Every finding on record at Shenandoah Senior Living Community

Based on a review of select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for four residents of 24 residents observed for the presence of drinking water. (Residents 1,2,3,4).Findings include: A review of the facility policy titled Serving Drinking Water last reviewed by the facility on June 2025, indicated the facility will provide a fresh supply of drinking water and provide adequate fluids for the residents. During the survey, an observation of a dietary cart with water pitchers stacked on it, was located in the hallway across from the nursing station of the C and D units. This surveyor observed the cart there at 10:00 AM, and at 12:30 PM. A review of the clinical record revealed Resident 1 was admitted to the facility July 18, 2018, A review of the quarterly Minimum Data Set(MDS , a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 14, 2026 revealed that Resident 1 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact) An interview with Resident 1 conducted on June 6,2026 at 11:20 AM revealed her water pitcher was picked up sometime during the night so it could be cleaned, but it had not yet been returned. She stated staff usually provide residents with a Styrofoam cup, but she did not get one. Observations of Resident 1's room revealed no water pitcher or Styrofoam cup at the resident's bedside. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 2 was cognitively intact with a BIMS score of 15. An interview conducted on June 11, 2026, at 11:45 AM revealed Resident 2 needs to drink as much as possible. He stated his pitcher was taken during the night but not yet returned to him. An observation of Resident 2's room revealed no water pitcher or Styrofoam cup at the resident's bedside. A review of the clinical record revealed Resident 3 was admitted on [DATE]. A review of a quarterly Minimum Data Set assessment dated March17, 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15. An interview conducted on June 11, 2026, at 11:20 AM revealed Resident 3 stated If I don't ask for it, it don't get it. She reported that night shift will come around with a water pitcher but it's not consistent. An observation in Resident 3's room revealed no water pitcher or Styrofoam cup. A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 4 was cognitively intact with a BIMS score of 15. An interview conducted on June 11,2026, 11:15 AM revealed that that she had to ask for the water today as night shift took her pitcher and left her without any water or anything to drink. She reported she woke up thirsty and did not have any water available to drink at the bedside. She stated no staff provided water until she asked for it around 11 :00 AM. An observation of a water pitcher was noted to be at Resident 4's bedside. An interview with Employee 1, LPN (Licensed Practical Nurse), on June 11, 2026, at 12:30 PM revealed that water pitchers are collected every other night by the night shift staff to send to dietary for cleaning. She indicated that usually residents are given a Styrofoam cup with water when the pitchers are being cleaned and residents can ask for them to be filled when needed. When asked by this surveyor when the stacks of water pitchers on a dietary cart located in the hallway by the nurse's station of the Cand D units will be passed, the nurse replied they would be passed after lunch. An interview with Employee 2, Nurse aide, on June 11, 2026, at 1:55 PM, revealed that Nurse-aides are to pass ice with water to the residents to the residents each shift. When this surveyor asked the nurse aide if they passed out the pitchers with water and ice to the residents, she indicated it was not yet passed during her shift. An observation on June 11, 2026, at 2:00 PM revealed the water pitchers stacked on a dietary care located in the hallway across from the nurse's station for the C and D nursing units was still present and not passed to the residents. An interview with the Director of Nursing (DON) on June 11, 2025, at 2:05 PM, confirmed that facility protocol requires residents to receive fresh water and ice with staff passing it each shift. On the nights pitchers are to be cleaned during the 11:00 PM to 7:00 AM shift, residents are to be provided with Styrofoam cups that are to be refilled as needed. The DON acknowledged that the facility did not ensure fresh ice water was consistently accessible to residents during all shifts as outlined in the facility policy. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (a)(d) Resident care policies.

Based on clinical record review, select facility policy review, and resident and staff interviews, it was determined the facility failed to ensure that pain management was provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of 24 residents reviewed (Resident 80). Findings include: A review of the facility policy titled Pain Management Policy, last reviewed June 13, 2025, revealed it is the facility policy that the provider and staff will identify individuals who have pain or who are at risk of having pain. It includes a review for any treatments the resident is currently receiving for pain including implementing pharmacological (medication) and non-pharmacological (non-medication) interventions and evaluating the effectiveness of interventions. Clinical record review revealed Resident 80 was admitted on [DATE], with diagnoses including mechanical loosening of an internal right hip prosthetic joint (a condition in which an artificial hip joint becomes unstable or loose, causing pain and difficulty moving) and Reiter's Disease (also known as reactive arthritis, an inflammatory condition affecting joints and other body systems following infection). A review of Resident 80's current plan of care identified acute and chronic pain related to right hip surgery. Interventions included assessing pain, administering medications as ordered, implementing non-pharmacological interventions, and monitoring effectiveness of treatment. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 20, 2025, revealed that Resident 80 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A physician's order dated February 14, 2026, directed Oxycodone HCL 5 mg by mouth every four hours as needed for severe pain rated 7 to 10 (pain rating refers to a standard numeric pain scale of 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable; a rating of 7 to 10 is generally considered severe pain requiring stronger interventions), for 14 days. Oxycodone is an opioid (narcotic) pain medication classified as a Schedule II controlled substance, meaning it has an accepted medical use but carries a high potential for misuse and requires close monitoring. An additional order dated February 25, 2026, directed Acetaminophen 975 mg every eight hours for moderate pain (rated 4 to 6). Acetaminophen (commonly known as Tylenol) is a non-opioid analgesic used to relieve mild to moderate pain. A CRNP (Certified Registered Nurse Practioner) progress note dated February 25, 2026, at 1:21 PM documented the resident reported pain rated 8 out of 10 and that pain medication had not been administered as ordered overnight. Review of the Medication Administration Record (MAR, a legal record documenting medications administered to a resident) confirmed no pain medication was administered during the overnight shift. Nursing progress notes dated February 28, 2026, at 11:56AM; March 20, 2026, at 11:48AM; March 28, 2026, at 11:41AM; and April 2, 2026, at 7:13AM consistently documented that Oxycodone 5 mg was administered for right hip pain with only short-term or minimal effectiveness. A review of the clinical record revealed no documented evidence that the physician was notified that the prescribed Oxycodone regimen was consistently ineffective in relieving the resident's pain. During an interview on April 29, 2026, at 11:00AM, Resident 80 reported the Oxycodone was causing me to be more anxious, and that seems to increase my pain, so why take it. I've told them the medication was not working more than once but nothing got changed. The resident reported that during a recent orthopedic consultation (a specialist evaluation for bone and joint conditions), the provider recommended a trial of Dilaudid (hydromorphone, a stronger opioid medication used to treat severe pain when other medications are ineffective). The resident stated I haven't gotten it yet. I am just taking Tylenol now, but that does nothing. A review of an orthopedic consultation record dated April 28, 2026, revealed documented post-operative care instructions and treatment recommendations. The record indicated the surgical incision staples were removed and steri-strips (adhesive wound closure strips used to support healing) were applied, with instructions to keep the area dry for one week. The resident could begin showering after one week but was not to submerge the surgical site in water for three months post-operatively (after surgery). The consultation included orders for Doxycycline (an antibiotic medication used to treat or prevent infection) for 12 weeks post-operatively and Eliquis (an anticoagulant medication used to prevent blood clots) for 12 weeks. Activity restrictions included non-weight bearing status (inability to place weight on the affected leg) and no range of motion exercises (movement of the joint) at that time due to right knee pain and swelling. The consultation further indicated that, per the resident's request, a trial of Dilaudid (hydromorphone, an opioid medication used to treat severe pain) by mouth could be considered in place of Oxycodone, with a recommendation to avoid continued opioid use beyond three months post-operatively. The record also indicated Acetaminophen (Tylenol) could be administered as needed for pain and that non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen, used to treat pain and inflammation) were not recommended. A follow-up appointment was scheduled in two weeks. A review of a physician progress note dated April 29, 2026, at 7:46AM revealed the resident returned from the orthopedic appointment in stable condition. The note documented that follow-up instructions were acknowledged, including a scheduled appointment on May 12, 2026, and permission to begin showering on May 8, 2026, with continued non-weight bearing status to the right leg. The note further documented the resident requested Dilaudid for pain management; however, the physician elected not to change the current pain medication regimen and to continue Oxycodone at that time, and the resident was informed. An interview conducted with Resident 80 on May 1, 2026, at 9:30AM revealed the resident reported she was only taking Acetaminophen for pain management. Resident 80 stated, I am going to file a grievance over this; my pain is a 9 today. I've been suffering for days, and my medication still has not been changed. An interview with the Director of Nursing (DON) on May 1, 2026, at 10:00AM confirmed that the orthopedic consultation record indicated the resident's pain medication could be changed; however, the facility physician elected not to change the resident's pain medication from Oxycodone to Dilaudid (hydromorphone, a stronger opioid medication used to treat severe pain). The DON further confirmed that nursing staff had contacted the physician regarding the resident's ongoing complaints of pain. An additional interview was conducted with the DON on May 1, 2026, at 11:15AM to review the above findings related to the facility's failure to ensure pain management was provided in accordance with professional standards of practice, including ongoing assessment, monitoring, and adjustment of the pain management regimen. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, and staff interviews, it was determined the facility failed to consistently implement person-centered care plan interventions for pressure injury prevention for one of 24 residents reviewed (Resident 2).Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include Diabetes Mellitus (a chronic disorder characterized by consistently high blood sugar levels) and hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction (stroke) affecting the resident's right side. Review of Resident 2's current comprehensive care plan, initiated September 20, 2023, and revised January 12, 2026, indicated the resident was at risk for impaired skin integrity related to impaired mobility, advanced age, moisture, and pressure. Interventions included the use of a specialty mattress, Protekt Proactive air mattress (a therapeutic mattress designed to prevent and treat pressure injuries by alternating pressure and reducing moisture), with staff to check the function every shift. Review of a physician's order dated November 11, 2025, confirmed an order for a Protekt Proactive specialty air mattress with instructions for staff to check the function every shift. Observation on April 29, 2026, at 8:40AM revealed Resident 2 in bed without a specialty air mattress in place. A follow-up observation on April 30, 2026, at 11:12AM, conducted in the presence of Employee 4 (Licensed Practical Nurse) and Employee 5 (Licensed Practical Nurse), confirmed a standard mattress was in use rather than the ordered specialty air mattress. Review of the April 2026 Treatment Administration Record (TAR) revealed nursing staff documented each shift that the air mattress function check was completed, despite the absence of the ordered specialty mattress. Interview with the wound care nurse on April 30, 2026, at 11:55AM revealed that although Resident 2's prior pressure areas had resolved, the physician order and care plan intervention for the Protekt Proactive air mattress remained in place for ongoing prevention. The wound care nurse confirmed the resident continued to require the intervention due to persistent risk factors. The nurse further indicated the facility had experienced prior issues with malfunctioning air mattresses but was unaware that Resident 2 did not have the ordered mattress in place. During an interview on April 30, 2026, at 1:30PM, the Nursing Home Administrator and Director of Nursing acknowledged that staff failed to implement the physician-ordered and care planned intervention for pressure injury prevention. They further acknowledged the TAR documentation was inaccurate and were unable to provide documented evidence explaining why staff recorded completion of air mattress checks when the intervention was not in place. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review, select facility policy review, investigative documentation provided by the facility, and staff interviews, it was determined the facility displayed past noncompliance by failing to ensure the safety and supervision of one resident from exiting through unsecured doors for one out of 24 residents reviewed (Resident 99).Findings include: A review of the facility policy titled Elopement/Wandering Risk Guideline, last reviewed by the facility on June 13, 2025, revealed it is the policy of the facility to provide a safe and secure environment for the residents and be proactive in preventing resident elopement. Elopement is defined as a resident leaving a safe area of the facility without authorization. Upon admission, readmission, quarterly, and with a significant change of condition, residents will be assessed for elopement risk. A review of the facility policy titled Wandering, Unsafe Resident, last reviewed by the facility on June 13, 2025, revealed it is the policy of the facility to identify residents who are at risk for harm because of unsafe wandering. A review of the clinical record revealed that Resident 99 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (brain damage that results from a lack of blood) and cognitive-communication deficit (difficulties in communication arising from impairments in cognitive processes such as attention, memory, or problem-solving). A review of Resident 99's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 28, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of an elopement risk assessment dated [DATE], identified the resident as being at low risk for elopement. Review of facility-provided investigative documentation dated August 2, 2025, at 11:05AM, revealed Resident 99 was observed ambulating unattended in the parking lot outside the facility. Documentation indicated the resident was last seen at approximately 9:00AM during morning medication administration. A Nurse Aide (Employee 8) observed the resident outside near the rear doors of C hall and re-entered the building to assist the resident back inside through a side emergency exit. A head-to-toe assessment (body audit) revealed no injuries. Documentation revealed Resident CR1 reported observing Resident 99 exit through the front entrance, sitting on the porch, then ambulate through the parking lot toward the personal care area and out of view. A written witness statement dated August 4, 2025, at 1:22PM, indicated the resident remained outside unsupervised for approximately 30 minutes. A witness statement from Employee 8, NA dated August 4, 2025, at 1:38PM, confirmed the resident was observed outside through the rear door windows and was not authorized to be outside independently. The employee exited the building and escorted the resident back inside. A written statement from Employee 9 (Licensed Practical Nurse), dated August 4, 2025, indicated the resident had been seen earlier at approximately 9:00AM for medication administration and was later reported to be outside. The nurse turned off the door alarm to allow re-entry and subsequently applied a wander guard device. A review of a physician order dated August 2, 2025, at 12:03PM, revealed an order was obtained after the incident for a Wander Guard (an electronic monitoring device worn by a resident that triggers an alarm if the resident approaches or exits through secured doors) and for staff to monitor placement each shift. A nursing progress note documented by the Assistant Director of Nursing (ADON) on August 2, 2025, at 12:34PM, confirmed Resident 99 was found outside the facility and that a Wander Guard was applied after the incident. The note indicated the resident had previously gone outside with his sister but was not permitted to exit independently. Staff re-educated the resident regarding this restriction following the event. A subsequent elopement risk assessment dated [DATE], identified the resident as moderate risk for elopement, indicating a change in risk status following the incident. During an interview on April 29, 2026, at 1:00 PM, the ADON confirmed the resident exited the facility unsupervised on August 2, 2025. The ADON stated the resident had a history of going outside with a family member but should not have been exiting independently. The ADON further confirmed there was no staff assigned to monitor the front entrance on weekends, which limited oversight of resident exits. During a telephone interview on May 1, 2026, at 12:45 PM, Employee 8 NA confirmed observing the resident outside the building and escorting him back inside after determining he was not permitted to be outdoors independently. An observation on April 28, 2026, at 11:00 AM, of Resident 99 revealed a Wander Guard to their left wrist as ordered by the physician. Observation on April 28, 2026, at 11:00AM, revealed Resident 99 had a Wander Guard device in place as ordered. These findings demonstrated the facility failed to implement adequate supervision and monitoring systems, including door monitoring and staff oversight, to prevent a cognitively impaired resident from exiting the facility unsupervised and remaining outside for an extended period. The failure to recognize and address elopement risk prior to the incident, despite significant cognitive impairment, and the lack of environmental safeguards (including consistent monitoring of exit points) resulted in the resident leaving the facility without staff awareness. This deficiency is cited as past noncompliance. The facility's corrective action plan was to identify other residents with the potential to be affected and to identify those listed at risk for elopement. Elopement assessments were initiated and completed on all residents. Any newly identified residents with moderate or high scores for risk of elopement had their plans of care reviewed to ensure accuracy and appropriate interventions, and wander guards were applied if applicable. New signage was posted encouraging families and visitors not to let residents out and ask staff for assistance. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to facility staff regarding the facility's elopement policy, including procedures and protocols, initiated on August 4, 2025, with completion on August 5, 2025. To monitor and maintain ongoing compliance, the facility performed audits on all new admissions to determine if risk was present and is ongoing at the facility on a daily basis during the morning meetings. The findings of the plan of correction were submitted to QAPI for review. Documentation provided by the facility indicated corrective actions were completed on August 5, 2025, and no further similar incidents were identified, demonstrating the facility achieved substantial compliance after that date. Therefore, this deficiency is cited as past noncompliance. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on observation, clinical record review, select facility policy review, and staff interviews, it was determined the facility failed to ensure that appropriate physician orders, a documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for one of 24 residents reviewed (Resident 83).Findings include: A review of a facility policy titled Urinary Continence and Incontinence Assessment and Management, last reviewed by the facility on June 13, 2025, revealed it is the policy of the facility that indwelling urinary catheters will be used sparingly, for appropriate indications only. If the resident is admitted from the hospital with a newly placed indwelling catheter, the attending physician and staff will evaluate the potential for removing it, depending on the current condition and the rationale for its original placement. The physician will identify and refer, as appropriate, individuals who might benefit from urological procedures to improve continence. The physician will identify situations in which an indwelling catheter is indicated and will document why other alternatives are not feasible. If a catheter is used, the physician and staff will document the clinical indications for use of the catheter and utilize a standardized tool to document its ongoing need. A review of Resident 83's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and overactive bladder (a condition causing a sudden and frequent urge to urinate). A review of Resident 83's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 25, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 05 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of Resident 83's comprehensive care plan, initiated November 16, 2021, and last revised January 28, 2026, indicated the resident had urinary incontinence (involuntary loss of urine) with interventions including a scheduled toileting program (a structured plan to assist the resident to the bathroom at regular intervals) upon rising, at meal times, at bedtime, and as needed and a urology appointment on February 5, 2026. The care plan did not include any interventions related to the use or management of an indwelling urinary catheter. A review of a urology consultation report dated February 5, 2026, revealed the resident was evaluated for urinary retention (inability to fully empty the bladder). The report indicated a cystometrogram (CMG, a test that measures how well the bladder stores and releases urine) was completed. The urologist recommended placement of a Foley catheter (a thin, flexible tube inserted through the urethra into the bladder to continuously drain urine) due to an atonic bladder (a bladder with weakened muscle function) and significant residual urine (urine remaining in the bladder after voiding). The report also recommended a follow-up appointment in one month, along with initiation of medications including Urecholine (a medication used to stimulate bladder contraction) and Flomax (a medication used to improve urine flow). The consultation was signed as acknowledged by the facility on February 5, 2026. A review of the clinical record failed to reveal evidence that the recommended follow-up urology appointment was scheduled or completed. A review of physician orders revealed an order dated March 30, 2026, for an 18 French Foley catheter (the term French refers to the diameter size of the catheter; 18 French is a relatively larger size used for drainage) with a 10 cubic centimeter (cc) balloon (a small inflatable balloon at the tip of the catheter used to keep it in place inside the bladder) attached to a drainage bag to gravity (a collection bag that allows urine to drain continuously without suction). The order included instructions to change the catheter monthly and as needed for leakage, dislodgement (movement out of place), or occlusion (blockage), and to check placement and patency (whether the catheter remains open and draining) every shift. Further review of physician orders failed to reveal any documented clinical justification (medical reason) for the continued use of the indwelling catheter. An observation conducted on April 28, 2026, at 12:50PM revealed Resident 83 had a Foley catheter in place with a drainage bag. Despite the presence of the indwelling catheter, a review of the care plan failed to include the catheter, lacking interventions for catheter care (such as monitoring for infection, ensuring proper positioning, and maintaining hygiene), and did not address the ongoing need for the device. An interview with the Director of Nursing and Regional Nurse Consultant on May 1, 2026, at 10:30AM confirmed the facility did not have documented physician justification for the catheter, did not ensure follow-up with urology as recommended, and did not include the catheter in the resident's plan of care. They acknowledged the care and treatment provided to Resident 83 were not consistent with facility policy or acceptable standards of practice. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on clinical record review, consultant pharmacist documentation review, and staff interview, it was determined the facility failed to ensure the attending physician responded to and acted upon consultant pharmacist recommendations regarding identified irregularities in the medication regimen for one of 24 residents reviewed (Resident 13).Findings include: Review of Resident 13's clinical record revealed admission to the facility on October 20, 2018, with diagnoses to include schizoaffective disorder (mental health condition characterized by a combination of hallucinations, delusions, disorganized speech and mood disorder symptoms), major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated November 5, 2025, addressed the physician's orders for Olanzapine (an antipsychotic medication used to treat schizophrenia and bipolar disorder) 5 mg every 12 hours and Fluoxetine (an antidepressant used to treat major depressive disorder)10 mg daily. The consultant pharmacist recommended a Gradual Dose Reduction (GDR, a systematic process of slowly tapering a medication's dosage to determine if a lower dose or discontinuation is possible while managing symptoms) or trial discontinuation, noting that CMS guidelines require a periodic review of psychoactive medications. The pharmacist further noted that if the drug therapy is clinically contraindicated (inadvisable because it could be harmful or dangerous to the resident), the physician must document the clinical rationale. This recommendation indicated the physician documentation must include the reason(s) why an attempted GDR would likely impair the resident's' function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. The clinical record failed to provide written documented evidence the attending physician responded to, acknowledged, or acted upon the consultant pharmacist's recommendation regarding the resident's psychoactive medications. During an interview on May 1, 2026, at 1:00 PM, the Regional Nurse Consultant confirmed that the facility was unable to provide documented evidence the attending physician responded to or acted upon the consultant pharmacist's recommendations.28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa Code 211.5 (f)(vii) Medical records. 28 Pa. Code 211.2 (d)(7) Medical director.

Based on a review of controlled drug shift count records, clinical records, facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure accurate accountability and documentation of controlled medications on three of four medication carts observed and failed to maintain accurate records related to the administration and reconciliation of controlled medications for one of 24 residents reviewed (Resident 80).Findings include: A review of the facility policy titled, Controlled Substances, (medications regulated by state and federal law due to the potential for abuse, dependence, misuse or diversion) last reviewed June 13, 2025, revealed controlled substance inventory is monitored and reconciled to identify loss or potential diversion (the unauthorized redirection or misuse of medications) in a manner that minimizes the time between loss or diversion and detection and follow up. The policy indicated the nurse coming on duty and the nurse going off duty are to complete the controlled medication count together and document and report any discrepancies to the Director of Nursing Services. The policy indicated that the facility would comply with all laws, regulations, and requirements related to the handling, storage, disposal, and documentation of controlled medications. The policy identified the system of reconciling the receipt, dispensing, and disposition of controlled substances includes records of personal access and usage, medication administration records, declining inventory records, and destruction, waste, and return-to-pharmacy records. A review of the facility Shift Change Narcotic Audit for the Blue Unit B Hall medication cart serving Rooms 002 through 015 revealed the following: On April 27, 2026, the day shift off-going nurse failed to sign the narcotic count record indicating the controlled medication count was completed and correct. An interview conducted with Employee 1, Licensed Practical Nurse on April 29, 2026, at 9:13 AM confirmed the off-going nurse failed to sign the Shift Change Narcotic Audit for the identified date. A review of the facility Shift Change Narcotic Audit for the Blue Unit A Hall medication cart serving Rooms 001 through 017 revealed the following: On April 9, 2026, the off-going evening shift nurse failed to sign the narcotic count record indicating the controlled medication count was completed and correct. An interview conducted with Employee 2, LPN, on April 29, 2026, at 9:28 AM confirmed the off-going nurse failed to sign the Shift Change Narcotic Audit for the identified date. A review of the facility Shift Change Narcotic Audit for the Yellow Unit C Hall medication cart serving Rooms 001 through 017 revealed the following: On April 22, 2026, both the on-coming day shift nurse and the off-going nurse failed to sign the narcotic count record indicating the controlled medication count was completed and correct. An interview conducted with Employee 3, LPN, on April 29, 2026, at 9:41 AM confirmed the identified nurses failed to sign the Shift Change Narcotic Audit for the identified date. A review of Resident 80's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including mechanical loosening of an internal right hip prosthetic joint (a condition occurring after hip replacement surgery when the artificial joint becomes loose causing pain, instability, and discomfort) and Reiter's Disease (an inflammatory condition triggered by an infection somewhere else in the body affecting joints, eyes, and urinary tract). A review of the clinical record revealed a physician's order for Resident 80 to receive Oxycodone HCL oral tablet 5 milligrams (Schedule II controlled narcotic medication with a high potential for abuse and dependence) was initiated on February 14, 2026, with instructions to administer one tablet every four hours as needed for pain levels of seven through ten (a standardized pain rating scale in which zero indicates no pain and ten indicates the worst possible pain) for 14 days. A review of facility records revealed the facility utilized a Controlled Substance Record Form to track, monitor, and reconcile controlled medications, including Oxycodone. A review of facility clinical records revealed the facility tracked medication administration for each resident through the Medication Administration Record (MAR, a legal medical record used to document medications administered to a resident). The MAR indicated the medication administered, time and date of administration, staff administering the medication, pain level prior to medication administration, and the clinical rationale for administering the medication. A comparison of Resident 80's Controlled Substance Record Form with the resident's Medication Administration Record (MAR) from February 14, 2026, through April 17, 2026, revealed 68 instances in which Oxycodone 5 milligram tablets were documented on the Controlled Substance Record Form as removed from the medication supply; however, there was no corresponding documentation on the MAR indicating the medication was administered to Resident 80. The following dates and times reflected discrepancies between the Controlled Substance Record Form and the MAR documentation: February 14, 2026, at 12:00 AM, and 6:30 AMFebruary 15, 2026, at 6:00 AMFebruary 17, 2026, at 3:45 PMFebruary 18, 2026, at 3:45 PMFebruary 19, 2026, at 5:00 PM and 9:00 PMFebruary 21, 2026, at 8:00 PMFebruary 23, 2026, at 5:00 PM and 9:00 PMFebruary 24, 2026, at 6:30 PM and 10:30 PMFebruary 25, 2026, at 6:00 AM and 7:30 PMFebruary 26, 2026, at 3:30 PM and 8:30 PMFebruary 27, 2026, at 4:30 PM and 10:00 PMMarch 1, 2026, at 3:00 AMMarch 3, 2026, at 7:20 PM and 9:20 PMMarch 4, 2026, at 6:38 PMMarch 5, 2026, at 4:10 PM and 9:00 PMMarch 6, 2026, at 10:00 PMMarch 7, 2026, at 8:00 PMMarch 10, 2026, at 6:30 AMMarch 11, 2026, at 2:00 AM, 5:00 AM, 5:25 PM and 9:25 PMMarch 12, 2026, at 6:15 PM and 10:16 PMMarch 13, 2026, at 6:55 AMMarch 15, 2026, at 1:50 AMMarch 19, 2026, at 7:00 PM and 11:00 PMMarch 21, 2026, at 5:30 PM and 9:30 PMMarch 23, 2026, at 1:30 PM and 7:00 PMMarch 24, 2026, at 1:05 AMMarch 25, 2026, at 7:00 PMMarch 26, 2026, at 5:12 PM and 9:12 PMMarch 28, 2026, at 3:35 AMMarch 30, 2026, at 5:30 PM and 9:30 PMApril 1, 2026, at 4:30 PM and 8:30 PMApril 2, 2026, at 5:11 PM and 9:11 PMApril 4, 2026, at 8:00 PMApril 5, 2026, at 1:00 AM, 5:00 PM, and 9:00 PMApril 8, 2026, at 5:34 PM and 9:34 PMApril 10, 2026, at 10:00 PMApril 11, 2026, at 5:10 AMApril 13, 2026, at 8:40 PMApril 14, 2026, at 6:00 PM and 10:00 PMApril 15, 2026, at 06:34 AM and 7:00 PMApril 17, 2026, at 4:10 AM 5:00 PM and 9:00 PM An interview was conducted on May 1, 2026, at 10:05 AM with the Director of Nursing (DON) and Nursing Home Administrator (NHA) during which the above findings related to the reconciliation and documentation of controlled medications, including Resident 80's Oxycodone records, were reviewed. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa Code 211.9 (c)(k) Pharmacy services. 28 Pa Code 211.5(f)(x) Clinical records. 28 Pa. Code 211.10(a) Resident Care Policies.

Based on a review of clinical records, select facility policy, investigative documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to maintain a safe and homelike environment by not ensuring a bathroom safety handrail (grab bar) was securely affixed to the wall for one resident out of 24 residents reviewed (Resident 31).Findings include: A review of a facility policy titled Falls Management System, last reviewed by the facility on June 13, 2025, revealed it is the policy of the facility to provide each resident with appropriate evaluation and interventions to prevent falls and to minimize complications if a fall occurs. A review of Resident 31's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis that included morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues) and generalized muscle weakness. A review of Resident 31's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2026, revealed that Resident 31 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 31's comprehensive plan of care initiated on August 16, 2025, and last revised on April 20, 2026, indicated the resident had an ADL self-care performance deficiency related to generalized weakness and obesity (ADLs, fundamental self-care tasks required for independent living such as bathing, dressing, toileting, and feeding oneself). Interventions included assistance from one person for toilet use. The care plan also identified the resident as high risk for falls with interventions that included bed and chair alarms and an alarm to the bathroom door. A review of facility investigative documentation dated April 17, 2026, at 11:30 AM, revealed the resident was found on the floor in front of the toilet. The bathroom grab bar (a fixed safety handrail designed to provide stability during transfers) had detached from the wall and floor. The resident reported self-transferring when the bar came out of the wall. The resident's chair alarm was documented as being in the off position. A hematoma (a localized collection of blood under the skin) with surrounding bruising was observed on the left forehead; no measurements were documented. A review of a witness statement from Employee 6, Certified Nurse Aide, dated April 17, 2026, revealed the employee heard the resident calling out, entered the bathroom, and found the resident on the floor with the bathroom grab bar pulled out of the wall and floor. The chair alarm was noted to be off. A review of a nurse progress note completed by Employee 7 Licensed Practical Nurse (LPN) on April 17, 2026, at 11:52 AM, revealed the nurse responded after the resident was found on the floor. The note documented that the grab bar had come out of the wall and floor during the resident's attempt to transfer. A hematoma with bruising to the left forehead was recorded. Maintenance was notified and responded to assess the detached equipment. An interview with Resident 31 on April 28, 2026, at 1:00 PM, revealed the resident reported that while using the bathroom on April 17, 2026, the grab bar pulled out of the wall as the resident attempted to rise, causing the fall. The resident was observed to have residual bruising that appeared black and yellow around both eyes. The resident stated after the fall, maintenance had come in and fixed her grab bar in the bathroom. An interview with the Maintenance Director on May 1, 2026, at 11:05 AM, revealed he responded after the incident and confirmed the grab bar had detached from the wall and floor. He stated this had occurred previously and attributed it to the manner in which the resident used the bar to pull upward. He reported that larger screws were installed following the incident to secure the bar. No documented evidence was provided to demonstrate that prior reinforcement, inspection, or corrective measures had been implemented to ensure the grab bar remained secure before the fall. An interview with the Physical Therapy Director on May 1, 2026, at 1:10 PM, revealed the resident had previously been educated on safe use of the grab bar. The above findings were reviewed with the facility's Nursing Home Administrator and Director of Nursing on May 1, 2026, at 12:30 PM, and confirmed that resident bathrooms are expected to be maintained in a safe condition. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on a review of select facility policies, clinical records, and staff and resident interviews, it was determined that the facility failed to ensure an ongoing grievance system was maintained to track resident grievances, including the date and time the grievance was lodged and the date of resolution, for one of 24 residents reviewed (Resident 103). Findings include: Review of the facility's grievance policy, reviewed June 13, 2025, revealed that residents have the right to prompt efforts to resolve grievances they may have. The grievance process is overseen by the grievance official who is responsible for overseeing the grievance process, which includes receiving and tracking grievances through their conclusion. A reasonable timeframe the resident can expect a completed review of the grievance is within 5 to 7 days. Evidence shall be maintained, demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Clinical record review of Resident 103 revealed a Significant Change Minimum Data Set assessment, (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 30, 2026, which indicated that Resident 103 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information as score of 13-15 indicates intact cognition). An interview with Resident 103 on April 30, 2026, at 9:40 AM revealed the resident had lodged several complaints with the nursing home administrator within the past three months concerning call bell timeliness and had verbally spoken to the nursing home administrator on a weekly basis. The resident indicated the issue has been ongoing. The resident reported waiting up to one hour for assistance, particularly during the 3:00 PM to 11:00 PM shift, including weekends, and expressed concern that the facility did not have sufficient staff to meet residents' needs. During an interview with the nursing home administrator on April 30, 2026, at 12:00 PM, the surveyor requested the facility's grievance tracking records for the prior three months. Review of the records provided revealed the facility did not maintain a complete and ongoing system for tracking resident grievances. The documentation lacked essential elements, including the identity of the individual who made the grievance, the nature of the grievance, the date and time the grievance was lodged, and the date of resolution. Review of the facility's call bell policy dated June 13, 2025, revealed that it is the policy for the employees to respond to resident call bells within 15 minutes or less.During the interview on April 30, 2026, at 12:00 PM, the nursing home administrator was unable to provide call bell audit records upon request and was unable to provide evidence that Resident 103's concerns were being monitored, investigated, or trended through the grievance process. The administrator was further unable to provide documented evidence that the resident's verbal grievances were recorded, tracked, or processed in accordance with facility policy to ensure timely resolution. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services.

Based on a review of clinical records, select facility investigative documentation, facility policies, American Heart Association (AHA) guidelines, facility-provided witness statements, and staff interviews, it was determined that the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated for a resident in accordance with the resident's advance directives and nationally recognized standards of practice. This failure placed one of 10 residents sampled (Resident CR1) and 47 other residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, and 47) who desired CPR, out of the facility's 101 resident census, in Immediate Jeopardy to their health and safety with the potential for death as a result of a similar occurrence.Findings include: A review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support revealed the document identified Med Pass 2001 at the footer, indicating original policy development by an external vendor. The facility documented review of the policy on [DATE]. This current policy revealed that if an individual (resident, visitor, staff) is found unresponsive and not breathing normally a licensed/certified staff member will initiate CPR (Cardiopulmonary Resuscitation) defined as an emergency lifesaving procedure consisting of chest compressions and rescue breathing, when an individual is found unresponsive and not breathing normally, unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exist for that individual or there are obvious signs or irreversible death (e.g., rigor mortis). The policy further revealed if the resident's DNR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order to not administer CPR. The policy further outlined Preparation for Cardiopulmonary Resuscitation, requiring the facility to maintain systems to ensure CPR can be provided during an emergency. These requirements included, but were not limited to: Obtaining and maintaining Basic Life Support (BLS)/CPR certification for all clinical staff in accordance with AHA guidelines (BLS is a level of medical care used for victims of life-threatening illnesses or injuries until full medical treatment can be provided)Maintaining CPR certification through a provider that includes hands-on practice and skills assessmentProviding periodic drills, defined as simulated cardiac arrest events used to practice emergency responseSelecting and identifying a CPR team for each shift, including:Designating a team leader responsible for coordinating rescue effortsEnsuring at least two licensed nurses (Registered Nurse or Licensed Practical/Vocational Nurse) and two certified nurse aides are available and CPR-certified Maintaining CPR equipment and suppliesProviding information on advanced directives upon admission and documenting them in the medical recordEducating staff on how to determine and locate resident code status during an emergency. The policy also required staff to follow American Heart Association guidelines for CPR and defibrillation, including recognition of cardiac arrest, initiation of resuscitation, and airway management.According to American Heart Association guidelines presumptive Signs of Death include unresponsiveness, absence of respirations, absence of a detectable pulse, fixed and dilated pupils (black center of eye enlarged and does not react to light), cool skin relative to baseline, and generalized cyanosis (bluish discoloration due to lack of oxygen).AHA guidelines for Conclusive (irreversible) Signs of Death are presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin).While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body),decomposition (decay or putrefaction of the body), rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop) Clinical record reviews of Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, and 47 revealed current physician orders regarding code status to receive CPR in the event of cardiac arrest. A review of Resident CR1's closed clinical record revealed admission to the facility on [DATE], at 7:00 PM with diagnoses including chronic obstructive pulmonary disease (a progressive lung condition causing airflow blockage, inflammation, and breathing difficulties, often from smoking), hyperlipidemia (when there are too many fats in your blood), and hypertension (common condition where the force of blood against artery walls is consistently too high). A review of Resident CR1's closed clinical record revealed that a face sheet from the referring facility was scanned into the facility's electronic medical record on [DATE], at 1:52 PM, one day prior to the resident's admission. The face sheet, which is routinely provided by the transferring facility as part of the admission process, contained key resident information used to guide care upon arrival, including the resident's code status. Review of this document confirmed that at the referring facility, Resident CR1 was designated as Full Code, indicating the resident's preference to receive cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. A nursing progress note dated [DATE], at 7:00 PM documented that Resident CR1 was admitted with baseline confusion, required oxygen therapy, and exhibited dyspnea (shortness of breath). The note documented that attempts to complete admission documentation were unsuccessful due to the inability to reach family to confirm the resident's code status and to obtain the resident's CPAP (continuous positive airway pressure) machine (a common treatment for sleep apnea that uses a mask and gentle, constant air pressure to keep airways open during sleep, preventing breathing pauses and improving oxygen levels, which reduces risks for heart disease, stroke, and daytime sleepiness). At approximately 2:30 AM on [DATE], Employee 2 (Nurse Aide) and Employee 3 (Nurse Aide) entered Resident CR1's room and found the resident unresponsive. A nursing progress note dated [DATE], at 2:30 AM documented by Employee 1 (Registered Nurse) revealed the resident was unresponsive to verbal commands and sternal rub (a painful stimulus applied to the breast bone to assess responsiveness), had no apical pulse upon auscultation (listening to the heart with a stethoscope), and staff were unable to obtain blood pressure or oxygen saturation using a pulse oximeter (a device that measures blood oxygen levels). The note documented that one respiration was observed, the resident's pupils were fixed and dilated, and the resident's skin was warm and dry to touch. The nursing supervisor was notified. Review of a nursing progress note dated [DATE], at 3:55 AM written by Employee 4 (Registered Nurse Supervisor) documented when she entered the room the resident was unresponsive, pale, pupils blown (informal term for a pupil that is fixed and abnormally dilated (large), failing to constrict in bright light, signaling a severe, life-threatening neurological emergency), no blood pressure, no pulse oximetry reading, no apical or carotid pulse, and no respirations. Sternal rub produced no response. No DNR or POLST (Provider Orders for Life-Sustaining Treatment, a medical order documenting end-of-life care wishes into actionable medical orders for doctors, nurses, and emergency responders, covering interventions like CPR, ventilation, and feeding tubes, and ensuring these preferences travel with the patient across different care settings) was located in the chart or electronic system. The physician was contacted at 2:34 AM regarding the resident's death. A review of the closed clinical record revealed documentation indicating that the resident was last turned, repositioned, and checked for incontinence (involuntary leakage of urine or stool) on [DATE], at 11:23 PM. At that time, the resident was noted to be incontinent of urine. Interview with Employee 2 (Nurse Aide) on [DATE], at 12:45 PM confirmed she was not CPR or AED (Automated External Defibrillator, a device that analyzes heart rhythm and delivers an electrical shock during cardiac arrest) certified and did not initiate CPR. Employee 2 stated Employee 1 assessed the resident and directed Employee 3 to check code status, which was not documented. Employee 4 arrived, and CPR was not initiated. Interview with Employee 2 NA (Nurse Aide) on [DATE], at 12:45 PM confirmed that she was the assigned nurse aide to Resident CR1's unit and had found the resident unresponsive on the morning of [DATE]. Employee 2 confirmed that she was not CPR and AED certified, so she did not initiate CPR for Resident CR1 upon finding her unresponsive. Employee 2 stated she and Employee 3 (nurse aide) entered Resident CR1's room at 2:30 AM. Employee 3 stated I was unaware of her baseline because she was new to the facility, when I walked in, she blinked her eyes one time but then just stared and did not respond when I called her name. I had Employee 3 get Employee 1 (RN) who came and assessed Resident CR1. Employee 1 directed Employee 3 to check Resident CR1's code status in the computer. When Employee 3 returned, she stated Resident CR1 did not have a code status documented in the chart. Employee 2 NA further revealed as Employee 3 was checking the code status for Resident CR1, Employee 1 directed Employee 2 to call Employee 4 (RN supervisor). Employee 2 stated Employee 4 arrived and no CPR was initiated. Phone call attempts were made to Employees 1, 3, and 4 on [DATE], at 10:58 AM, 10:59 AM, 11:09 AM, and 11:59 AM for the purpose of obtaining interviews related to the incident involving Resident CR1 that occurred on [DATE]. All contact attempts were unsuccessful. A return telephone call was received on [DATE], at 12:15 PM from legal counsel representing Employee 4. Counsel declined the interview at that time and stated that any future requests to speak with Employee 4 would need to be submitted in writing through a judicial authority. Review of facility-provided witness statements revealed that Employee 3 documented upon entering Resident CR1's room, the resident was unresponsive and exhibiting signs of respiratory distress, prompting Employee 3 to leave the room and notify Employee 1 to assess the resident. Review of facility-provided witness statements revealed that Employee 1 documented entering Resident CR1's room and finding the resident unresponsive to verbal and tactile stimulation, with no apical pulse upon auscultation, inability to obtain blood pressure or oxygen saturation, absence of respirations, and pupils fixed and dilated. The witness statement further documented that the Registered Nurse Supervisor Employee 4, was notified. The witness statement did not document that cardiopulmonary resuscitation (CPR) was initiated by Employee 1 despite the absence of a documented Do Not Resuscitate (DNR) order or other medical order prohibiting CPR. Review of facility-provided documentation revealed that Employee 4 documented entering Resident CR1's room and observing the resident to be unresponsive, pale, without detectable blood pressure, pulse, respirations, or response to sternal rub, and without a documented DNR or POLST in the medical record or electronic system. The documentation further indicated the physician was notified regarding the resident's death. The documentation did not reflect that cardiopulmonary resuscitation (CPR) was initiated by Employee prior to contacting the physician, despite the absence of documented irreversible signs of death. An interview with the Director of Nursing (DON) on [DATE], at 10:00 AM revealed that Employee 4 refused to provide the facility with a witness statement following the incident. The DON confirmed education was initiated and provided to staff on [DATE], related to the facility's existing cardio-pulmonary resuscitation (CPR) policy. At the time the education was conducted, the CPR policy had not been revised, despite concerns regarding the policy's inclusion of a designated CPR team and the absence of clearly defined signs of irreversible death. An interview with Employee 5, Licensed Practical Nurse (LPN), conducted on [DATE], at 2:39 PM revealed that at no time throughout employment at the facility had the employee been informed of a CPR team assignment while on shift. The employee stated they were unaware that a CPR team was part of the facility's CPR policy, despite education reportedly provided on [DATE]. An interview with Employee 6, LPN, conducted on [DATE], at 2:32 PM revealed that at no time during employment was the employee aware of a CPR team being utilized within the facility. The employee stated a text message regarding CPR was provided on [DATE], and upon entrance to the building for the next shift, the employee signed documentation indicating education had occurred. The employees stated they were not provided with the CPR policy and were unable to reference any information within the policy regarding a CPR team. A review of Resident CR 1's closed clinical record revealed that on the morning of [DATE], nursing staff found the resident unresponsive and documented the resident had no heartbeat and no lung sounds auscultated. The resident was identified as full code status. The facility was unable to provide justification for Employee 1, RN, and Employee 4, RN Supervisor, not initiating CPR upon finding Resident CR1, despite the resident not exhibiting documented signs of irreversible death. As of the survey date of [DATE], the facility had not revised the CPR policy that was in effect on [DATE]. After the Immediate Jeopardy was identified, the facility revised the CPR policy to include detailed signs of irreversible death, defined as physical findings that indicate death has occurred and resuscitation is no longer medically appropriate, and removed references to the assignment of a CPR team. An interview with the facility's clinical consultant, conducted on [DATE], at 2:00 PM revealed the facility does not assign a CPR team during shifts due to staffing availability. The facility provided documentation indicating education on the revised CPR policy was conducted on [DATE], after the policy update. An interview with Employee 7 (LPN) on [DATE], at 5:46 PM revealed that upon arrival to work at 3:00 PM, the employee was asked to sign documentation confirming education on the revised CPR policy. When asked to identify signs of irreversible death, the employee was unable to do so, despite the information being included in the revised policy. The employee stated, I did not actually read the policy, I just signed the sheet. An interview with Employee 8 (LPN) conducted on [DATE], at 5:48 PM revealed that upon arrival to work at 3:00 PM, the employee was asked to review the revised CPR policy. When asked to identify signs of irreversible death, the employee stated they were not educated on any irreversible signs of death, despite the revised policy including detailed guidance. These findings demonstrated the facility failed to ensure staff were able to initiate cardio-pulmonary resuscitation (CPR) in accordance with resident wishes and facility policy, placing residents who desired CPR at risk for serious harm or death. These failures placed residents who desired CPR in the event of cardiac arrest in immediate jeopardy (IJ). The facility was notified of the Immediate Jeopardy on [DATE], at 11:35 AM and the IJ template was provided to the facility at 11:41 AM. An immediate plan of correction was requested and received on [DATE], and accepted on [DATE], at 7:06 PM The IJ removal plan included: Employee 1 (RN) and Employee 4 (Agency RN Supervisor) have been educated concerning the Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes and were immediately suspended. On [DATE], the Facility educated Licensed Clinical staff on Revisions of the CPR policy, which included updates on how to respond when someone is unresponsive and when not to initiate CPR such as obvious signs of irreversible death and if no code status documented they are a full code. Licensed staff education was initiated immediately, including staff currently located in the facility. The facility also utilized payroll system to send the updated CPR policy to be reviewed and acknowledged by staff electronically. Nursing education related to the updated policy and irreversible signs of death will continue to be completed with licensed staff prior to their next shift starting on [DATE], with 11pm to 7am shift staff. Starting with 11 PM - 7 AM shift on [DATE], Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes, where staff can locate the code status for each resident in Point Click Care (PCC), on the resident face sheet, and in the orders. Facility will ensure each licensed staff member is educated on irreversible signs of death to ensure staff is properly educated on when it is acceptable not to initiate CPR. Education will continue prior to each licensed staff member's next shift. Residents code statuses are reflected in PCC on the resident's face sheet and in the resident's orders. Completed as of survey date [DATE].Director of Nursing or designee will complete an audit EMR (electronic medical record) code status to validate consistency of records for staff reference. Completed as of Survey date [DATE]. DON or designee will complete an audit of CPR certification on Licensed Facility staff. Completed as of Survey date [DATE], revealing as of incident date [DATE], 7 licensed nursing staff were unable to produce a valid CPR certification. The facility conducted a CPR class on [DATE], and again on [DATE], for employees who were unable to produce up to date certification information. The Immediate Jeopardy was lifted on [DATE], at 7:20 PM, upon receipt of the facility's immediate action plan and verification that the actions had been implemented. 28 Pa. Code 211.2(d)(7) Medical Director. 28 Pa. Code 211.12 (d) Nursing care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18 (e)(1) Management.

Based on a review of clinical records, select facility policies, applicable state professional nursing standards, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of practice, resulting in actual harm. Specifically, the facility failed to initiate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure consisting of chest compressions and rescue breathing used when an individual is found unresponsive and not breathing normally) for one out of 10 residents reviewed (Resident CR1) who had documented wishes for Full Code status (meaning the resident wanted all possible life-saving measures, including CPR, if their heart or breathing stopped). This failure resulted in actual harm, as life-sustaining interventions consistent with the resident's documented treatment preferences and accepted nursing standards were not provided during a cardiopulmonary arrest.Findings A review of 49 Pa. Code S21.11(a)(4) (relating to general functions of a registered nurse) indicated that a registered nurse is responsible for carrying out nursing care actions that promote, maintain, and restore the well-being of individuals. A review of 49 Pa. Code S21.13(1) (relating to resuscitation and respiration) indicated that a licensed registered nurse shall only perform external cardiac resuscitation and artificial respiration, when respiration or pulse, or both, cease unexpectedly. A review of Section 21.15 of the Pennsylvania Code Title 49 Pa. Code S21.15 (relating to monitoring, defibrillating, and resuscitation) by registered nurses provides instruction that the Registered Nurse can perform resuscitation therapy when (1) the employer through written policy, has agreed that the registered nurse may administer the therapy. (5) The registered nurse has demonstrated competency in administering the therapy to the satisfaction of the employer. A review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support last reviewed [DATE], revealed that when an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, licensed or certified staff are to initiate CPR unless a valid Do Not Resuscitate (DNR) order specifically prohibiting CPR exists or there are clear signs of irreversible death (such as rigor mortis, which is post-death muscle stiffening). A review of Resident CR1's closed clinical record revealed admission to the facility on [DATE], at 7:00 PM with diagnoses including chronic obstructive pulmonary disease (a progressive lung condition causing airflow blockage, inflammation, and breathing difficulties, often from smoking), hyperlipidemia (when there are too many fats in the blood), and hypertension (common condition where the force of blood against artery walls is consistently too high/ high blood pressure). A review of Resident CR1's closed clinical record revealed that a face sheet from the referring facility was scanned into the facility's electronic medical record on [DATE], at 1:52 PM, one day prior to the resident's admission. The face sheet, which is routinely provided by the transferring facility as part of the admission process, contained key resident information used to guide care upon arrival, including the resident's code status. Review of this document confirmed that at the referring facility, Resident CR1 was designated as Full Code, indicating the resident's preference to receive cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. A nursing progress note dated [DATE], at 7:00 PM documented that Resident CR1 was admitted with baseline confusion, required oxygen therapy, and exhibited dyspnea (shortness of breath). The note documented that attempts to complete admission documentation were unsuccessful due to inability to reach family to confirm the resident's code status. At approximately 2:30 AM on [DATE], Employee 2 (Nurse Aide) and Employee 3 (Nurse Aide) entered Resident CR1's room and found the resident unresponsive.A nursing progress note dated [DATE], at 2:30 AM documented by Employee 1 (Registered Nurse) revealed the resident was unresponsive to verbal commands and sternal rub (a painful stimulus applied to the breast bone to assess responsiveness), had no apical pulse upon auscultation (listening to the heart with a stethoscope), and staff were unable to obtain blood pressure or oxygen saturation using a pulse oximeter (a device that measures blood oxygen levels). The note documented that one respiration was observed, the resident's pupils were fixed and dilated, and the resident's skin was warm and dry to touch. The nursing supervisor was notified. A subsequent nursing progress note dated [DATE], at 3:55 AM documented by the registered nurse supervisor, indicated that upon assessment the resident was unresponsive, pale, without measurable blood pressure, without respirations, and without detectable apical or carotid pulse (the carotid pulse is felt in the neck and reflects central circulation). No DNR order or POLST (Provider Orders for Life-Sustaining Treatment, a medical order translating a resident's treatment preferences into actionable medical orders) was located in the medical record or electronic system at that time. The physician was contacted regarding the resident's death at 2:34 AM. Review of the clinical record revealed no documentation of rigor mortis, dependent lividity (purplish skin discoloration that occurs after prolonged absence of circulation), or other findings indicative of irreversible death at the time the resident was found unresponsive. An interview with Employee 2, Nurse Aide, conducted on [DATE], at 12:45 PM revealed that Employee 2 was not certified in cardiopulmonary resuscitation (CPR) or use of an Automated External Defibrillator (AED, a device that analyzes heart rhythm and delivers an electrical shock during certain types of cardiac arrest) and therefore did not initiate CPR. Employee 2 stated that she observed Employee 1, Registered Nurse, assessed Resident CR1 and directed Employee 3, Nurse Aide, to check the resident's code status; however, this direction was not documented in the clinical record. Employee 2, Nurse Aide, further stated that Employee 4, Registered Nurse Supervisor, arrived in the resident's room and CPR was not initiated. Employee 2 confirmed that at no time during the event did she observe CPR being initiated by either Employee 1, Registered Nurse, or Employee 4, Registered Nurse Supervisor. A review of Employee 1's, Registered Nurse, employee record revealed that Employee 1 successfully completed the cognitive and skills evaluation in accordance with the American Heart Association Basic Life Support (CPR and AED) Program on [DATE], confirming that Employee 1 held current certification and was qualified to initiate CPR to Resident CR1. A review of Employee 4's employee record revealed that Employee 4 successfully completed CPR certification requirements through the American Red Cross, confirming that Employee 4 also held current certification and was qualified to initiate CPR at the time of the incident involving Resident CR1. Phone call attempts were made to Employee 1, Registered Nurse; Employee 3, Nurse Aide; and Employee 4, Registered Nurse Supervisor, on [DATE], at 10:58 AM, 10:59 AM, 11:09 AM, and 11:59 AM, for the purpose of obtaining interviews related to the incident involving Resident CR1 on [DATE]. All initial contact attempts were unsuccessful. A return telephone call was received on [DATE], at 12:15 PM, from legal counsel representing Employee 4, Registered Nurse Supervisor, who declined the interview at that time and indicated that any future requests to interview Employee 4 would need to be submitted in writing through a judicial authority. Based on review of the closed clinical record, staff statements, and training documentation, Employee 1, Registered Nurse, and Employee 4, Registered Nurse Supervisor, failed to initiate CPR for Resident CR1 despite hospital documentation indicating the resident's preference for Full Code status. An interview with the Regional Manager of the facility conducted on [DATE], at 3:38 PM confirmed that initiation of CPR is the responsibility of licensed nursing staff when a resident is found unresponsive and no Do Not Resuscitate (DNR) order exists. The Regional Manager further indicated that licensed nurses are expected to act within their professional scope of practice in accordance with Title 49 Pennsylvania Code, Professional and Vocational Standards. The facility failed to ensure that professional standards of nursing practice were followed when licensed nursing staff did not initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive and without a palpable pulse and who did not exhibit documented clinical indicators of irreversible death. As a result, the resident did not receive timely, potentially life-sustaining interventions required under generally accepted nursing standards and Basic Life Support principles. Because CPR was not initiated, the opportunity to attempt resuscitative measures consistent with the resident's Full Code status was not provided. The facility remains responsible for ensuring that nursing services are delivered in accordance with professional standards of practice. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, facility policies and procedures, facility-provided investigative documentation, job descriptions, witness statements, and staff interviews, it was determined that the facility failed to administer the facility in compliance with federal requirements to ensure resident health and safety. Specifically, the Administrator and Director of Nursing failed to establish, implement, oversee, and enforce an effective cardiopulmonary resuscitation (CPR) system, resulting in licensed nursing staff not initiating CPR for one resident (Resident CR1) out of 10 residents sampled who desired full resuscitative measures and did not exhibit documented irreversible signs of death. This failure resulted in Immediate Jeopardy.Findings included:A review of the facility policy titled Emergency Procedure -Cardiopulmonary Resuscitation, last reviewed [DATE], required licensed or certified staff to initiate CPR, defined as an emergency lifesaving procedure consisting of chest compressions and rescue breathing, when an individual is found unresponsive and not breathing normally, unless a valid Do Not Resuscitate (DNR) order exists or there are obvious irreversible signs of death. The policy further required that if code status is unclear, CPR must be initiated until a DNR or physician order not to resuscitate is confirmed. The policy also required administrative systems to ensure CPR readiness, including staff education, competency, and adherence to American Heart Association (AHA) guidelines. According to AHA guidelines, presumptive signs of death (such as unresponsiveness, absent respirations, absent pulse, fixed and dilated pupils, or cyanosis) do not preclude initiation of CPR. Irreversible signs of death, which indicate resuscitation is no longer appropriate, include livor mortis, rigor mortis, decomposition, or decapitation. A review of Resident CR1's clinical record revealed admission on [DATE], at 7:00 PM with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension. The record contained a physician order identifying the resident as Full Code, and a face sheet from the referring facility, scanned into the electronic medical record on [DATE], confirmed the resident's preference to receive CPR. On [DATE], at approximately 2:30 AM, staff found Resident CR1 unresponsive. Nursing documentation reflected the resident was unresponsive to verbal and painful stimuli, had no detectable pulse, no obtainable blood pressure or oxygen saturation, fixed and dilated pupils, and no documented DNR or POLST (Provider Orders for Life-Sustaining Treatment, which converts treatment preferences into medical orders). CPR was not initiated by licensed nursing staff prior to physician notification. Documentation did not reflect the presence of irreversible signs of death. Facility-provided witness statements and staff interviews confirmed that licensed nursing staff deferred CPR while attempting to verify code status, despite policy requirements to initiate CPR when code status is unclear. Interviews further revealed staff lacked understanding of irreversible signs of death and were unaware of any functional CPR team, despite policy language indicating such systems existed. Interviews with the Director of Nursing confirmed that, at the time of the incident, the CPR policy had not been revised to clarify irreversible signs of death and that staff education was conducted without ensuring comprehension or competency. As of [DATE], the facility had not demonstrated that staff were competent to initiate CPR in accordance with resident wishes and AHA guidelines. A review of the facility's Nursing Home Administrator job description, signed and dated [DATE], revealed that the Administrator is responsible for leading and directing the overall operations of the facility in accordance with applicable federal and state regulations, company policies, and resident care requirements. The job description identified the Administrator as accountable for ensuring regulatory compliance and maintaining a system that promotes quality care and resident safety while meeting the facility's operational objectives. The Administrator is responsible for overseeing regular facility rounds to monitor the delivery of nursing care, the operation of support departments, the cleanliness and appearance of the facility, staff morale, and whether resident needs are being met. The job description further identified responsibility for leading the facility management team and consultants in the development and execution of a comprehensive business and operational plan, including setting priorities, assigning responsibilities, and participating in process improvement initiatives designed to improve care delivery, workflow efficiency, and the overall work environment.A review of the Director of Nursing (DON) job description, signed and dated [DATE], revealed that under the supervision of the Administrator and Medical Director, the DON is responsible for planning, organizing, developing, implementing, evaluating, and directing the overall operation of the Nursing Services Department in accordance with current federal, state, and local laws, regulations, and professional standards. The job description identified the DON as responsible for ensuring the highest practicable level of quality nursing care is provided at all times. The DON is further responsible for developing, maintaining, and periodically updating nursing policies and procedures that govern day-to-day nursing operations, as well as ensuring staff are educated on and compliant with those policies. The job description also identified responsibility for coordinating nursing services with other departments to ensure continuity of care and the resident's total plan of care is consistently implemented.The failure of the Administrator and Director of Nursing to administer the facility in a manner that ensured timely initiation of CPR placed residents who desired resuscitative measures at risk for serious harm or death. The facility's noncompliance resulted in a situation in which a resident requiring emergency life-saving intervention did not receive CPR in accordance with physician orders, resident wishes, facility policy, and accepted standards of practice. Immediate Jeopardy was identified on [DATE], at 11:35 AM, as the facility's actions and inactions caused or were likely to cause serious injury, harm, impairment, or death. Refer F678 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code: 201.12 (a) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1) Management 28 Pa. Code:211.12(c) Nursing Services

Based on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders were consistent in reflecting a resident's elected code status for two of 23 residents reviewed (Residents 29 and 80). Findings include: A review of a facility policy titled Advanced Directives, last reviewed by the facility on [DATE], revealed it is the facility policy that the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment, and advanced directives are honored in accordance with state law and facility policy. Further review revealed Physician Orders for Life Sustaining Treatment, or POLST, is a form designed to improve resident care by creating a portable medical order form that records the resident's treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration. A review of the clinical record of Resident 29 revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident 29's current physician orders, revealed an order dated [DATE], in the electronic health record, and identified the resident's code status as Full Code, indicating CPR (cardiopulmonary resuscitation) was to be performed in the event of cardiopulmonary arrest (if breathing stops or if the heart stops beating). Further review of Resident 29's clinical record revealed a completed and signed POLST dated [DATE]. The POLST indicated the resident elected DNR status (Do Not Resuscitate, a medical order directing that cardiopulmonary resuscitation, a life-saving procedure performed when the heart or breathing stops, should not be attempted), with a goal of allowing a natural death. Following surveyor questions, there was a physician's order dated [DATE], for DNR (Do Not Resuscitate-a medical order directing that CPR should not be attempted) for Resident 29. A review of the clinical record of Resident 80 revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia and urine retention (difficulty urinating and completely emptying the bladder). A review of Resident 80's current physician orders, revealed an order dated [DATE], in the electronic health record, and identified the resident's code status as DNR, indicating CPR was not to be performed in the event of cardiopulmonary arrest. Further review of Resident 80's clinical record revealed a completed and signed POLST dated [DATE]. The POLST indicated the resident elected CPR and to attempt resuscitation. Following surveyor questions, there was a physician's order dated [DATE], for Full Code (attempt CPR) for Resident 80. An interview with the Regional Nurse Consultant on [DATE], at approximately 10:00 AM, confirmed the physician orders did not align with the most current, signed POLST for Resident 29 and 80. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of select facility policy, employee files, and staff interview it was determined that the facility failed to timely train one agency employee out of four employees reviewed on the facility's abuse prohibition policy and procedures. Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on June 13, 2025, revealed the facility's abuse prevention program provides training for mandated staff and others that includes topics such as abuse prevention, identification, and reporting requirements and to support an environment in which covered individuals report a reasonable suspicion of a crime, freedom from retaliation or reprisal, stress management, dealing with violent behavior or catastrophic reactions, etc. training is provided at the time of hire, annually, and as needed. A review of Employee 1's personnel file, who was employed as an agency licensed practical nurse (LPN) with a documented start date of November 19, 2022, revealed no evidence that the facility provided the required training on the facility's abuse prohibition policy prior to Employee 1 (LPN) assuming resident care responsibilities. Furthermore, there was no documentation to show that Employee 1 received the training on an annual basis or as needed as required by the facility policy. During an interview conducted on August 26, 2025, at 1:20 PM, the Nursing Home Administrator (NHA) confirmed that there was no documentation verifying Employee 1 (LPN) received the required training on the facility's abuse prohibition policy and procedures either prior to beginning assigned duties or thereafter.28 Pa. Code 201.20(b) Staff development 28 Pa Code 201.18 (e)(1) Management 28 Pa Code 201.10 (d) Resident Care Policies

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for 2 residents out of 23 residents sampled (Resident 56 and 80). According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of facility policy titled Anticoagulation Clinical Protocol, last reviewed by the facility on June 13, 2025, revealed the physician will prescribe anticoagulation therapy(commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) appropriately consistent with recognized guidelines and should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant and/or monitor the PT/INR (a blood test that tells you how long it takes for your blood to clot) very closely while the individual is receiving warfarin (a blood thinner) to ensure that the PT/INR stabilizes within a therapeutic range. Further review revealed the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications, for example, periodically checking hemoglobin, hematocrit, platelets, and PT/INR. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and hypertension (blood pressure that is higher than normal). A review of a state Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 12, 2025, revealed that Resident 56 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of Resident 56's clinical record revealed a physician's order, dated May 29, 2025, for Warfarin 2.5 mg, one tablet daily at bedtime, for treating/preventing blood clots. A review of Resident 56's clinical record revealed a laboratory result on June 2, 2025, of a PT/INR, which was 1.9 (the therapeutic range is 2.0-3.0). A review of a nurse progress note for Resident 56, dated June 2, 2025, revealed the nurse spoke with the doctor regarding the June 2, 2025, PT/INR results and noted to keep the Coumadin (brand name for warfarin) dose the same with repeat PT/INR in one week. A review of Resident 56's clinical record revealed a physician's order dated June 2, 2025, and noted an order for PT/INR on June 9, 2025. A review of the clinical record revealed no evidence that a PT/INR resulted on June 9, 2025, as ordered by the physician, and the facility was unable to provide evidence of the result. Following surveyor inquiry, a physician's order for Resident 56, dated July 1, 2025, revealed an order for a PT/INR. A review of the clinical record of Resident 80 revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and urine retention (difficulty urinating and completely emptying the bladder) and had an indwelling Foley catheter (small flexible tube inserted into the urethra to drain urine from the bladder). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 18, 2025, revealed that Resident 80 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of Resident 80's clinical record revealed a physician's order, dated February 19, 2025, to consult urology and the resident would need an appointment due to heavy calcifications (significant mineral deposits composed of salt crystals) at the end of Foley causing bleeding when the Foley was dislodged. A review of Resident 80's clinical record revealed no evidence that any consults were called to urology and no evidence that an appointment was made for Resident 80. A review of a nurse progress note for Resident 80, dated February 19, 2025, revealed that urine was collected for urinalysis (UA a test of urine used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes; urinalysis involves checking the appearance, concentration and content of urine) and culture and sensitivity (C & S-analysis helps find the most effective antibiotic to kill an infecting microorganism; sensitivity analysis is a test that determines the sensitivity of bacteria to an antibiotic) via catheter after it was changed, and it was noted that the collected urine was described as a blood-tinged, milky urine. A review of Resident 80's clinical record revealed a laboratory result of a UA on February 20, 2025, which was abnormal due to over 50 white blood cells, over 50 red blood cells, 26-50 bacteria cells, a large amount of blood, and turbid color (not clear or cloudy) urine. A review of a nurse's progress note, dated February 20, 2025, revealed the physician was aware of the UA result and no new orders were noted and was awaiting the culture result. A review of Resident 80's clinical record revealed a laboratory result of a urine C & S on February 24, 2025, which was abnormal and showed growth of greater than 100,000 colonies of Proteus vulgaris (type of bacteria), greater than 100,000 colonies of Morganella morganii (a type of bacteria), and 10,000 to 100,000 colonies of Serratia marcescens (a type of bacteria). A review of a nurse's progress note for Resident 80, dated February 24, 2025, revealed the physician was made aware of the urine C&S results and noted an order to follow up with infectious disease and urology. It was noted that results were faxed to urology, and follow-up with infectious disease was to be scheduled. A review of Resident 80's clinical record revealed no evidence of any new orders for urology or infectious disease consults. A review of Resident 80's clinical record revealed no evidence that any consults were called to urology and infectious disease and no evidence that appointments were made for Resident 80. A review of a nurse's progress note dated on April 3, 2025, revealed the resident's urine was noted to be thick and brown in color with a foul smell and that the nurse practitioner in the facility was made aware. A review of a nurse's progress note, dated April 4, 2025, at 9:00 A.M., revealed the nurse was called to assess the resident who was diaphoretic (sweating) with a low blood pressure of 82/52 (normal is 120/80) and a high pulse of 112 (normal is 60-100). It was noted the resident was alert but confused and unable to follow simple instructions. It was also noted the Foley had minimal urine output, and the lower abdomen was distended and tender to touch. The primary doctor evaluated Resident 80 at the bedside, and he was then sent to the emergency room. A review of a nurse's progress note, dated April 4, 2025, at 9:40 P.M., revealed the resident was being admitted to the hospital for sepsis (a life-threatening complication of an infection that leads to a bloodstream infection) and renal failure (kidney failure). Further review of Resident 80's clinical record revealed that during the hospitalization it was noted the resident underwent placement of bilateral nephrostomy tubes (a tube that is put into the kidney to drain urine directly from the kidney) and required a PICC (Peripherally Inserted Central Catheter) line with the requirement of intravenous antibiotics. An interview with the Regional Nurse Consultant on July 2, 2025, at approximately 12:00 PM confirmed the above findings regarding Residents 56 and 80's treatment and care were not` in accordance with physician orders. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interview, it was determined the facility failed to timely report an instance of resident neglect to the State Survey Agency for one out of the 23 residents reviewed (Resident 30). Findings include: A review of the facility policy titled Abuse Policy indicated as last reviewed by the facility on June 13, 2025, revealed all reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies. The policy indicates that the nature of the allegations and the names of the resident(s) and individual(s) implicated will be reported to the appropriate agencies within five (5) working days of the incident. A clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included above-the-knee right leg amputation, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and cognitive communication deficit. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 28, 2025, revealed that Resident 30 was severely moderately impaired with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). A physician's order dated May 19, 2025, specified that Resident 30 required assistance from two staff members, using a two-wheeled walker and gait belt (a safety device used to assist residents with mobility issues during transfers and ambulation) for all transfers. The resident's Kardex (a nursing information system used to obtain specific care information for each resident) also indicated two-person assistance was required for transfers. Nursing documentation dated May 24, 2025, at 12:00 PM indicated the nurse was notified that Resident 30 had fallen on the floor in the bathroom. Preliminary assessment was completed in the bathroom and no injuries were noted. Vital signs were obtained. A full head to toe assessment was performed once the resident was back in bed. Plus (+)1 edema (swelling of an area where pressure forms at the site when pressed leaving a depth that disappears at a +1) was noted in the left foot and ankle. The resident complained of pain rated 2/10 (pain rated as one being least amount of pain and ten being the worst amount of pain) in the left ankle. The resident did not have a previous injury to that ankle. The LPN provided pain medication. An x-ray of the ankle was ordered and the resident's sister was notified. A review of a facility investigative report dated May 24, 2025 determined that Employee 2 (nurse aide) transferred the resident alone, in violation of the physician's order and Kardex instructions requiring two-person assist. A witness statement dated May 24, 2025, (no time indicated) provided by Employee 2, revealed that the resident had asked to go to the bathroom. Employee 2 asked the resident if he required a one or two-person assist, and he said one. She asked if he used a wheelchair or walker, and he said walker. During transfer in front of the toilet, the resident's leg slid, resulting in a fall onto the floor. A review of the facility document titled Post Fall Root Cause Analysis dated May 24, 2025, concluded that Employee 2 failed to follow the resident's documented transfer status as indicated on the Kardex, contributing to the fall. During an interview on July 2, 2025, at approximately 9:30 AM, the Nursing Home Administrator confirmed the incident of neglect involving Resident 30 which occurred on May 24, 2025 was never reported to the state agency, neither at the time of the incident and including the date of this interview. The incident was not reported within the required five day time frame for reporting allegations of neglect. Refer to F600 28 Pa Code 201.1 (a) Responsibility of licensee. 28 Pa Code 201.18 (e)(1) Management.

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the facility failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident out of 23 residents reviewed (Resident 30). Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on June 13, 2025, revealed it is the facility's policy that the resident has the right to be free from abuse, neglect, misappropriation or resident property, and exploitation. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included above-the-knee right leg amputation, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and cognitive communication deficit. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 28, 2025, revealed Resident 30 was severely moderately impaired with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). A physician's order dated May 19, 2025, specified that Resident 30 required assistance from two staff members, using a two-wheeled walker and gait belt (a safety device used to assist residents with mobility issues during transfers and ambulation) for all transfers. The resident's Kardex (a nursing information system used to obtain specific care information for each resident) also indicated two-person assistance was required for transfers. Nursing documentation dated May 24, 2025, at 12:00 PM indicated the nurse was notified that Resident 30 had fallen on the floor in the bathroom. Preliminary assessment was completed in the bathroom and no injuries were noted. Vital signs were obtained. A full head to toe assessment was performed once the resident was back in bed. Plus (+)1 edema (swelling of an area where pressure forms at the site when pressed leaving a depth that disappears at a +1) was noted in the left foot and ankle. The resident complained of pain rated 2/10 (pain rated as one being least amount of pain and ten being the worst amount of pain) in the left ankle. The resident did not have a previous injury to that ankle. The LPN provided pain medication. An x-ray of the ankle was ordered and the resident's sister was notified. A review of a facility investigative report dated May 24, 2025 determined that Employee 2 (nurse aide) transferred the resident alone, in violation of the physician's order and Kardex instructions requiring two-person assist. A witness statement dated May 24, 2025, (no time indicated) provided by Employee 2, revealed the resident had asked to go to the bathroom. Employee 2 asked the resident if he required a one or two-person assist, and he said one. She asked if he used a wheelchair or walker, and he said walker. During transfer in front of the toilet, the resident's leg slid, resulting in a fall onto the floor. A review of the facility document titled Post Fall Root Cause Analysis dated May 24, 2025, concluded that Employee 2 failed to follow the resident's documented transfer status as indicated on the Kardex, contributing to the fall. During an interview on July 2, 2025, at approximately 9:30 AM, the Nursing Home Administrator confirmed the above information indicating that Employee 2 did not follow established protocols for safe transfers, placing the resident at risk of injury. The facility failed to implement appropriate care interventions and ensure staff compliance with the physician-ordered transfer protocol. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services.

Based on clinical record review, observations, and staff interview, it was determined the facility failed to maintain infection control practices to prevent potential spread of infection for two out of 20 residents sampled (Resident 77 and 83) and failed to offer and/or provide SARS-CoV-2 (COVID-19) immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one of five residents reviewed (Resident 2). Findings include: A review of facility policy titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures, last reviewed by the facility on June 21, 2024, revealed the facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. A review of the CDC ' s Use of an Additional Updated 2023-2024 COVID-19 Vaccine Dose for Adults Aged greater than or equal to [AGE] years: Recommendations of the Advisory Committee on Immunization Practices-United States, 2024, revealed according to the Advisory Committee on Immunization Practices (ACIP) recommendations as of February 28, 2024, all persons aged [AGE] years and older should receive one additional dose of an updated (2023-2024 Formula) COVID-19 vaccine (Moderna, Novavax, or Pfizer-BioNTech). This dose should be given at least four months after their previous updated dose to enhance immunity and reduce the risk of severe COVID-19-associated illness. A review of the CDC's Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 (COVID-19) and Influenza Viruses are Co-circulating, lasted reviewed November 14, 2023, revealed that residents confirmed to have SARS-CoV-2 infection should be placed in a single room, if available, or housed with other residents with only SARS-CoV-2 infection. A review of the COVID-19 Infection Control and Outbreak Response Toolkit for Long Term Care Published July 2023 by the Pennsylvania Department of Health indicates; Dedicating an area within the facility to cohort residents on isolation for confirmed COVID-19 during their infectious period is best practice for decreasing the likelihood of transmission. Components of a COVID-19 Care Unit ideally include the following: Physical separation from other rooms and spaces where residents are not confirmed with COVID-19; Single-person room(s) with designated bathroom(s); Place a resident with suspected or confirmed COVID-19 in a single- person room. The door should be kept closed, if safe to do so. The resident should have a dedicated bathroom. If limited single rooms are available, or if numerous residents are simultaneously identified to have symptoms concerning for COVID-19, residents may remain in their current location until cause of symptoms is determined. If cohorting, only residents with the same pathogen should be housed in the same room. Multidrug-resistant organism (MDRO) colonization or infection status, and/or presence of other communicable disease should also be taken into consideration during the cohorting process. A clinical record review revealed Resident 77 was admitted to the facility on [DATE], with diagnoses that included aftercare following digestive system surgery. A clinical record review revealed Resident 83 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A clinical record review revealed Resident 77 and Resident 83 shared resident room Blue Wing 07. Facility infection control tracking records indicate that Resident 77 tested positive for SARS-CoV-2 (COVID-19) on September 3, 2024. A clinical record review failed to find documented evidence that the facility attempted to isolate Resident 77 in a single room. A clinical record review failed to find documented evidence that the facility provided Resident 83 or Resident 83's representative information regarding the risks of sharing a room with a resident that tested positive for SARS-CoV-2 (COVID-19), including current CDC recommendations. There was no documented evidence in the clinical record the facility provided Resident 83 or Resident 83's representative with an opportunity to make an informed decision to change rooms. Facility infection control tracking records indicate that Resident 83 tested positive for SARS-CoV-2 (COVID-19) on September 5, 2024. During an interview on September 13, 2024, at approximately 9:30 AM, the Director of Nursing (DON) was unable to provide evidence the facility attempted to isolate Resident 77 in a single resident room or in a room with only other residents that tested positive for SARS-CoV-2 (COVID-19). The DON confirmed there was no documented evidence the facility provided Resident 83 or Resident 83's representative with an opportunity to make an informed decision to change rooms. A review of the DON's Nursing Home Infection Preventionist Training credentials revealed that she was not certified as an infection preventionist until August 27, 2024. During an interview on September 13, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility did not currently have an infection preventionist. The NHA explained that the Director of Nursing (DON) has been covering the duties of the infection preventionist since July 18, 2024. The NHA confirmed that the DON was not certified as an infection preventionist until August 27, 2024. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A clinical record review revealed no evidence that Resident 2 or Resident 2's representative received education regarding the benefits and potential side effects of SARS-CoV-2 (COVID-19) immunization. The clinical record did not contain evidence that Resident 2 was offered SARS-CoV-2 (COVID-19) immunization since May 19, 2022. Resident 2's clinical record did not indicate that receiving SARS-CoV-2 (COVID-19) immunization is medically contraindicated. During an interview on September 13, 2024, at approximately 9:30 AM, the Director of Nursing (DON) was unable to provide evidence Resident 2 or Resident 2's representative received education regarding the benefits and potential side effects of SARS-CoV-2 (COVID-19) immunization, evidence Resident 2 was offered SARS-CoV-2 (COVID-19) immunization since May 19, 2022, or evidence that SARS-CoV-2 (COVID-19) immunization is medically contraindicated for Resident 2. The DON confirmed that the facility is responsible for ensuring residents/resident representatives are afforded the opportunity to make informed decisions regarding SARS-CoV-2 (COVID-19) immunization. Refer F882 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa code 211.12 (c)(d)(1)(5) Nursing Services

Based on observation, a review of clinical records, a review of nurse staffing, and interviews with staff and residents, it was determined the facility failed to provide sufficient nursing staff to provide timely and quality care for residents that sustained falls, for three residents out of 20 sampled (Residents 7, 70, and 90) and failed to provide timely care expressed by residents during a resident group interview (Residents 1, 35, 52, 65, and 71). Findings included: The facility failed to provide sufficient supervision and implement effective fall prevention interventions for two residents at high risk for falls, Resident 7 and Resident 70, both of whom experienced repeated falls despite being identified as high fall risks. A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia and severe cognitive impairment. Resident 7 has a documented history of falls from her Broda chair, often accompanied by agitation and behaviors. Despite various care plan interventions (e.g., chair alarms, non-skid footwear), the resident continued to experience falls, including incidents on April 5, April 18, April 22, and May 22, 2024. Staff repeatedly documented the resident's agitated behaviors and attempts to get out of her chair unassisted, yet adequate supervision and effective fall interventions were not sustained. A clinical record review revealed Resident 70 was admitted to the facility on [DATE], with diagnoses that included dementia and a documented fall history. Despite various care plan interventions to mitigate Resident 70's risk of falling and protect him from injury (e.g., ensuring his bed is in the lowest position, bilateral floor mats, a bed alarm, and ensuring his call bell is within reach), the resident continued to experience falls, including incidents on February 24, March 2, March 29, and June 2, 2024. A clinical record review revealed Resident 90 was admitted to the facility on [DATE], with diagnoses that included orthopedic aftercare and with inflammation and infection to an internal right hip prosthesis (hip replacement). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 4, 2024, revealed that Resident 90 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on September 10, 2024, at 12:05 PM, Resident 90 reported experiencing pain and stated that he had been waiting to be helped into bed to rest since 11:00 AM. He explained that he is new to the facility and has been experiencing long wait times for care. He mentioned that he typically waits 30 minutes to an hour, and last night, he waited for over an hour. Resident 90 clarified that he does not blame the staff, as they are doing their best, but there aren't enough staff members to assist the residents promptly. He expressed frustration with the long wait times for care. During an interview on September 10, 2024, at 12:18 PM, Employee 6, Nurse Aide, confirmed that Resident 90 had been waiting for about 45 minutes to be assisted into bed. She explained that she is the only staff member in the area at the time and needs assistance to safely transfer him. Employee 6 emphasized that she is doing her best, but there are not enough staff to meet the residents' needs in a timely manner. She also noted that there are about 27 residents in the hallway and only two staff members available to care for them. While she is busy with resident care now, she mentioned the evening shift often faces even greater staffing shortages. During an interview on September 10, 2024, at 12:20 PM, Employee 5, Nurse Aide, reported that Resident 90 had requested to be transferred into bed around 11:30 AM. She explained that it requires two staff members to transfer him, but no one was available to help her at that moment because staff were busy serving meals. At 12:31 PM on September 10, 2024, Employees 5 and 6 were observed entering Resident 90's room to assist him into bed. During a resident group interview, with alert and oriented residents, on September 11, 2024, at 10:00 AM, Residents 1, 35, 52, 65, and 71 indicated the lack of nursing staff has negatively affected the care services they receive at the facility. During the resident group interview, Resident 1 indicated that he often waits 30 minutes to an hour for care, and the wait times are the longest on the evening and night shifts. He explained that when the facility uses agency staff because of staff shortages, the care is not any better. Resident 1 indicated that facility staff will give him a bed bath instead of a shower because they are low on staffing. He indicated that a few times this week he was not offered a snack because the nurse aides were busy providing care to other residents. During the resident group interview, Resident 35 indicated that she is independent and does not need to rely on staff for assistance with care. However, she indicated that two or three times this week there were not enough staff to pass out evening snacks. She explained that when the facility uses agency staff, they do not know that snacks need to be offered to residents. During the resident group interview, Resident 52 indicated that she sometimes waits 30 minutes or longer for care after ringing her call bell for assistance. She indicated that sometimes there is only one nurse aide assigned to her hallway and that the one staff is not able to take care of all the residents needs. During the resident group interview, Resident 65 indicated that he waits 30 minutes on the evening and night shift for staff to respond to his call bell after he rings for assistance. During the resident group interview, Resident 71 expressed concerns about staffing levels at the facility, stating that there is not enough staff. She explained that staff members never ask or remind her about taking her scheduled shower. Resident 71 reported that if she does not inform the staff that it is her shower day, she missed her shower for the week, resulting in a two-week gap between showers. A review of the facility's nurse staffing from September 5, 2024, to September 11, 2024, revealed that the facility failed to meet the state's minimum requirement for direct care hours per patient on all seven days. The required direct care hours represent the minimum amount of care each resident must receive daily, which may increase based on individual resident needs. The facility provided an average of 2.72 hours of care per resident per day, falling short of the state-mandated minimum of 3.2 hours. A review of the facility's nurse staffing from September 5, 2024, to September 11, 2024, revealed the facility failed to meet the required minimum state ratio for nurse aides on 9 of the 21 shifts reviewed. The facility failed to meet the required minimum state ratio for licensed practical nurses on 6 of the 21 shifts reviewed. The facility failed to meet the state minimum required nursing staff direct care hours per day for each resident on 7 out of 7 days reviewed. During an interview on September 13, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to meet the state minimum requirements for nurse aides, licensed practical nurses, and nurse staff direct care hours for residents per day. The NHA confirmed that it is the facility's responsibility to provide sufficient nursing staff to provide timely and quality care to each resident. Furthermore, the NHA confirmed the facility is responsible to ensure that there is sufficient nurse staffing to provide adequate supervision to residents who are at risk of falling, to protect residents from injury, and mitigate residents' risk of falling. Refer F656 F689 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(4)(i)(2) Nursing services.

Based on review of clinical records, information submitted by the facility, select facility reports, and staff interviews it was determined the facility failed to provide a resident who sustained repeated falls the necessary supervision and/or effective fall interventions to prevent a fall with a monor injury for one out of five sampled residents for accidents (Resident 7). Findings include: A review of a facility policy entitled Falls Management that was last reviewed by the facility on June 21, 2024, indicated that each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs, as appropriate, to prevent accidents. It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and minimize complications if a fall occurs. A review of Resident 7's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia ( a general decline in cognitive abilities that affects a person's ability to perform everyday activities), generalized anxiety (fear characterized by behavioral disturbances), dysphagia (difficulty swallowing), and behavior disturbances (common behaviors associated with dementia include hoarding, restlessness, and accusatory behaviors). A review of a quarterly Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 11, 2024, revealed the resident's BIMS was a 4 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 indicates severe impairment) indicating severe cognitive impairment. A review of the resident's fall risk evaluation dated February 22, 2024, at 5:41 PM, revealed she was at a high for falls. A review of a behavior progress note completed by Employee 9, a Licensed Practical Nurse (LPN), dated April 5, 2024, at 6:52 PM, revealed at the beginning of the shift, Resident 7 had extreme agitation, anxiety, restlessness, and was screaming and yelling making derogatory remarks. The resident was propelling herself in her Broda chair (chair or wheelchair that provides comfort, support, and mobility throughout the day) throughout the unit and she was wandering in other resident's rooms. The resident was redirected out of other resident's rooms and required much encouragement to leave resident the rooms. Occasionally, the resident was leaning forward attempting to pick up things from the floor that were not there causing the chair alarm system to sound and alert staff of her unsafe movements. In response to her behaviors Employee 9 noted the resident was not receptive to taking oral medication and the resident threw the water and swung at Employee 9 and it was noted she was not receptive to conversation, snack, or fluids. The resident continued to propel herself throughout unit within direct supervision. Numerous interventions attempted and continued with periods of anxiety, restlessness, and agitation with no effect The resident's comprehensive person-centered care plan for falls, initiated on April 8, 2021, identified that Resident 7 was at risk for falls due to deconditioning and gait balance (refers to a person's pattern of limb movement while walking) problems with a goal to be free of falls. Planned fall prevention interventions included an alarm to her chair to alert staff of unassisted transfers, the alarms placement and function was to be checked on each shift and prn (as needed), ensure proper fitting gripper socks on at all times, low bed for safety, nonskid footwear at all times, and staff to anticipate and meet the resident's needs. Additionally, a review of Resident 7's cognitive impairment plan of care indicated the resident had impaired thought processes related to dementia with mood swings and behaviors with a planned intervention to cue, reorient and supervise her as needed. A review of the facility documentation revealed the Resident sustained an unwitnessed fall from her Broda chair on April 5, 2024 at 10:30 PM and sustained purpura (small blood vessels burst) tear to her right lateral forearm 5.0 centimeters. It was noted the resident was asleep in the Broda chair and when she awoke she sustained a fall. The resident's alarm sound and she was heard calling out Oh! Oh! An intervention after this fall was to place the resident at the nursing station for closer observation. A review of a rehabilitation screen completed by Employee 12, an Occupational Therapist (OT), dated April 11, 2024, at 11:32 AM, revealed that the screen was completed in response Resident 7's unwitnessed fall on April 5, 2024. Employee 12 commented that the resident utilized a Broda chair with sheep wool, Dycem (nonskid material), chair alarm, and reclined position and recently received occupational therapy services for previous fall and provided left lateral support. No change was made to the wheelchair set up and nursing was made aware to provide periodic checkup secondary to noted confusion, agitation, and hallucinations. A review of an investigative report completed by the Director of Nursing (DON), dated April 18, 2024, at 12:23 AM, revealed Resident 7 was observed laying on the floor of the hallway on her right side. Resident denied pain and physical assessment did not reveal any other injury. Redness was noted to the right shoulder, however the resident stated it was red from her scratching the area. The resident had Crocs (slip on rubber shoes) on her feet and staff noted that she was asleep in her Broda chair when a loud snore was heard and then she fell to the floor. The Broda chair was not fully reclined. Immediate action taken was to assist the resident back into her Broda chair and reclined it back. Resident 7 refused to go into her bed and stated, I have not slept in a bed for fifteen years. Further it was indicated the facility will have therapy evaluate seating and remind staff to keep Broda chair reclined when she was in it. A review of a rehabilitation screen that was initiated by the DON on April 18, 2024, at 12:38 AM, and completed by Employee 12, a Physical Therapist (PT), on April 23, 2024 (five days post her fall on April 18, 2025), revealed that skilled physical therapy was not indicated at this time due to circumstances of fall and that the resident's history of delusions, hallucinations, and agitation contributing to falls. A nursing progress note for behavior monitoring completed by Employee 2, LPN, on April 22, 2024, at 12:13 PM, indicated that Resident 7 was yelling out while self-propelling up and down hallways and was exit seeking and trying to get out of the doors. Redirection attempts for safety resulted in agitation and yelling from the resident telling staff to get away from her. Additionally, nursing progress notes reiterated Resident 7's continued behaviors (yelling and cursing staff since start of shift, hitting, attempting to bite and scratch staff) throughout the day shift. A review of an incident report completed by Employee 10, RN, dated April 22, 2024, at 5:00 PM, revealed that while in the hallway Resident 7 tumbled out of her Broda chair on to the floor. Employee 10 assessed the resident and found an 8-centimeter hematoma (is an area of blood that collects outside of the larger blood vessels due to injury or trauma) on the left side of her hairline and a 3-centimeter-long skin tear under the hematoma (a collection of blood underneath the skin). Resident was screaming to leave her alone and was resistant to all verbal conversations. The immediate action taken was cleansed skin tear and hematoma. The physician was notified and new orders noted to obtain an x-ray of head due to the possibility of serious injury. Vitals and neuro check within normal limits and X-ray results unremarkable. Further review of a witnessed fall investigation completed by Employee 16, a RN, dated May 11, 2024, at 5:00 PM, revealed that Employee 15 NA, alerted Employee 9 LPN, that the resident was in her room and slid to the floor from her Broda chair. Employee 15 stated that she walked into the resident's room and observed her reaching for her popcorn and slid out of her chair and onto her buttocks and did not bump head. All fall prevention interventions noted to be in place. Post fall intervention was to issue a reacher (devise used to pick up items without need to bend over) but it had to be removed due to Resident 7 swinging it at people. A review of an unwitnessed fall investigation completed by Employee 17, a RN, dated May 17, 2024, at 10:00 AM, revealed that the resident was found by Employee 18, a Physical Therapist (PT), on the floor in the resident dining room. The resident refused a body assessment multiple times was unable to obtain to complete an assessment due to the resident's agitation/restlessness. The resident able to standup from floor to wheelchair with extensive assistance of two-persons with no signs or symptoms of discomfort noted. Immediate intervention put in place was to not to leave resident alone in the dining room. A review of a witness statement completed by Employee 18, PT, dated May 17, 2024, at 10:15 AM, regarding the aforementioned incident, noted that she was alerted by a visitor that Resident 7 had fallen in the dining room, but had not seen it happen. The resident was observed sitting on the floor with Broda chair approximately five feet from the resident. No alarm was sounding but her non-skid socks were in place. The resident refused interventions or an assessment, yelling to leave her alone, The resident was returned to the Broda chair with assistance of two staff. While the employee was waiting for the RN supervisor, the employee observed the resident reaching toward the floor for nothing. The employee attempted to redirect and offer her the reacher to facilitate safety. The resident became agitated so the employee returned resident to the nurses' station to await further evaluation. Additionally, Resident 7 had another fall from her Broda chair on May 22, 2024, without injuries and every fifteen-minute checks were implemented. During an interview with Employee 18, a PT, on September 12, 2024, at approximately 10:30 AM, discussed Resident 7's repeated falls from her Broda chair and indicated that resident had two different wheelchairs since admission and that the Broda chair was chosen due to not wanting to compromise her mobility. The facility failed to provide sufficient supervision to a resident that was a high fall risk with known unsafe behaviors and repeated falls from the Broda chair. Additionally, the facility failed to develop and implement effective fall interventions to deter repeated falls. An interview with the Director of Nursing (DON) on September 13, 2024, at 10:15 AM, confirmed that the facility failed to provide sufficient supervision to a resident that was a high fall risk with known unsafe behaviors and repeated falls and that the facility failed to develop and implement effective fall interventions to deter Resident 7's repeated falls. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of the facility's abuse prohibition policy and procedures, clinical records, and select investigative reports and staff interview it was determined that the facility neglected to provide care and services necessary to avoid physical harm, a fractured hip and a fractured ankle, and maintain physical health of two residents out of eight residents sampled (Residents CR1 and 2). Findings include: A review of the facility's policy entitled Abuse Policy states the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the lung, muscle weakness, difficulty walking, and need for assistance with personal care. A Significant Change Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 31, 2023, indicated that the resident was cognitively intact. A review of the resident's plan of care initially dated December 8, 2023, that the resident had limited physical mobility related to weakness and debility related to end stage disease process with planned interventions that the resident was to be transferred with the assistance of two staff members with her rolling walker. A nursing progress note dated January 9, 2024, at 7:30 AM indicated Resident CR1 was complaining of left leg pain. The entry noted that the resident stated she was taken to the bathroom that morning, and now has leg pain. The resident's left was externally rotated. A nursing progress note dated January 9, 2024, at 1:45 PM revealed that the facility had concerns with compliance with the resident's plan of care, noting that the resident requested the bedpan for toileting, but was instead transferred with the assistance of only one staff member to the toilet. The resident reported increased pain after toileting. The resident notified her daughter, and the resident's daughter came to the facility. The concern was then reported to staff and upon assessment found that the resident's left leg had a noted deformity. The resident's left hip and leg were shortened and externally rotated. The resident had pain and swelling and was sent out to the hospital on that date. A review of a hospital Xray report dated January 9, 2024, revealed the resident had a displaced angulated fracture (two ends of the broken bone are at an angle to each other) of the left hip. A review of the facility's investigation report dated January 9, 2024, revealed Resident CR1 reported to Employee 1 LPN (license practical nurse) that Employee 2, a nurse aide (NA), on night shift took her to the bathroom when Resident CR1 requested to use the bedpan to relieve herself. Employee 2 got the resident up into the wheelchair and took her to the bathroom to use the toilet instead of providing the bedpan as the resident requested. Employee 2 transferred the resident by herself to the wheelchair when the resident's plan of care indicated that the resident is to be transferred with the assistance of two staff. Employee 2 then transferred the resident by herself onto the toilet. The employee was unable to transfer the resident back to the wheelchair from the toilet, so Employee 2 used a sit to stand lift, without the assistance of another staff member, to transfer the resident back into the wheelchair. Resident CR1 reported to Employee 1 that she heard snapping while Employee 2 was transferring her to the toilet. The facility concluded that Employee 2 neglected to follow Resident CR1's plan of care to ensure the proper staff assistance was provided to safely transfer the resident. Employee 2 was terminated from employment at the facility. A review of Resident CR1's statement regarding the event dated January 9, 2024, revealed that the resident stated Employee 2, NA, transferred her to the wheelchair to take her to the bathroom by herself. The resident stated that she was yelling out in pain during the transfer. The resident stated that Employee 2 told her to stop yelling so people don't think she is hurting the resident. The resident stated that Employee 2 took her to the bathroom and had her pivot and sit on the toilet. The resident stated while she was having her do that, she was yelling out in pain again. Resident CR1 stated Employee 2 transferred her off the toilet using a lift and that is when she heard two snaps. The resident stated Employed 2 then transferred her to the wheelchair as the resident continued to yell out in pain. The resident then stated Employee 2 brought the wheelchair to the side of the bed and the resident stated, oh no not again. The resident stated at that time Employee 2 left the room to get Employee 3, another nurse aide. The resident stated the Employee 2 and Employee 3 then placed the resident back in bed. The resident further indicated that Employee 4, LPN, came into the room after Employee 2 and Employee 3 left and administered her the scheduled pain medication. The resident then stated she called her daughter around 7:20 AM that morning to inform her of what happened during the night shift on January 9, 2024. A review of a statement from Employee 2 dated January 9, 2024, revealed that the employee reported that Resident CR1 rang the call bell and indicated that she needed to be toileted. The employee stated that she transferred the resident by herself to the wheelchair. When asked about the resident's transfer status, the employee stated she did not know the resident was an assist of two. The employee stated when the resident sat down on the toilet it sounded like a crunch. When the employee was asked if she notified the LPN, or the RN (registered nurse) supervisor, Employee 2 stated no. Employee 2 indicated that she had a difficult time getting the resident up from the toilet and stated that she told Employee 4 she was going to have to use the lift to get her up. Employee 2 stated that she used the sit to stand lift by herself to get the resident up and on the side of her bed. Employee 2 then stated Employee 3 came into the room to help lift the resident's legs into bed. Employee 2 was asked if the resident complained of pain during these transfers, the employee stated yes, but I thought it was normal for her. A review of a statement from Employee 3 dated January 9, 2024, revealed that Employee 2 came to Employee 3 for help with Resident CR1. Employee 3 indicated that when she entered the room Resident CR1 was already sitting on the side of the bed. Employee 3 revealed that Employee 2 stated to her, I keep trying to lay her down and she keeps screaming that her legs hurt. Employee 3 stated she helped assist her legs into bed. Further Employee 3 indicated she was not aware that Employee 2 had transferred the resident to and from the bathroom. A review of a statement from Employee 4 dated January 9, 2024, revealed that a little after 6:00 AM he administered Resident CR1's scheduled pain medications. The employee stated at that time she did not appear at ease and assumed pain was the culprit. The employee indicated that Employee 2 had cared for the resident that night (tour of duty). Employee 4's statement did not indicate awareness that Employee 2 had transferred to the toilet and needed a sit to stand lift to be transferred off the toilet and back to bed. An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed that prior to the incident Employee 2 was educated on abuse, neglect and following a resident's plan of care in August 2023, and she knew where to find the information regarding the resident's transfer status. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, difficulty walking, and need for assistance with personal care. An Annual MDS dated [DATE], indicated the resident was moderately cognitively impaired. A review of the resident's plan of care, initially dated June 8, 2020, revealed that the resident had limited physical mobility related to osteoarthritis with planned interventions initially dated August 3, 2023, for the resident to be transferred with the assistance of two staff members with a walker. A nursing progress note dated January 12, 2024, at 7:38 PM revealed staff was assisting Resident 2 to the toilet when the resident's right knee buckled causing the resident to lose balance. Staff assisted the resident to a chair. The resident complained of pain to the right ankle. The physician was made aware, and x-rays were ordered. A review of a facility investigation report dated January 12, 2024, revealed that at 4:15 PM Employee 5, a nurse aide, took Resident 2 to the bathroom. Employee 5 was transferring the resident, without the assistance of another staff member, to the toilet when the resident's knee gave out causing the resident to fall to her knees and her ankle to turn outward. Employee 5 called out for assistance from other staff and the resident was placed back into the wheelchair. The resident was required an assist of two staff members for all transfers. Upon assessment the resident's right ankle was swollen, painful, and bruised. X-rays were ordered. The facility's investigation concluded that Employee 5 neglected to follow the resident's plan of care and transferred the resident alone when the resident required assistance of two staff. The facility notified the employee's nurse staffing agency, and she was placed on the do not return list. A review of an x-ray report dated January 12, 2024, revealed the resident had a mildly displaced acute oblique fracture (break in the bone at an angle that does not line up) of the right ankle. The resident was transferred out to the hospital On January 12, 2024, for further treatment. A review of a statement from Employee 5 dated January 12, 2024, revealed that the employee stated she was trying to toilet the resident. As the employee was assisting her turn, the resident screamed out, oh my god my legs hurt. The employee indicated that she then assisted the resident to the floor and yelled for help. An interview with the Director of Nursing on February 16, 2024, at approximately 11:15 AM revealed Employee 5 was just educated on January 12, 2024, prior to her shift on the importance of reviewing resident's Kardex and transfer status prior to performing any care involving resident transfers. This education was completed in response to the prior incident with Resident CR1 on January 9, 2024. Employee 5 was educated on the abuse policy, resident rights policy, following resident transfer orders and plan of care due Employee 2's he neglect of Resident CR1. The Director of Nursing confirmed Employee 5 still failed to implement the resident's plan of care and use the correct amount of transfer assistance for Resident 2, and the facility's education failed to prevent another incident of neglect from happening. An interview with the Nursing Home Administrator and Director of Nursing on February 16, 2024, at approximately 1:45 PM confirmed that the facility failed to ensure that Resident CR1 and Resident 2 were provided the services necessary to avoid physical harm and Employee 2 and Employee 5 neglected to provide care planned for the resident, sufficient staff assistance with transfers, resulting in serious injuries. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on review of resident clinical records, select facility policy and reports and interview with facility staff it was revealed that the facility failed to assure that two out of five residents sampled were free of significant medication errors resulting in one resident requiring hospitalization in intensive care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of a facility policy for administering medications, dated as reviewed April 2022, revealed that, medications are administered in a safe and timely manor and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering medications verifies the resident's identity before giving the resident his/her medications. The individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, the right time and the right method (route) of administration before giving the medication. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If this continues at high levels, it can eventually lead to kidney failure). A review of a 5-day Minimum Data Set assessment (MDS - a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status utilized in nursing homes) dated May 15, 2022, revealed that Resident CR1 was cognitively intact and required staff assistance for activities of daily living. A review of a facility medication administration error report dated May 20, 2022, at 12 PM, revealed that on May 17, 2022, at 1 PM, Resident CR1 received Resident 62's (his roommate) medications. The report indicated that Resident CR1 erroneously received: -[MEDICATION(S)] tablet 25 mg, an antihyperglycemic, used to control blood sugar in diabetics -[MEDICATION(S)] tablet 1000 mg, an Insulin Response Enhancers, used to control blood sugar in diabetics -[MEDICATION(S)] tablet 4 mg, Antihyperglycemic - Sulfonylurea Derivatives, used to control blood sugar in diabetics - [MEDICATION(S)] tablet 30 mg, a muscle relaxant medication -[MEDICATION(S)] DR (delayed release) 240 mg capsule, a [CONDITION(S)] Agent -[MEDICATION(S)] 175 mg, an antidepressant medication -Zinc 220 mg, a dietary supplement -multi vitamin -Vitamin C 1000 mg -Aspirin 81 mg -Vitamin B-12, 1000 mcg -Allegra 180 mg, an allergy medication -Tylenol 650 mg, a non narcotic pain medication A review of prescribing information from the [MEDICATION(S)]® ([MEDICATION(S)] tablets), for oral use revealed that limitations of use were noted as Not recommended for use to improve glycemic control in adults with type 2 diabetes mellitus with an eGFR (A glomerular filtration rate (GFR) is a blood test that checks how well your kidneys are working. Your kidneys have tiny filters called glomeruli. These filters help remove waste and excess fluid from the blood. A GFR test estimates how much blood passes through these filters each minute) of less than 30 ml/min/1.73 m2 A review of the results of Resident CR1's recent lab studies dated May 18, 2022 revealed an estimated glomerular rate of 26 ml/min with the normal noted as greater than 60 ml/min. The lab report noted that the resident's result was low. The laboratory report also revealed that Resident CR1's glucose level was 12 mg/dl (normal value 70-120 mg/dl) and the lab value was flagged as critical low. According to the lab report the resident's blood sample was drawn at the facility on May 18, 2022, at 7:49 AM; received at the lab on May 18, 2022 at 5:28 PM and reported to the facility on [DATE] at 12 AM. The medication error report revealed that the error occurred on May 17, 2022 at 1 PM. A review of a hand written employee witness statement with no date or time indicated, revealed that Employee 2 (PTA-physical therapy assistant) stated, While treating Resident CR1 (at the bedside) Resident CR1 made me aware that he had not received his medicine yet that day. (the date and time was noted as 1 PM on May 17, 2022). I discussed with nursing that Employee 1 (LPN), who was his nurse for the day. Employee 1 (LPN) stated that the resident was correct, he had not receive his medicine today and she would be in to give them (meds) to him. Minutes later, Employee 1 (LPN) returned and Resident CR1 began to take his medicine. Almost immediately, following taking one half of the meds given to him he stated that he usually takes 8 to 10 pills. I counted how many pills were left in the cup, there were 10 (remaining). He then asked that I take a picture of the remainder of the pills in the cup and send the picture to his sister from his phone. Resident CR1 was very confused as to why he would be taking so many extra pills, and was uncomfortable with it. After talking to his sister on his cell phone, the sister then called nursing. Employee 1 (LPN) returned to the resident's room to explain the mix up, stating that sometimes when pharmacy cannot get the regular doseage, they have to substitute, increasing the amount of pills. Resident CR1 agreed and took the rest of the pills in the cup, and our therapy session continued as planned. The report concluded that Employee 1 (LPN) failed to follow the facility's medication policy and failed to check to ensure that Resident CR1 was given the correct medications. Employee 1 (LPN) was suspended at that time. Nursing documentation dated May 18, 2022 4:10 PM revealed Called to evaluate resident Resident in bed. Jerking movement of arms noted. head turned to the left blank stare noted non verbal unable to follow directions. Grunts with tactile stimulation. Physician made aware and order received and noted to transport to emergency room for eval. Sister made aware. 911 called awaiting arrival. Nursing documentation dated May 18, 2022 at 4:45 PM Called to resident's room to assess. Resident was nonverbal but responsive. Eyes opened but staring. Upper and lower body appeared to be in contracture. 911 arrived (emergency medical transport) and resident transported to hospital via ambulance litter accompanied by EMS crew. A review of hospital emergency room documentation dated May 18, 2022, at 5:33 PM revealed complaints of low glucose level at nursing facility. The patient has no history of diabetes and was found with a glucose of 30mg/dl after [CONDITION(S)] like episode and unresponsive state. EMS checked blood sugar to be 30 mg/dl. Given an amp of D50 (intravenous fluid with sugar in it it increase the residents blood glucose level.) The patient is back to baseline status. The sister called and denied any history of diabetes. The patients blood glucose went from 30 mg/dl to 150 mg/dl after an amp of D50. Blood glucose has now come down to 64 mg/dl. I have ordered an amp of D50 at this time. Resident CR1 was then transferred to another hospital and admitted to the intensive care unit for further care. A review of hospital documentation revealed that Resident CR1 was transferred from the emergency room and admitted to another acute care hospital on May 19, 2022, at 12:41 AM. He was admitted to the intensive care unit. The admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital documentation revealed that his hospital course included presented to the hospital with severe [CONDITION(S)], after [CONDITION(S)] like activity. After treatment in the ED, he continued to have [CONDITION(S)] he was transferred to the ICU for continued medical management. Upon further investigation, it was found he was given his roommate's diabetic medications in error at the skilled facility. He was discharged from the hospital on May 24, 2022, and admitted to another skilled nursing facility. A review of a facility grievance form dated May 23, 2022 (no time indicated) filed by Resident CR1's sister, revealed that resident received wrong medications due to increased amount of pills in the cup that her brother received. A review of a statement written by the Director of Nursing (DON) at the time of the grievance revealed Resident CR1 was sent out to the hospital on May 18, 2022, at 4:45 PM after being found with an altered mental status and decreased level of consciousness. Resident CR1 was evaluated in the emergency room and found to have a glucose of 30. Resident had labs at 7:46 AM on May 18, 2022, and when blood work results came back, the resident had already left the facility. The blood sugar was 12. The resident was admitted to the ICU with [CONDITION(S)] and receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ? I asked what she was referring to and she (Employee 1 LPN) stated Employee 3 (LPN) told me (DON) that the residents sister called and said Resident CR1 didn't feel good since he took his meds. Unknowing the entire situation, I responded, he had several other medical and was still being worked up by the hospital. Employee 1 (LPN) was appreciative at that time and left my office. The DON then noted on May 20, 2022, I received a message from Employee 4, LPN, stating, Resident CR1's sister is concerned with the meds he received from Employee 1 (LPN) on May 17, 2022, at 1 PM and the way she (Employee 1 LPN) talked to her on the phone. I (DON) reached out to Resident CR1's sister regarding concerns that were brought to my attention. There were 16 pills in the cup. She reported that he had never been on this many pills. She said her brother texted her and took a picture of all the pills and sent to her as she is a registered nurse She reports that she doesn't know what the pink pill was. Resident CR1's sister asked Employee 1 (LPN) to please go in and evaluate the pills and discuss with the resident. Employee 1 (LPN) went to the resident's room and told the resident the same explanation and did not evaluate the pills and discuss with the resident. The resident then took the pills. The sister sent the pictures of the pills to the DON. Six of the remaining pills remaining in the cup were able to be identified. These medications were not on Resident CR1's medication list, but identified as his roommate, Resident 62's meds. During an interview May 31, 2022 at approximately 12 PM, the DON confirmed that Employee 1 had administered the incorrect medications to Resident CR1 resulting in the resident's hospitalization in intensive care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review revealed that Resident 64 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, documentation indicated that the resident did not receive the prescribed and scheduled insulin until 10:30 AM on May 17, 2022, two and half hours after the resident's breakfast. Facility documentation revealed that Resident 64's breakfast meal was delivered to his room at approximately 8 AM on May 17, 2022. During an interview on May 31, 2022, at approximately 12 PM, the Director of Nursing confirmed that Resident 64's insulin was not administered timely and was a significant medication error because of the potential for negative outcome to the resident related to blood sugar management. Refer F770 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services 28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on a review of clinical records and select facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and assistance for a resident identified at risk for falls and known unsafe behaviors to prevent a fall with serious injury, a [MEDICAL CONDITION], for one resident out of 23 residents reviewed (Resident 75). Findings include: A review of the Resident 75's clinical record revealed that the resident was admitted to the facility on (MONTH) 23, 2019, with a [DIAGNOSES REDACTED].{stroke} sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery in the brain). A review of the resident's fall evaluation, completed by the facility dated (MONTH) 23, 2019, indicated that the resident was at high risk for falls. A review of an admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 30, 2019, revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) was an 8, indicating that the resident was moderately cognitively impaired. The resident required the extensive assistance of two people for transfers and bed mobility. The resident was not steady with ambulation and only able to stabilize with staff assistance. A review of an incident/accident report dated (MONTH) 16, 2019, at 7:29 a.m. indicated that the resident was found sitting on the floor in her room between the door and her bed. According to the incident/accident report, the resident sustained [REDACTED]. The facility provided health teaching with the resident to call for assistance and staff were educated to document correctly on allotted times scheduled on programs and the proper documentation assures that {the} program is effective when reviewed to prevent independent attempts to bathroom. Review of Resident 75's bowel and bladder schedule revealed that a scheduled program was not initiated until (MONTH) 28, 2019. There was no documented evidence that a scheduled toileting program was in place at the time of this resident's fall on (MONTH) 16, 2019, as noted on the incident/accident report. The facility did not institute any further fall prevention interventions after this resident's fall of (MONTH) 16, 2019. A review of Physical Therapy progress notes dated (MONTH) 15, 2019, indicated that the resident required contact guard assistance (CGA) with transfers and that the resident continued to demonstrate balance deficits, decreased safety awareness and strength impairments. Further review of Physical Therapy Progress notes revealed that on (MONTH) 18, 2019, this resident continued to require contact guard assistance for transfers. A review of an incident/accident report dated (MONTH) 19, 2019, at 6:00 a.m. indicated that the resident was observed on the floor in her room in front of the bathroom door, sitting in an upright position. The resident complained of pain in her left knee. The resident stated she was trying to go to the bathroom. The resident was transferred to the hospital on that date. Review of the history and physical examination [REDACTED]. A review of an operative report dated (MONTH) 21, 2019, revealed that the resident required repair of a pertrochanteric fracture (the fracture line involves both the greater trochanter and lesser trochanter) of the left femur. A review of the resident's clinical record and interview with the Director of Nursing on (MONTH) 11, 2019, confirmed that there was no evidence of when staff had last assisted Resident 75 with toileting needs prior to the resident's fall on (MONTH) 19, 2019. Following this fall with serious injury, the facility implemented the use of a bed alarm (a personal bed alarm that allows a caregiver to monitor the activity of a patient in bed), a low bed (allows patients to place their feet flat on the floor while they are sitting on the edge of the bed) and fall mats (safety mats placed on the floor along the side(s) of the bed). A review of employee witness statements with the incident/accident report dated (MONTH) 19, 2019, revealed that Employee 4, Nurse Aide, responded to a bathroom call light at 1:30 a.m. and 4:30 a.m. (in the resident's room) and found that this resident had transferred herself to the bathroom and back into bed without staff assistance. According to Employee 4's witness statement, after each time this resident self-transferred and ambulated to the bathroom, he instructed the resident to use her call bell for staff assistance. An additional witness statement by Employee 5, dated (MONTH) 19, 2019 revealed that the resident had self-transferred to the bathroom several times throughout the night. Again, the staff asked the resident to use {the} call bell for help and not to get up by herself. A review of the resident's care plan revealed that on (MONTH) 23, 2019, a care plan was initiated due to an actual fall related to poor balance. There was no evidence that the resident's high risk for falls, identified by the facility on (MONTH) 23, 2019, was addressed on the resident's care plan prior to her fall on (MONTH) 16, 2019. A review of this resident's toileting program revealed that a bowel and bladder toileting schedule was initiated for the resident on (MONTH) 28, 2019, after the resident's fall and [MEDICAL CONDITION]. No further evidence of an established toileting program for this resident was presented during the survey ending (MONTH) 11, 2019. The DON (director of nursing) confirmed during an interview on (MONTH) 11, 2019, that the facility had failed to provide adequate staff supervision and effective fall prevention measures for this resident who was identified at risk for falls and with a known history of self-transfers/toileting. The resident had been displaying repeated instances of unsafe behaviors, self-transfers and self-toileting, but the facility failed to timely provide necessary staff supervision, at the frequency and level required, to prevent a fall, which resulted in fractured left hip. 483.25(d) Accidents Previously cited 9/14/18 28 Pa. Code: 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 9/14/18 28 Pa. Code 211.11(d) Resident care plan

Based on clinical record and select facility policy review and staff interviews, it was determined that the facility failed to timely identify declines in skin integrity and provide prompt treatment and services to prevent the development of a pressure sore for two residents (Resident 108, Resident 37) out of 22 sampled. Findings include: A review of the facility policy entitled Skin and Wound Prevention Process last reviewed by the facility January 2015, indicated that it is the policy of the facility to have an organized process of assessment, prevention, intervention and treatment of [REDACTED]. This will include areas dealing with pressure related injuries. Weekly skin assessments are to be completed, preferably on shower days and documented on the treatment administration record. Review of Resident 108's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Braden Scale (a tool used to predict pressure sore risk) dated May 15, 2015, revealed that the resident scored 18, indicating that she was at low risk for developing a pressure area. According to a nursing admission assessment dated [DATE], the resident was admitted with a [MEDICAL CONDITION] ankle distal tibia, with a brace donned on the resident's right lower leg. Physician's orders dated May 15, 2015, included to remove ace wrap and soft brace from right foot/lower leg every shift for skin checks. The order noted to keep the brace in place at all times, remove for care and showers. A review of an Orthopedic Consult dated June 8, 2015, revealed that the consultant physician discontinued the resident's use of the splint (brace). Nurses notes dated June 8, 2015, at 9 AM, revealed that the resident left the facility for the consultant appointment in good condition and returned to the facility at 11:30 AM in good condition at 12 PM with an order to discontinue the splint. The nurse's note failed to indicate if the splint was in place when the resident went to the orthopedic consult or if the device was in place when she returned to the facility following the appointment. The facility was unable to provide documented evidence of condition of the skin on the resident's resident's right foot/lower leg a the location where the brace/splint was applied, which was verified during interview with the Director of Nursing on October 2, 2015. A review of a restorative nursing flow sheet dated June 2015, revealed documentation that the ace wraps were removed and the resident's skin was checked on the 7 AM to 3 PM shift on June 8, 2015. There was no documentation that the ace wrap was removed or skin was checked on the 3 PM to 11 PM shift. It was noted that on the 11 PM to 7 AM shift that the ace wrap was removed and skin checks were completed. According to interview with the Director of Nursing during the survey, the nurse aides complete the task of removing the ace wraps and checking the skin and the licensed nursing staff is responsible for applying the ace wrap and soft brace. The documentation on the restorative nursing flow sheet conflicted with nursing entries reflected on the electronic treatment record, dated June 8, 2015. The electronic treatment record revealed no documented evidence that the ace wrap and soft brace were in place at any time on June 8, 2015. A review of a resident incident/accident report dated June 9, 2015, at 10:30 AM, revealed that during AM care a nurse aide noticed an unstageable area (a full thickness loss with eschar (hard crust or scab) may be present) on the resident's right heel. The area measured 1 x 1 cm (centimeter) as was described as a black/red area. A review of the facility's wound/skin assessment dated [DATE], revealed that the resident had developed an unstageable DTI (deep tissue injury), which measured 1 x 1 cm. A full description of the wound was documented on this wound/skin assessment. The next wound assessment of this area was completed on June 22, 2015, (13 days after the initial assessment) which noted that the wound was brown in color, but no measurements of the area were documented at that time. Wound measurements were not noted until July 13, 2015. The facility was unable to provide a completed body assessment form, which the facility uses to to ensure that all areas of skin breakdown are identified and addressed, for the month of June 2015 for this resident. During an interview with the Director of Nursing on October 1, 2015 at 1:45 PM, she was unable to explain why the pressure sore on resident's heel was found as an unstageable deep tissue injury. The facility was unable to demonstrate that the resident's skin integrity in the areas of right lower extremity was consistently monitored and that declines in skin integrity were timely identified and acted upon to prevent pressure sore development or worsening of skin breakdown. A review of the clinical record revealed that Resident 37 was admitted to the facility May 10, 2015, with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set assessment ( MDS - a federally mandated assessment conducted periodically to plan resident care) dated May 17, 2015, indicated that the resident was cognitively impaired, required assistance with activities of daily living including toileting, was incontinent of bowel and bladder and was at risk for developing pressure sores. A review of a resident incident report dated June 7, 2015, at 1:30 PM, revealed that a 0.5 cm round open area was found on the resident's left inner buttock and a 0.5 cm x 2 cm open area noted on the resident's right inner buttock, which was described as MASD (moisture associated skin damage, skin damage due to moisture against the skin such as incontinence). The facility determined the root cause of the skin breakdown was that resident was incontinent and has a [DIAGNOSES REDACTED]. The facility planned an intervention to check (for incontinence) and change the resident every two hours. A resident incident report dated June 11, 2015, indicated that the pressure sore on the resident's left inner buttock had increased in size and now measured 3 cm x 2 cm and the right inner buttock was measured 2 cm x 1 cm. The interventions planned included to continue the check and change bladder and bowel program. The physician was notified of the assessment of the resident's pressure sores and a new treatment was ordered. There was no evidence that the facility had evaluated the adequacy and timeliness of the resident's incontinence care and bladder and bowel management in response to the deterioration of the pressure sores. On June 22, 2015, the left inner buttock pressure sore was noted as Stage ll measuring 2 cm x 1 cm x 0.1 cm and the right inner buttock pressure sore also had depth and was noted as 2 cm x 1 cm x 0.1 cm. The resident as admitted to the hospital June 29, 2015, and readmitted to the facility on [DATE], with these same pressure areas on his right and left inner buttocks. The wound tracking indicated that the pressure sores on the resident's right and left buttocks resolved on July 20, 2015. A review of a resident incident report and wound tracking dated September 11, 2015 at 8 A.M., revealed that Resident 37 again developed a facility acquired MASD pressure area on his right lower buttock measuring 2.6 cm x 1.5 cm x 0.1 cm. The facility identified the resident's incontinence as the cause of the skin breakdown, but failed to indicate that staff's consistency and timeliness of providing necessary incontinence care and meeting the resident's toileting needs had been evaluated for adequacy and implementation. During an interview October 1, 2015 at 1 pm, the wound nurse confirmed that weekly wound tracking was not completed timely for residents during June 2015. He further confirmed that an assessment of the resident's bowel and bladder were not considered as an intervention for Resident 37 with recurrent MASD wounds and frequent incontinence. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 9/9/15, 9/25/14 28 Pa. Code 211.10 (a)(c)(d) Resident care policies Previously cited 9/25/14

Based on review of clinical records and facility investigation into select incidents and staff interview it was revealed that the facility failed to identify and fully assess a resident's behavioral symptom of restlessness and implement approaches to promote resident comfort and prevent negative outcome sustained by one resident out of five reviewed (Resident A1). Findings include: According to review of Resident A1's clinical record, the resident was admitted to the facility with a [DIAGNOSES REDACTED]. In response to the dislocation, the resident had a physican's order initiated on July 14, 2014 for the use of a left knee immobilizer (device to keep leg stable and limit movement) to be worn at all times, with removal of the device for care. The resident's skin was to be checked every two hours. A review of the clinical record revealed that on July 29, 2014, while completing morning care (10:30 a.m.,) the nursing assistants discovered a deep tissue injury (according to the National Pressure Ulcer Advisory Panel a pressure related injury likely to have been caused by a high level of pressure at the muscle/bone connection, beginning as a purple area with intact skin over the underlying tissue damage) to the resident's left lower calf, beneath the immobilizer. The area measured 7.5 cm x 2 cm without depth. Another 2 cm round blanchable area was also discovered on the resident's right knee. A review of the facility's investigation into the skin injury, revealed that the facility identified the extreme restlessness the resident displays at times as a contributing factor in the development of the skin breakdown. However, a review of the resident's clinical record revealed no mention of this type of behavior displayed by the resident. The statements completed by those staff members who had cared for the resident included with the facility's investigation into the DTI, were limited to staff stating that the area had not been there the previous day or that they had discovered the area. There was no indication that the facility attempted to determine when the resident was last checked and if the resident had been restless when last checked during the 11 PM to 7 AM shift and/or when first checked for the 7 AM to 3 PM shift during the two hour skin checks. A review of the resident's treatment records for July 2014 and August 2014, revealed that staff documented once per shift to signify completion of the skin checks that were conducted every two hours during that shift. Neither this documentation nor any other identified and addressed the resident's restlessness when the two hour checks were conducted or noted the specific time periods when the resident appeared most restless. As the result of the facility acquired pressure sore, the facility COTA/L (certified occupational therapy aide) examined the resident along with the immobilizer and determined that a combination of improper placement of the immobilizer and the resident's activity was causing the brace to move into a lower position, which was not considered proper placement of the device. A representative from the company that provided the immobilizer, also came into the facility on [DATE], to examine the device. She determined that the device was not defective, but had not been in the proper placement when the injury occurred. It was again noted that the resident moved about and adjusted her clothing and positioning when told not to do so. In response to this conclusion, the facility in-serviced the staff on proper placement of the device and the necessity of completing two hour skin checks. The resident was also given instruction on not manipulating the device and to ring for assistance. The nurse completing this education, however, was uncertain of the resident's retention of this information due to the resident's cognitive status. The resident received routine consultation with a wound care specialist. A review of the most recent available evaluation, dated August 25, 2014, revealed that the pressure area was 6 cm. (length) x 1.8 cm.(width) x 0.2 cm (depth) The area was described as 80% necrotic tissue with 20% granulation. The area was surgically debrided at that time with the removal of both necrotic tissue and muscle. A review of the resident's wound/skin assessment revealed that the area was assessed at the facility on September 5, 2014 and was 5.8 cm by 1.6 cm by 0.2 cm. There was no further indication that the facility attempted to determine the underlying causes of the resident's restlessness. A review of nursing progress notes revealed that on August 4, 2014 the facility removed the resident's call bell from her reach. A corresponding physician's orders [REDACTED]. A review of the documentation in the resident's clinical record provided no indication what necessitated this action. When interviewed on September 5, 2014, at 11:30 a.m., the Director of Nursing Services stated that the reason that the resident's call bell had been removed was due to the resident's extreme restlessness. She stated that the staff was afraid that the resident was going to harm herself due to her extreme restlessness and history of repositioning herself at odd angles in the bed. A review of physician's orders [REDACTED]. A review of the resident's clinical record revealed no indication why the facility had returned the call bell at that time. When interviewed on September 5, 2014, the Director of Nursing Services, stated that the call bell had been returned to the resident after a discussion with a family member who had questioned the facility's approach. During this meeting, according to the Director of Nursing Services, this family member stated that it appeared that approximately 40 minutes after the resident received her as needed medication she appeared restless. A review of the resident's physician's orders [REDACTED]. A review of the resident's "PRN Effective Report" ( a report used by the facility to track the use and effectiveness of as needed medications) for August 2014, revealed that the resident consistently requested the as needed pain medication on a daily basis (multiple daily requests on most days.) On August 28, 2014, a telephone order was received for a [MEDICATION NAME] Patch(opiod pain medication delivered slowly through the skin) 12 mcg/hr, change every three days. When interviewed on September 5, 2014 at 1:45 p.m., the Director of Nursing Services stated that this medication had been changed after the family had mentioned the resident's restlessness around the time of the administration of the as needed [MEDICATION NAME]. The interdisciplinary team determined that the resident was likely having pain and the use of routine [MEDICATION NAME] would provide consistent as opposed to reactive pain management for the resident. According to the Director of Nursing Services, this change in medication was effective in controlling the resident's symptoms of restlessness. A review of the resident's clinical record and facility investigation into resident incidents, revealed that the resident had either physican's orders or recommendations for pain evaluations on July 30, 2014, August 8, 2014, August 14, 2014 and August 28, 2014. When interviewed on September 5, 2014, regarding the outcome of these pain evaluations the Director of Nursing Services stated that the purpose of these evaluations was mainly to determine if medications used were effective once administered. There was no indication that the facility had adequately addressed the resident's restlessness and thoroughly and timely evaluated the adequacy of the resident's pain management program. The resident's discomfort and restlessness affected the positioning of the immobilizing device and subsequently the resident's skin integrity, as the device was only effective if maintained in a stable position. Once the facility determined that the resident's behaviors had likely contributed to an acquired pressure area, they failed to timely assess the behavioral symptom and evaluate possible causes for the restless behavior. The facility also removed the resident's customary means of alerting staff (the call bell) as the result of the resident's restlessness without evidence of a thorough assessment of the resident's behaviors. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing Services. Previously cited: 10/23/13 28 Pa. Code 211.10 (a)(d) Resident Care Policies Previously cited:10/23/13 28 Pa. Code 201.29(j) Resident Rights. .