concerns) revealed that Resident 4 was considered at risk for elopment and that elopement precautions should be initiated. Review of Resident 4's care plan, developed (MONTH) 16, 2019, revealed a problem area for elopement risk with approaches which included initiate elopement bracelet ( a device that alerts staff when the resident is exiting the building) one to o one to vent feelings, identify concerns, and redirect resident. Review of Resident 4's (MONTH) 2019, physician orders [REDACTED]. Review of Resident 4's admission Minimum Data Set assessment (MDS-a tool used to assess all care areas specific to the resident), dated (MONTH) 2019, revealed Section E-Behavior, subsection E0900 Wandering-Presence and Frequency was coded as 1, Behavior of this type occurred 1 to 3 days, but less than daily (during the seven-day lookback). Review of facility incident report dated (MONTH) 19, 2019, at 8:15 PM, revealed the following: someone (a man) entered the facility and approached staff and stated he thought one of our residents may have walked off. Staff followed the man outside through the main doors and across the street of the corner of W. South St. and Orange St. where his wife was waiting with resident. House supervisor and LPN (licensed practical nurse) form hall able to walk resident back inside. Staff found a screen off window in dining room Resident stated I climbed out the window Foot prints noted in mulch. Skin assessment completed with no noted injury. Review of witness statements attached to the incident report revealed that resident had been in the lounge watching TV. Notifications to Resident 4's physician and responsible party were done. Immediate interventions included every 15 minute checks and the maintenance director secured windows with screws. Interview with the Director of Nursing on (MONTH) 28, 2019, at approximately 1:30 PM revealed that Resident 4 had told staff she wanted to stay in the dining room, where she was seated near the window, and watch TV. She was left to do so and subsequently climbed out of the window undetected. The facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by elopement risk for Resident 4 who removed a screen and climbed out of the a window in the dining room. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3)(d) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 and other drugs subject to abuse, for one of two medication carts observed (Hall 3 medication cart). Findings Include: Review of facility policy titled, Controlled Medication Storage, with a policy review date of (MONTH) (YEAR), revealed the access system used to lock controlled medications and other medications subject to abuse cannot be the same access system used to obtain the non-scheduled medications. Observation of Hall 3 medication cart on (MONTH) 21, 2019, at 11:59 AM revealed 355 50mg tablets of [MEDICATION NAME] (Pain medication) and 28 tablets of [MEDICATION NAME] ER (extended release pain medication) stored in the medication cart, not separately locked in a permanently affixed compartment. Review of Drug Enforcement Administration fact sheet on [MEDICATION NAME], dated (MONTH) (YEAR), revealed Dependence and abuse, including drug-seeking behavior and taking illicit actions to obtain the drug are not limited those patients with prior history of opioid dependence. The risk in patients with substance abuse has been observed to be higher. [MEDICATION NAME] is associated with craving and tolerance development. Review of Food and Drug Administration fact sheet on [MEDICATION NAME], revised (MONTH) 2008, on page 18 revealed: [MEDICATION NAME] can be abused and may be subject to criminal diversion. During an Interview with the Nursing Home Administrator on (MONTH) 23, 2019, at 10:30 AM revealed that she would expect the medications to be stored in compliance with facility policy and federal regulation and that they are now locked as such.

Based on observation, interviews and record reviews it was determined that the facility failed to timely identify and address declines in skin integrity under a fracture brace to the right upper arm which resulted in harm in the development of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) to the right axilla (armpit) area for one of three residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 on (MONTH) 31, 2019, at 9:00 AM revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident 1 was admitted to the facility on (MONTH) 21, 2019, and at that time presented with an Ace wrap (elastic bandage used to decrease swelling and protect contused joints) and splint (a device used for support or immobilization of a limb) to her right upper arm. On (MONTH) 27, 2019, Resident 1 went to a scheduled appointment with her orthopedic (bone) physician. Documentation of this consult included the following recommendations: convert to a Samiento Humerus Fracture Brace (a type of brace for a broken humerus bone applies compression to the soft tissue around one's upper arm, which helps control the humeral segments as needed when one sustains a humerus fracture or some other break of this bone), to be provided by your facility; may shower with brace, loosen brace to dry skin, otherwise brace is always to be worn; range of motion of hand and elbow OK-no shoulder range of motion; return in 5-6 weeks for updated X-ray. Review of the facility's daily documentation of the Neurovascular Assessments (also called a circulation check is performed to determine if there is adequate circulation and sensation to an extremity) for the right upper arm dated (MONTH) 23, 2019 through (MONTH) 29, 2019, were marked no [MEDICAL CONDITION]. The clinical record revealed that the facility purchased a different style of fracture brace on (MONTH) 28, 2019, which was not the specified brace recommended by the orthopedic consultant. The alternate brace was delivered to the facility, fitted and applied to Resident 1 on (MONTH) 7, 2019. The physician orders [REDACTED]. Review of the Occupational Therapy notes, with a late entry date for (MONTH) 21, 2019, state the following: The COTA (Certified Occupational Therapy Assistant) treating the resident (Resident 1) brought to my attention that the axillary (armpit - the junction between the arm and the body) region of the resident's brace had a discolored fluid on it, and skin cells. I took the brace to the Licensed Practical Nurse (LPN) and Registered Nurse (RN) who immediately performed a skin check of the resident's axillary region. This therapist was consulted to assess the brace and assist with moving the (UE) upper extremity per doctor's instructions. This therapist spoke with the resident's orthopedic doctor's nurse to clarify if the current brace could be modified, and donned. The nurse stated that after modifying the brace this therapist may put the brace back on the resident. This therapist asked if the office could fit her for a different type of brace and asked for specific shoulder adduction degrees. This therapist went with the wound nurse to don the brace and check where the brace may be causing pressure. There was no documentation to reveal that the orthopedic nurse was informed that an alternate brace was already chosen and placed on the resident. Further documentation for the late entry for (MONTH) 21, 2019, revealed that OT 1 (Occupational Therapist-a health care professional who provides services designed to restore self-care, work, and leisure skills to patients/clients who have specific performance incapacities or deficits that reduce their abilities to cope with the tasks of everyday living), marked the axillary region of the fracture brace and removed a significant section of the brace in the axillary region. There was no documentation that the physician was notified about the modifications to the fracture brace. An additional review of the clinical record revealed that on (MONTH) 20, 2019, staff removed the fracture brace to perform a superficial wound check. The facility documented that the underside of the arm and axillary region were not observed on (MONTH) 20, 2019, or previously due to range of motion restrictions. On (MONTH) 21, 2019, the brace was removed again and taken to therapy for modification to the distal/elbow area of the brace, because the therapist thought that the zipper on the brace was a too tight at the elbow region. The facility documented that upon inspection of the brace a large amount of foul-smelling serosanguineous (blood-tinged wound drainage) drainage was found on the axillary region of the brace. The Registered Nurse's assessment of Resident 1's right axillae region revealed a unstageable (slough) pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) that measured 2 cm long (centimeters-metric measurement 2.5 cm equals 1 inch) by 3 cm wide. The resident's temperature was 99.6 degrees Fahrenheit (a metric form of measurement). Review of the Medication, Treatment and Task Administration Record Report for (MONTH) 2019, revealed an order for [REDACTED]. The facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore which resulted in harm in the development of a pressure sore to the right axilla area of Resident 1. 28 Pa. Code 201.29(d) Resident rights. Previously cited 5/12/17. 28 Pa. Code 211.5(f) Clinical records. Previously cited 5/12/17. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(a)(c)(d)(3) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/12/17.

Based on clinical record review, review of select policies and procedures, observations and staff interviews, it was determined that the facility failed to provide an environment free from accident hazards and to provide supervision to prevent accidents, regarding access to a construction area containing power tools, for the residents on Hall 4 and the Activities Hall. This created the potential for actual harm and placing the residents in Immediate Jeopardy for 6 of 30 residents reviewed (Residents 18, 22, 23, 27, 28, and 29). The facility also failed to prevent potential hazards to residents by placing used lancets in the open trash bin located at the base of the medication cart while in the hall. Findings include: During the initial tour on May 8, 2017, at approximately 9:00 a.m. observations were made of Hall 4 and the Activities Hall, which revealed two doors on each hall which opened to an unfinished construction area. It was observed that on Hall 4, one door was located across the resident corridor from Room 51, which entered into one room under construction, and one door was located across from the nurses' station, which led into a separate room under construction. On the Activities Hall, it was observed that there were two doors across from the resident activity room, which opened to an unfinished construction area. An observation on May 9, 2017, at approximately 1:05 p.m. revealed that Resident 18 was seated in a wheel chair which was in the hallway, approximately 3 feet away from the construction entrance door located across from Room 51. Observation of Hall 4, where Resident 18 was seated, revealed no staff personnel in the area. An observation of the construction room, located across from Room 51, on May 9, 2017, at approximately 1:09 p.m. revealed multiple tools including: cordless electric drills with attached drill bits, a cordless electric nail gun, a cordless electric reciprocating saw with the blade attached, a utility razor blade, and metal cutting sheers. Also, located in the room were multiple unfinished electrical outlets hanging from the ceiling, multiple unfinished metal frames, and a square hole cut in the concrete floor which measured approximately, one foot square and approximately 8 inches deep, which led to an undetermined area of the building due to an obstruction by sheet metal. During the observation, it was revealed that no nursing staff or construction staff were present inside the room. At approximately 1:20 p.m. a construction staff person entered the room. An observation on May 9, 2017, at 6:15 p.m. revealed one of the doors leading into the construction area, located in the Activities Hall, was unlocked. Located inside the construction area were multiple battery powered tools; such as, a reciprocating saw, drills, hammers, saw blades and multiple hazardous chemicals such as, paint and glue. During interviews on May 9, 2017, between 6:26 p.m. and 6:50 p.m. the nursing staff were asked, What is the facility's process or procedure, in regards to the construction area and keeping residents safe? At approximately 6:26 p.m. Nurse Aide (NA) 1 revealed that she was not aware of any incidents/injuries incurred by residents during the construction and that she had not seen any residents enter the construction area. At approximately 6:37 p.m. NA 2 revealed that they are to keep the residents away from the boarded areas and make sure that the small doors are locked. NA 2 revealed that the registered nurses and construction workers were responsible to check that the doors were locked. At approximately 6:39 p.m. Registered Nurse (RN) 2 responded, Not to go in there. I think the RN (supervisor) had the key. At approximately 6:40 p.m. RN 3, acting RN supervisor stated, We have done hourly fire checks when told to depending on if the fire system is down, but that has been sporadically. All construction doors are locked. At approximately 6:42 p.m. Licensed Practical Nurse (LPN) 1 stated, By the time we (second shift staff) arrive the construction people are gone. So, they have cleared the dangerous stuff. At approximately 6:43 p.m. NA 3 revealed she was told to keep the residents out of way of the construction. Review of Resident 18's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 18's clinical record revealed that Resident 18 required assistance of staff to move about, however, during a staff interview on May 9, 2017, at approximately 6:44 p.m. Registered Dietician 1 stated Resident 18 does self-propel by himself at times. On May 9, 2017, at approximately 6:50 p.m. RN 1 revealed that she had been training in the facility for about two weeks and had not been given any specific instruction regarding residents and construction concerns. RN 1 revealed that she was aware of signs to, keep out in the construction areas and that the areas were taped off. At approximately 6:50 p.m. Activities Assistant (AA) 1 revealed that all the doors to the construction areas are locked at all times and that the staff monitor the resident to keep them out of those rooms. AA 1 stated, Residents have tried to enter the construction area but do not get in because the door was locked. During staff interviews during the aforementioned times staff were asked, Do you care for any residents who wander? RN 2 responded, Yes. Depends where I am. I'm (as-needed). RN 2 revealed Resident 27 utilized a walker to ambulate independently on the unit which included Hall 2, Hall 3, Hall 4, and the Activities Hall. RN 2 revealed Resident 27 is, .confused at times. I would say (Resident 27) has moderate dementia. LPN 1 stated, (Resident 29) is independent in (Resident 29's) wheel chair. (Resident 29) is alarmed, indicating that the resident would sound an alarm if the Resident 29 attempted to leave the doors of the unit/facility, and that the facility performs safety checks on Resident 29 every 30 minutes. LPN 1 revealed that Resident 29 was, .confused, has dementia. But, has times (that Resident 29) is lucid. (Resident 29) has behaviors, gets frustrated sometimes (and) needs redirection. Observation of the doors leading into the construction areas revealed they were not equipped with an alarm. NA 1 revealed that Resident 28 wandered the unit and was cognitively impaired. NA 2 revealed that Resident 27 and Resident 28 wandered the unit. NA 2 revealed Resident 28 was equipped with an alarming bracelet for the prevention of elopement. NA 2 revealed Resident 27 had wandering behavior and was confused. NA 3 revealed that Resident 28 wandered the unit. During a staff interview on May 9, 2017, at approximately 7:20 p.m. the Nursing Home Administrator (NHA) was asked, What is the facility's process or procedure, in regards to the construction and keeping residents safe? NHA stated, That's why we have walls up. We do rounds. And locks on the doors that are under construction. The State Surveyor asked when the facility did rounds and the NHA responded, daily. The Director of Nursing (DON) stated at this time, through-out the day. The State Surveyor asked, what was the facility's expectation regarding the doors leading to the construction area, to which the NHA responded, They're locked. The DON stated, (The doors that are used to access the construction doors) are open during the day while they are attended. Dietician 1, at that time, stated, (The doors that are used to access the construction doors) have signs on them that say, 'construction personnel only'. When asked if the facility had residents who had wandering behaviors the DON stated, Yes, we have identified residents who are on 15 minute and 30 minute checks. The DON was unable to provide a list at that time of which residents of the facility were on 15 minute and 30 minute checks. A list was requested by the State Surveyor at that time. At approximately 8:38 p.m. the DON provided a list that included Residents 22, 23, 26, 27, 28, 29, and 30 and stated those residents were identified as elopement risks and they were either receiving visual checks by staff every 15 or 30 minutes to ensure resident safety. The State Surveyor then asked, Do you expect the (doors leading to construction areas) to be locked? The NHA confirmed that the facility expected the doors to the construction areas to be locked. The DON responded, (The construction personnel) may leave them unlocked sometimes. If (the construction personnel) leave for a short time . and that the doors are sometimes left unlocked if the construction personnel are retrieving an item and are only leaving the door unattended for, a short time. When the DON was asked to define a short time, DON responded, It's all relative. When asked what the procedure was to ensure that the doors were locked after the construction workers, work days were over, the DON stated that different areas may be open later than others due to different construction workers leaving at different times and stated, It wouldn't be unheard of to have (construction) workers here late. On May 9, 2017, at 7:53 p.m. the NHA was notified that the facility was placed in Immediate Jeopardy status related to the door to the construction area being unlocked posing an accident hazard and harm to residents. A corrective action plan was requested. On May 9, 2017, at 11:39 p.m. the Plan of Correction was accepted which included the * when the doors would be locked and by whom, * the persons responsible to ensure that the doors were locked and when they would ensure that the doors were locked, * changes to the door knobs/locks that would keep them locked at all times and unlocked with a code for use, * how the facility would ensure that the doors were locked, * audits to ensure that the doors were locked, * the staff were educated regarding resident safety, locking the doors, and the notification of unlocked doors to the Maintenance Director immediately. On May 9, 2017, at 11:44 p.m. the Plan of Correction was reviewed, observations and interviews were done to ensure that the Plan of Correction was implemented which included new locks installed on all construction doors that were locked at all times unless a numeric code was used to unlock them for a short period of time for access, door security logs performed by nursing staff and the Maintenance Director. On May 10, 2017, at 12:15 p.m. the NHA was notified that the Immediate Jeopardy status was lifted. Review of Resident 22's clinical record on May 9, 2017, at approximately 8:00 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 22's quarterly Minimum Data Set (MDS - assessment tool utilized to identify physical, mental, and psychosocial strengths and needs), dated April 12, 2017, revealed Resident 22 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS - assessment of cognitive status) which indicated severe cognitive impairment. Review of Resident 22's most recent elopement assessment, dated April 14, 2017, revealed that Resident 22 was independently mobile. Review of Resident 22's plan of care revealed Resident 22 was care planned to self-ambulate without assistance and that staff were to perform visual checks for safety every 30 minutes. Review of Resident 23's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 23's annual MDS dated [DATE], revealed Resident 23 scored a 4 out of 15 on the BIMS assessment, which indicated severe cognitive impairment. Review of Resident 23's most recent elopement assessment, dated March 16, 2017, revealed that Resident 23 was independently mobile. Review of Resident 23's plan of care revealed the staff were to perform visual checks on Resident 23 for safety every 15 minutes. Review of Resident 27's clinical record on May 9, 2017, at approximately 8:20 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 27's quarterly MDS dated [DATE], revealed Resident 27 scored a 8 out of 15 on the BIMS assessment which indicated a moderate cognitive impairment. Review of Resident 27's plan of care revealed Resident 27 was care planned for wandering behavior. Review of Resident 27's most recent elopement assessment, dated April 10, 2017, revealed Resident 27 was independently mobile and has a history of exit seeking (attempting to open doors to exit the building). Resident 27 was care planned to have safety checks every 30 minutes. Resident 27 was care planned to utilize a walker for ambulation. Review of Resident 28's clinical record on May 9, 2017, at approximately 8:40 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 28's change of therapy MDS, dated [DATE], revealed Resident 28 scored a 4 out of 15 on the BIMS assessment, which indicated severe cognitive impairment. Review of Resident 28's plan of care revealed Resident 28 was care planned for wandering behavior and care planned for elopement. Review of Resident 28's elopement risk assessment, dated April 6, 2017, revealed Resident 28 was independently mobile and had a history of [REDACTED]. Review of Resident 29's clinical record on May 9, 2017, at approximately 9:30 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 29's quarterly MDS, dated [DATE], revealed Resident 29 scored a 3 of 15 on the BIMS assessment, which indicated severe cognitive impairment. Review of Resident 29's plan of care revealed that Resident 29 was care planned for elopement risk. Review of Resident 29's elopement risk assessment, dated February 17, 2017, revealed the Resident 29 was independently mobile and that Resident 29 had a history of [REDACTED]. Review of the plan of care revealed that Resident 29 was to be visually observed every 30 minutes for safety. Based on clinical record review, observation and staff interview it was determined that Residents 18, 22, 23, 27, 28, and 29 were cognitively impaired and could ambulate independently which put them at risk of environmental accident hazards. Review of the facility policy titled Sharps Injury Protection Program last reviewed February 2017, revealed that lancets (a device used to perform blood sugar checks) should be discarded in biohazard sharp containers. During an observation on May 9, 2017, at 3:33 p.m. LPN 1 completed a blood sugar check on Resident 108. After completing the blood sugar check, LPN 1 disposed of the used lancet in an open trash bin located at the base of the medication cart, approximately 2 feet from the floor. During an interview on May 9, 2017, at 3:38 p.m. LPN 1 confirmed that she should have disposed of the lancet in the biohazards sharps containers and not in the open trash bin. During an observation on May 9, 2017, at 4:42 p.m. RN 2 completed a blood sugar check on Resident 58. After completing the blood sugar check, RN 2 disposed of the used lancet in an open trash bin located at the base of the medication cart, approximately 2 feet from the floor. During an interview on May 9, 2017, at 3:38 p.m. RN 2 confirmed that she should have disposed of the lancet in the biohazards sharps containers and not in the open trash bin. During an interview with the Director of Nursing on May 11, 2017, at 2:45 p.m. it was confirmed that lancets are to be disposed of in the biohazard sharp container and not in open trash bins. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 5/7/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/7/15.