Every finding on record at Shippensburg Rehabilitation and Health Care Center

Based on clinical record review, resident and staff interviews, and facility notices pertaining to physician change, it was determined that the facility failed to ensure that each resident had the right to choose his or her attending physician and failed to inform residents of the physician's name responsible for his/her care and failed to provide contact information for that physician for two residents reviewed (Residents 1 and 2).Findings include: A facility notice addressed to residents and families, dated June 24, 2026, stated that there would be a change in the medical director for the facility effective August 1, 2026. The notice included the following statement regarding the medical director's new team, group of providers is comprised of physicians, physician assistants, and nurse practitioners.residents will have the right to choose their attending physician, as applicable, and this change relates specifically to the medical director role. A second notice addressed to residents dated August 3, 2026, informed the residents that as of August 1, 2026, the facility has transitioned to a new medical director. The notice to the residents and family did not state who their attending physician would be. The facility contracted with a new physician group and all residents were transferred from their existing attending physician to a new attending physician. The residents were not made aware or given a choice. They were also not provided the name and contact information for the new attending physician. During an interview with Resident 1 on August 26, 2026, at 9:30 AM, he said that he was aware that there was going to be a change in the medical director. Resident 1 stated he was unaware that he would no longer have his regular provider who last signed off on his orders July 13, 2026. Resident 1 said he believed he would stay with his current physician. Resident 1 said that he was informed by his current provider that he would continue to be his physician. Resident 1 added that on Friday, August 21, 2026, a Nurse Practitioner (NP) showed up to his room and informed him that she was with the new group of providers and informed him he will no longer be seeing his previous provider and gave him the name of his new provider. Resident 1 said to the Nurse Practitioner does this mean I won't have Dr. [name] anymore? And the NP replied no, your new doctor is Dr. [name]. Resident 1 asked the NP well when will I see him? And the NP replied he's around. During an interview with Resident 2 on August 26, 2026, at 10:00 AM, said she was unaware of the name of her new physician and stated, but I guess I don't have a choice since I'm here. Both Residents 1 and 2 were alert, oriented and, based on their Minimum Data Assessments (MDS - a periodic assessment of care needs) had a BIMS (brief interview of mental status) score of 15, indicating they were cognitively intact. During an interview with the Director of Nursing and the Assistant Director of Nursing on August 27, 2026, at 11:30 AM, they confirmed the residents were never provided with the names or contact information for their new providers of care. When asked why the previous provider for Resident 1 did not remain on staff, they stated that he could only remain on staff if he joined the new group in the company. 28 Pa Code 211.2(d)(6) Medical Director

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents reviewed (Residents 3 and 35).Findings Include: Facility policy, titled Trauma Informed Care, reviewed February 2026, read, in part, Policy: .Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing.Procedure: . 7. When a resident has experienced a traumatic event, the SW (social worder) will interview resident/resident representative regarding: Potential/actual triggers that may cause re-traumatization of the resident. Review of Resident 3's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). Review of Resident 3's trauma informed care assessment, dated February 16, 2026, revealed that Resident 3 was able to participate in the interview and had experienced trauma. Further review of the assessment revealed that Resident 3 reported experiencing feeling very upset when something reminded her of the stressful experience and feeling jumpy or easily startled quite a bit. In addition, Resident 3 indicated that she moderately experienced trouble falling or staying asleep. Review of Resident 3's comprehensive care plan revealed a care plan focus for potential to exhibit behaviors that are a result of past trauma due to abuse as a child from a family member, with an initiated date of February 16, 2026, and a revision date of March 2, 2026. Interventions included, but were not limited to, identify potential triggers dated February 16, 2026. Further review of Resident 3's care plan failed to reveal that her resident-specific triggers had been identified. Review of Resident 3's clinical record revealed a physician's order for a psychiatry consult dated February 16, 2026. Review of Resident 3's clinical record progress notes revealed that Resident 3's Representative gave consent for a psychiatry consult on February 17, 2026. Further review of Resident 3's clinical record failed to reveal any documentation that she had received a psychiatry consult since February 17, 2026. During a staff interview with the Director of Nursing (DON) on April 22, 2026, at 10:44 AM, the DONconfirmed that Resident 3 had not received any psychiatry services yet. During a final staff interview with the Nursing Home Administrator (NHA) and DON on April 23, 2026, at 11:17 AM, the DON confirmed that she would expect trauma assessments to be completed in a more thorough manner to identify actual triggers, which should also then be care planned. In addition, she confirmed that she would expect residents to receive psychiatric services in a timely manner. Review of Resident 35's clinical record revealed diagnoses that included PTSD and major depressive disorder. Review of Resident 35's trauma informed care assessment, dated December 17, 2025, revealed that Resident 35 was able to participate in the interview and had experienced trauma. Further review of the document revealed that Resident 35 reported experiencing repeated, disturbing and unwanted memories of the stressful event quite a bit and moderately having repeated, disturbing dreams of the stressful experience. Review of Resident 35's comprehensive plan of care revealed a focus area for a potential to exhibit behaviors that are a result of past trauma with an intervention to identify potential triggers. Further review of Resident 35's comprehensive plan of care failed to reveal Resident 35's specific trauma or any triggers had been identified. Continued review of Resident 35's clinical record failed to reveal that any follow up relating to Resident 35's PTSD had occurred. During an interview on April 23, 2026 at 11:22 AM, with the NHA and DON, it was revealed that the facility had no additional information relating to Resident 35's PTSD. The DON stated it was the expectation of the facility that trauma and triggers be identified and that residents receive trauma informed care. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 24 residents reviewed (Residents 3, 11, and 28).Findings include: Review of facility policy, titled Care Plans-Comprehensive, with a last review date of February 2026, revealed, in part, The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition changes. Review of Resident 3's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. Review of Resident 3's care plan revealed a care plan revealed that a care plan was developed initially developed on February 16, 2026, for a focus for potential to exhibit behaviors that are a result of past trauma due to abuse as child from a family member. Interventions included, but were not limited to, identify potential triggers dated February 16, 2026. Review of Resident 3's clinical record revealed that her Representative was made aware of an incident on March 13, 2026, and at that time Resident 3's Representative reported that Resident 3 was timid and gets scared by noises and agreed to a room move to a private room. Further review of Resident 3's care plan failed to reveal that her trigger of being scared by noises was added to her care plan after the facility was made aware on March 13, 2026.Review of Resident 3's clinical record revealed a social services progress note dated March 13, 2026, which indicated that Resident 3's Representative had reported that Resident 3 was timid and gets scared by noises.During a staff interview with the Director of Nursing (DON) on April 23, 2206, at 9:50 AM, the DON confirmed that Resident 3's fear of noise should have been added to her care plan when facility was made aware. A review of the clinical record for Resident 11 revealed diagnoses that included dementia (decline in cognitive status, including memory, language and problem-solving) and anxiety disorder. A review of Resident 11's clinical record revealed an admission date to the facility on January 23, 2025, with a primary admitting diagnosis of Dementia. A review of Resident 11's care plan failed to include a comprehensive, person-centered care plan for the diagnosis of dementia. The nutrition section of the care plan is the only section that included the diagnosis of dementia. During an interview with the DON on April 23, 2026, at approximately 11:00 AM, the DON agreed that Resident 11's care plan should have been revised to include a care plan specific for the diagnosis of Dementia. Review of Resident 28's clinical record revealed diagnoses that included atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs). Review of Resident 28's current physician orders revealed an order for apixaban (Eliquis-a blood thinning medication used to prevent blood clots from forming) 5 milligrams administer one tablet twice a day, dated October 30, 2025. Review of Resident 28's care plan failed to reveal her use of anticoagulant medication. During a staff interview with the DON on April 22, 2026, at 1:42 PM, the DON indicated that anticoagulant therapy had been removed from Resident 28's care plan by accident and that staff were adding it back on Resident 28's care plan. The DON confirmed that she would expect the anticoagulant use to have remained on her care plan. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 24 residents reviewed (Residents 6 and 35).Findings Include: Review of Resident 6's clinical record revealed diagnoses that included gastro esophageal reflux disease ([GERD] when stomach acid flows back up into the esophagus) and major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life). Review of Resident 6's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated March 25, 2026, indicated in Section N0415 High-Risk Drug Classes: Use and Indication, section E, indicated that Resident 6 had taken an anticoagulant during the look-back period. Review of Resident 6's clinical record failed to reveal any evidence that Resident 6 had taken any anticoagulant medications. Interview with the Director of Nursing (DON) on April 23, 2026, at 11:45 AM, revealed that it was marked in error and a correction was being completed. Review of Resident 35's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and major depressive disorder. Review of Resident 35's admission MDS dated [DATE], and quarterly MDS dated [DATE], revealed Resident 35 was not coded a diagnosis of PTSD. An interview with Employee 7 on April 23, 2026 at 9:50 AM, revealed Resident 35's aforementioned MDS reports were coded incorrectly and that a modification would be done to correct them. During an interview with the Nursing Home Administrator and DON on April 23, 2026 at 11:22 AM, the DON stated that it was the expectation of the facility that MDS reports accurately reflect the resident's status. 28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of two residents reviewed (Residents 1 and 2). Findings include:Review of facility policy, titled Administering Medications, read, in part, Policy Interpretation and Implementation: . 3. Medications must be administered in accordance with the orders, including any required time frame.8. The following information must be checked/verified for each resident prior to administering medications.b. Vital signs, if necessary.Review of Resident 1's clinical record revealed diagnoses that included Parkinson's disease (neurodegenerative disorder causing motor issues) and hypertension (high blood pressure).Review of Resident 1's physician orders revealed the following orders:Lisinopril (antihypertension medication) 2.5 milligrams (mg) one tablet in the morning for hypertension. Give if systolic blood pressure (SBP) 150s - 160s only. Start date of August 2, 2025; end date September 9, 2025.Lisinopril 2.5 mg one tablet in the morning for hypertension. Give if SBP is greater than 160. Start date of September 10, 2025; end date September 18, 2025.Lisinopril 2.5 mg one tablet in the morning related to hypertension. If SBP is greater than 140 give extra dose of Lisinopril 2.5 mg. Start date of September 19, 2025; end date October 31, 2025.Lisinopril 2.5 mg one tablet every 24 hours as needed for SBP greater than 140. Start date of September 19, 2025; end date of October 31, 2025.Lisinopril 2.5 mg one tablet in the morning related to hypertension. If SBP is greater than 140 give extra dose of Lisinopril 2.5 mg. Start date of November 1, 2025; end date January 6, 2026.Lisinopril 2.5 mg one tablet every 24 hours as needed for SBP greater than 140. Start date of October 31, 2025; end date of January 6, 2026.Lisinopril 2.5 mg one tablet in the morning related to hypertension. If SBP is greater than 140 give extra dose of Lisinopril 2.5 mg. Hold if SBP is less than 120. Start date of January 7, 2026.Lisinopril 2.5 mg one tablet every 24 hours as needed for SBP greater than 140. Start date of January 7, 2026.Review of Resident 1's August 2025 Medication Administration Record (MAR) revealed Resident 1's Lisinopril had been administered outside of the physician ordered parameters as follows: August 4, SBP 138August 5, SBP 123August 6, SBP 132August 7, SBP 140August 8, SBP 141August 12, SBP 142August 13, SBP 148August 16, SBP 122August 17, SBP 139August 18, SBP 119August 19, SBP 143August 20, SBP 137August 21, SBP 138August 26, SBP 143August 28, SBP 144August 29, SBP 131Review of Resident 1's September 2025 MAR revealed Resident 1's Lisinopril had been administered outside of the physician ordered parameters as follows: September 2, SBP 118September 4, SBP 129September 8, SBP 144September 10, SBP 156September 11, SBP 130September 15, SBP 130Review of Resident 1's January 2026 MAR revealed Resident 1's Lisinopril had been administered outside of the physician ordered parameters as follows: January 9, SBP 118January 18, SBP 118Further review of Resident 1's MARs for August 2025 - February 2026 revealed Resident 1's PRN [as needed] dose of Lisinopril was not administered per physician orders for a SBP greater than 140 on the following dates:September 22, SBP 140September 24, SBP 153September 25, SBP 161September 30, SBP 141October 1, SBP 170October 13, SBP 149October 20, SBP 154November 11, SBP 143November 12, SBP 151November 26, SBP 143December 1, SBP 153December 10, SBP 144December 14, SBP 151December 24, SBP 141January 2, SBP 156January 12, SBP 142Review of Resident 2's clinical record revealed diagnoses that included hypertension and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs).Review of Resident 2's physician orders revealed an order for hydralazine HCL (antihypertensive medication) 20 mg two times a day related to hypertension, hold for blood pressure (BP) less than 100/60.Review of Resident 2's January 2026 MAR revealed Resident 2's hydralazine HCL had been administered outside of the physician ordered parameters as follows: January 8, BP 98/50January 9, BP 96/57January 19, BP 84/51During an interview with the Director of Nursing on February 2, 2026, at approximately 1:15 PM, it was revealed that it was the facility's expectation that medications be administered following physician orders and physician ordered parameters for medication administration be followed.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, each resident received written notice, including the reason for the change, before the resident's room was changed for one of three residents reviewed (Residents 1). Findings include: Review of facility policy, titled Change of Room or Roommate, stated, 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as resident and their representatives, will be given advance notice of such a change as in possible. Parties can be notified either in person, via telephone or in writing.Review of Resident 1's clinical revealed diagnoses that included Parkinson's disease (neurodegenerative disorder causing motor issues) and dementia (progressive decline in memory, thinking, and behavior).Review of Resident 1's clinical record progress notes revealed a note dated January 6, 2026, at 11:01 AM, that indicated Employee 1 (Social Services Coordinator) informed Resident 1's wife that Resident 1 would be moving out of his private room due to a B bed being available.Further review of Resident 1's clinical record failed to reveal documentation that Resident 1 or his Representative had received written notice of the room change or the reason for the room change.During an interview with the Director of Nursing (DON) and Employee 1 on February 2, 2026, at approximately 11:00 AM, it was revealed that Resident 1's Representative had been notified six months prior to the move that Resident 1 would be moved to a semiprivate room once a B bed became available. Employee 1 stated that she had spoken with Resident 1's Representative the morning of the move prior to Resident 1 leaving for an appointment, and Resident 1's Representative was in agreement with the move. Upon returning from the appointment, Resident 1's Representative was upset that the move occurred while they were out of the building and felt that it would have negative effects on Resident 1 due to his cognitive level. Employee 1 stated that no written notice had been given to Resident 1 or Resident 1's Representative and that she typically just has a conversation with the resident or representative to obtain consent for room moves. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.29(j) Resident rights.

Based on facility policy review, observations, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas. Findings include: Review of facility policy, titled Food Storage last reviewed [DATE], read, in part, Food will be purchased in quantities that can be stored properly and arranged in food groups for organized storage and inventory. All stock must be rotated with each new order received. Food should be dated as it is placed on the shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. Scoops should be kept covered in a protected area near the containers rather than in the containers. Thermometers should be checked at least two times each day. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. All foods should be covered, labeled and dated routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. Observation in the main kitchen on [DATE], at 9:25 AM, revealed one bin of brown sugar not labeled or dated, and one bin of white sugar dated ,d+[DATE]. Interview with Employee 1 (Dietary Manager) on [DATE], at 9:27 AM, revealed the brown sugar should be labeled and dated, and the white sugar had been replenished since [DATE]. Observation in walk-in freezer unit on [DATE], at 9:30 AM, revealed four packs of succotash vegetables not dated, and one appeared to be freezer burned; and one box of green beans with the packaging unwrapped and left open to air. Observation in the dry storage area on [DATE], at 9:41 AM, revealed three packages of hot dog buns with a best by date of [DATE]; one package of hot dog buns with a best by date of [DATE]; three boxes of fudge round cookies not dated; seven boxes of oatmeal cookies not dated; six bags of devil's food cake mix not dated; and seven bags of fudge brownie mix not dated. Observation in the 2nd Floor pantry area on [DATE], at 9:49 AM, revealed refrigerator and freezer temperatures were missing from the [DATE] temperature log on [DATE]-5, 10, and 11, 2025. Further observation in the 2nd Floor pantry area on [DATE], at 9:50 AM, revealed one bag of Texas toast not dated; and a bin of individual snacks containing oatmeal cookies, fudge round cookies, and fig cookies not dated. Observation in the 2nd Floor pantry area refrigerator on [DATE], at 9:51 AM, revealed two cartons of fat free milk with a sell by date of [DATE]. Observation in the 3rd Floor pantry area on [DATE], at 9:56 AM, revealed refrigerator and freezer temperatures were missing from the temperature log on [DATE]-11, 2025. Further observation in the 3rd Floor pantry area on [DATE], at 9:57 AM, revealed half of a loaf of Texas toast not dated; three containers of corn flake cereal not dated; and a bin of individual snacks containing oatmeal cookies, fudge round cookies, and fig cookies not dated. Observation in the 3rd Floor pantry area refrigerator on [DATE], at 9:58 AM, revealed a container of two open vanilla puddings in the refrigerator labeled medication pass. Interview with Employee 1 on [DATE], at 9:59 AM, revealed she has had numerous conversations with nursing staff that they are not to leave open puddings in the refrigerator that are left over from medication pass. Follow-up visit in the 3rd Floor nourishment area on [DATE], at 12:37 PM, revealed refrigerator and freezer temperatures failed to be logged on [DATE], in AM and PM. Follow-up visit in the 2nd Floor nourishment area on [DATE], at 12:44 PM, revealed refrigerator and freezer temperatures failed to be logged on [DATE], in AM and PM; and revealed one container of thickening powder labeled with two different open dates of [DATE], and [DATE], that was open with a scoop stored inside. Review of select facility temperature logs provided revealed the facility was unable to provide kitchen equipment temperature logs for the dish machine, reach in three-door refrigerator, kitchen walk-in refrigerator and freezer, or 2nd and 3rd floor nourishment areas from [DATE], [DATE], and [DATE]. Review of the February 2025 2nd Floor pantry area nourishment room temperature log, revealed refrigerator temperatures failed to be recorded on February ,d+[DATE] in AM, and February ,d+[DATE] in PM; and revealed freezer temperatures failed to be recorded on February ,d+[DATE], 2025, in AM and PM. Review of the February 2025 3rd Floor pantry area nourishment room temperature log, revealed refrigerator and freezer temperatures failed to be recorded on February ,d+[DATE], 2025, in AM and PM. Review of the [DATE]nd Floor pantry area nourishment room temperature log, revealed refrigerator and freezer temperatures failed to be recorded on [DATE]-23, 25, and ,d+[DATE] in AM; refrigerator temperatures failed to be recorded on [DATE]-23, 25, and ,d+[DATE] in PM; and freezer temperatures failed to be recorded on [DATE], and ,d+[DATE] in PM. Interview with the Nursing Home Administrator on [DATE], at 10:17 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, monitored, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.12(d)(3) Nursing services

Based on facility document review and staff interview, it was determined that the facility's Quality Assurance Committee failed to meet on a quarterly basis for one quarter of four reviewed (first quarter of 2025). Findings include: Review of the facility's Quality Assurance Committee meeting signatory pages revealed that the facility's Quality Assurance Committee did not meet during the first quarter of year 2025 (January, February, and March). During a staff interview on May 15, 2025, at approximately 10:20 AM, Nursing Home Administrator confirmed that it was the facility's expectation that the Quality Assurance Committee meets at least once every quarter. 28 Pa code 201.18(b)(3) Management

Based on clinical record review and staff interview, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for one of 21 residents reviewed (Resident 76). Findings include: Review of Resident 76's clinical record revealed diagnoses that included congestive heart failure (CHF- a condition characterized by a gradual loss of kidney function), atrial fibrillation (irregular heart rhythm), and hyperlipidemia (high blood cholesterol). Review of Resident 76's physician orders revealed an order for Daily weights. Notify doctor and give PRN (as needed) Lasix (diuretic- a medication that increases urine production and excretion of water) if weight gain > or = 2 lbs (pounds) in 1 day or 5lbs in a week, in the morning related to CHF, with a start date of September 22, 2023. Further review of Resident 76's physician orders revealed an order for Lasix Oral Tablet 40 MG, Give 0.5 tablet by mouth every 24 hours as needed for Weight gain, give for weight gain of 2 pounds in 1 day or 5 pounds in 1 week. Give half a tab to equal 20 mg, with a start date of May 16, 2024. Review of Resident 76's care plan revealed a focus area [Resident 76] has cardiac disease, with an intervention for obtain weights as indicated and report significant changes, initiated May 1, 2023. Review of Resident 76's clinical record revealed she had a weight gain of 2.8 lbs from August 28 to 29, 2024. Further review of her clinical record failed to reveal doctor notification, and review of her August MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) failed to reveal the PRN Lasix order was administered. Review of Resident 76's clinical record revealed she had a weight gain of 4.6 lbs from November 2 to 3, 2024; further review of her clinical record failed to reveal doctor notification, and review of her November MAR failed to reveal the PRN Lasix order was administered. Interview with the Director of Nursing on May 15, 2025, at 10:37 AM, revealed the doctor was not notified of the weight gain on the aforementioned dates and the PRN Lasix was not given. She further revealed her expectation of doctor notification and PRN Lasix administration per physician order. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and Resident Responsible Party and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents reviewed (Resident 91). Findings include: Review of facility policy, titled Policy and Procedure Trauma Informed Care, last revised April 15, 2024, read, in part: Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD [Post Traumatic Stress Disorder] will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Procedure . 7. When a Resident has experienced a traumatic event, The Social worker will interview the resident/resident representative regarding potential/actual triggers that may cause re-traumatization. Experiences, preferences, and/or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident. 8. The IDT team will ensure that an individualized resident centered care plan is developed for resident that has experienced a traumatic event. The care plan will include but is not limited to the following: Identification of the stressor/past life trauma. Identification of interventions that mitigate against re-traumatization. Identify triggers that could cause re-traumatization. Review of Resident 91's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and severe recurrent major depressive disorder with psychotic symptoms (a serious mental health condition that combines a depressed mood with psychosis [a disconnection from reality] that can manifest as hallucinations or delusions). During an interview on June 10, 2024, at 1:24 PM, with Resident 91's Responsible Party, it was revealed that Resident 91 suffered from PTSD from fighting in the Vietnam War and being exposed to harmful chemicals. Review of Resident 91's clinical record revealed a social services assessment dated [DATE]. The assessment indicated Resident 91's PTSD was related to fighting in a war and witnessing various acts of violence, being a prisoner of war, and being exposed to harmful chemicals while in the war. The assessor indicated active signs or symptoms of trauma and interventions were needed. Review of Resident 91's comprehensive plan of care revealed a focus area for risk for changes in mood related to dementia, depression, PTSD and is at risk for adverse effects related to use of antipsychotic and depression medication use, but failed to indicate the source of Resident 91's PTSD or any known triggers or interventions. Further review of Resident 91's clinical record failed to reveal evidence that the facility identified or attempted to identify Resident 91's PTSD triggers. During a staff interview with Employee 2 (Social Services Director), on June 12, 2024, at 2:00 PM, it was revealed that she had no further information to provide and that the previous social services director had completed Resident 91's screening. During a staff interview on June 13, 2024 at 10:14 AM, with Employee 1 (Assistant Director of Nursing), in the presence of the Director of Nursing, it was revealed that the facility was unable to provide any further evidence that culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident had been provided. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 23 residents reviewed (Resident 100). Findings include: Review of Resident 100's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and presence of cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). Observation of Resident 100 on June 10, 2024, at 10:19 AM, revealed a pacemaker monitoring device (a device used by a cardiologist [heart specialist] to perform an electronic periodic pacemaker function test) that was noted to be plugged into the electrical outlet and turned on. Review of Resident 100's physician orders on June 11, 2024, at 12:08 PM, failed to reveal any orders regarding their pacemaker monitoring or follow-up cardiology appointments. Review of Resident 100's care plan on June 11, 2024, at 12:15 PM, revealed a care plan focus for cardiac disease related to hypertension, initiated on April 5, 2024, which included an intervention for pacemaker checks as ordered, but failed to include any safety interventions associated with the presence of the pacemaker or cardiology follow-up visits. Review of Resident 100's hospital discharge paperwork dated April 5, 2024, revealed that the Resident had a cardiology follow-up appointment on Thursday, September 12, 2024, at 1:30 PM. During an interview with the Nursing Home Administrator, Director of Nursing (DON), and Assistant Director of Nursing on June 12, 2024, at 11:10 AM, the DON indicated that Resident 100 had not had any pacemaker checks since admission as none were due to be completed. The DON further indicated that when Resident 100 returned from an appointment at the wound clinic on June 11, 2024, all their cardiac appointments including pacemaker checks were listed on the after-visit summary and nursing staff added them to Resident 100's orders. The DON confirmed that the facility knew that Resident 100 had a pacemaker at their admission on April 4, 2024, and that nursing staff should have obtained all necessary information from Resident 100's cardiologist regarding pacemaker checks and follow-up appointments. The DON also confirmed all safety measures associated with the presence of a pacemaker should have been implemented at the time of Resident 100's admission and that their care plan has now been revised. During a follow-up interview with the DON on June 13, 2024, at 10:15 AM, the DON indicated that she had researched Resident 100's pacemaker checks a little further that morning. The DON said that Resident 100 was to have an electronic remote check on April 18, 2024, however, the POA had canceled it because the pacemaker monitoring device was still at Resident 100's prior assisted living facility. The DON provided a copy of an after-visit summary dated June 12, 2024, that indicated that a remote electronic pacemaker check was completed on June 12, 2024. The DON also indicated that the cardiologist's office said that if there were to be a problem with Resident 100's pacemaker, an alert would be sent to the cardiologist's office who would then contact the facility. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 26 residents reviewed (Resident 9 and 26). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included obstructive sleep apnea (characterized by episodes of a complete [apnea] or partial collapse [hypopnea] of the upper airway with an associated decrease in oxygen saturation or arousal from sleep) and seizures (a burst of uncontrolled electrical activity between brain cells). Review of Resident 9's quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated April 4, 2024, revealed in Section O0110. Special Treatments, Procedures, and Programs, G1. Non-invasive Mechanical Ventilator, that Resident 9 did not use a non-invasive mechanical ventilator during the previous 14 days. Review of Resident 9's Treatment Administration Record (TAR) for the month of April 2024, revealed that Resident 9 used a CPAP machine (continuous positive airway pressure machine - is a machine that uses mild air pressure to keep breathing airways open while you sleep) from April 1-4, 2024. Interview with the Director of Nursing (DON) on June 13, 2024, at 9:35 AM, revealed that the MDS completed on April 4, 2024, should have been coded to reveal that Resident 9 used a CPAP machine. Review of Resident 26's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a persistent feeling of worry, nervousness, or unease), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and fibromyalgia (a disorder that causes widespread pain, fatigue, sleep problems, and cognitive difficulties). During an interview with Resident 26 on June 10, 2024, at 11:46 AM, revealed she has pain in her abdomen and medicine is not always effective in managing her pain. Review of Resident 26's clinical record revealed a nursing progress note written on June 5, 2024, that stated she had been more focused on having abdominal discomfort and believes she has colon cancer. Review of Resident 26's routine physician notes and clinical record failed to reveal notation that the Resident has any type of active cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. Review of Resident 26's Quarterly MDS assessment dated [DATE], revealed under Section I - Active Diagnoses, the Resident was marked yes for having cancer. During an interview with the DON on June 13, 2024, at 9:17 AM, she revealed Resident 26 has been followed by the physician and gynecology for fibroids (a non-cancerous tumor in the uterus) that contribute to her abdominal pain, and that she has no record of having an active cancer diagnosis. Follow-up interview with the DON on June 13, 2024, at 11:25 AM, revealed she would expect the residents' MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 8). Findings include: Based on facility policy, titled Care Plan Policy, not dated, read, in part, Changes in the resident's condition must be reported to the MDS Assessment Coordinator (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) so that a review of the resident assessment and care plan should be made. Review of Resident 8's clinical record revealed diagnoses that included difficulty in walking and muscle weakness. Review of Resident 8's clinical record on June 11, 2024, at 9:28 AM, revealed she was discharged to the hospital on May 1, 2024, and returned to the facility on [DATE]. Observation of Resident 8 on June 11, 2024, at 09:49 AM, revealed her face was heavily bruised. Interview with Resident 8 on June 11, 2024, at 09:52 AM, revealed she had a fall after an appointment and went directly to the hospital on May 1, 2024. Review of Resident 8's clinical record revealed she had an MDS assessment completed after her return from the hospital on May 15, 2024. Review of Resident 8's care plan on June 11, 2024, at 1:57 PM, revealed a focus area: [Resident 8] is at risk for falls due to deconditions (decline in physical fitness), last revised April 24, 2024, with a goal Minimize [Resident 8's] risk for injury related to falls through the next review last revised March 21, 2024. Interview with the Director of Nursing on June 13, 2024, at 10:25 AM, revealed she would expect Resident 8's fall care plan to be revised that she has had a fall with injury. 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on facility policy review, observations, and staff interviews, it was determined the facility failed to maintain a safe, clean, and home-like environment for 2 of 63 residents reviewed (Residents 12 and 54) and in two of two dining rooms. Findings Include: Review of facility policy, titled Meal Service and Distribution revealed, A comfortable, attractive atmosphere will be maintained in the dining room area .suggestions for a pleasant environment include use of clean, wrinkle-free tablecloths, centerpieces, background music, and placemats. Observation of the second floor dining area on August 14, 2023, at 11:49 AM, revealed 17 residents were eating meals served on trays. Further observation in the second floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. Interview with Employee 2 in second floor dining area on August 14, 2023, at 11:51 AM, revealed residents have been eating on trays in the dining room since COVID. Observation of the third floor dining area on August 14, 2023, at 12:17 PM, revealed 27 residents were eating meals served on trays. Further observation in the third floor dining room revealed all tables were bare without anything but the residents' trays, and no music was playing. During an interview with Nursing Home Administrator (NHA) on August 16, 2023, at 2:00 PM, the surveyor revealed a concern with residents being served meals on trays and lack of a pleasant environment in the dining rooms. No further information was provided. Observation in Resident 12's room on August 15, 2023, at 9:34 AM, and on August 16, 2023, at 1:20 PM, revealed bilateral enablers were present on Resident 12's bed. Observation of the inside of the enablers bars revealed an accumulation of dried liquid, crumbs and debris. During an interview with Employee 16 (Licensed Practical Nurse) on August 15, 2023, at 9:46 AM, she acknowledged the enablers were soiled, and revealed that she was uncertain about who normally cleans them. Observation on August 17, 2023, at 10:58 AM, revealed Resident 12's enabler bars had been cleaned. During an interview with the Director of Nursing (DON) on August 17, 2023, 11:55 AM, she confirmed that the enabler bars had been cleaned, and revealed the expectation that Resident 12's enabler bars should have been clean. Observations of Resident 54's room on August 15, 2023, a 10:03 AM and 1:25 PM, and on August 16, 2023, at 9:20 AM, revealed bilateral enabler bars attached to Resident 54's bed. Observation of the left side enabler bar revealed the bar appeared dirty, with a dried, brown substance splattered on the enabler bar. Further observation revealed a pool of a dried, brown substance on the bottom of the enabler bar. On August 16, 2023, at 1:45 PM, the NHA and DON were made aware of the observations of Resident 54's enabler bar. Observation of Resident 54's enabler bars on August 17, 2023, at 10:55 AM, revealed the enablers had been cleaned. During an interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that she personally cleaned Resident 54's enabler bars and stated that enablers should be cleaned as needed. 28 Pa. Code 201.18(e)(2.1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for four of 26 residents reviewed (Residents 55, 58, 71, and 110). Findings Include: Review of Resident 55's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive mental deterioration due to generalized degeneration of the brain, characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and delusional disorders (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 55's current physician orders revealed an order for Quetiapine (Seroquel) (antipsychotic medication) 25 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Review of Resident 55's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of November 22, 2022, revealed in section N Medications, that Resident 55 had not received an antipsychotic medication in the look back period. Review of Resident 55's November 2022 Medication Administration Record revealed that they had received Quetiapine (an antipsychotic medication) 25 milligrams at bedtime daily, as per the physician's order. Review of Resident 55's Modified Annual Comprehensive MDS with the assessment reference date of February 13, 2023, revealed in Section N Medications, that the physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 3, 2023. Review of physician services progress notes and pharmacy recommendations revealed that the clinical contraindication for a gradual dose reduction was dated February 2, 2023. Review of Resident 55's Quarterly MDS with the assessment reference date of May 16, 2023, revealed in Section N Medications, that they had not had any gradual dose reductions and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 23, 2023. Review of psychiatric physician services progress notes dated February 16, 2023, revealed that their Quetiapine (an antipsychotic medication) was to be reduced to 12.5 milligrams at bedtime, daily. Review of Resident's clinical record failed to reveal any physician services progress notes dated February 23, 2023. Review of Resident 55's physician orders revealed that their current order was for Quetiapine 25 milligrams give 0.5 tablet by mouth at bedtime daily, dated February 17, 2023. Review of Resident 55's Quarterly MDS with the assessment reference date of May 31, 2023, revealed in Section N Medications, that they were coded as not having a gradual dose reduction and that their physician had indicated that a gradual dose reduction of the antipsychotic was clinically contraindicated, with a date given of February 2, 2023. As stated above, Resident 55 had a gradual dose reduction of their Quetiapine on February 17, 2023. During an interview with Employee 2 (MDS Coordinator) on August 17, 2023, at 10:39 AM, all the above coding concerns were shared. Employee 2 indicated they would follow-up on the concerns identified. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 17, 2023, at 11:43 AM, the aforementioned concerns were shared with them as well. Email communication received from Employee 2 on August 17, 2023, at 12:33 PM, indicated that corrections were completed for MDS November 11, 2022, to code the receiving of antipsychotics; February 13, 2023, to code the correct date of the clinical contraindication of a gradual dose reduction to February 2, 2023; May 16, 2023, to code the gradual dose reduction completed on February 17, 2023; and May 31, 2023, to code the gradual dose reduction completed on February 17, 2023. During an interview with the DON on August 17, 2023, at 1:04 PM, she confirmed that she would expect the MDSs to have been coded accurately. Review of Resident 58's clinical record on August 15, 2023, revealed diagnoses that included chronic conjunctivitis (chronic eye inflammation caused by an infection), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 58's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution (antibiotic eye drops) 0.3 % Instill two drops in both eyes, two times a day for chronic conjunctivitis, wait five minutes to prevent wash out, with a start date of March 15, 2023. Review of Resident 58's Quarterly MDS (Minimum Data Set- assessment tool utilized to identify resident's physical, mental, and psychosocial needs) with ARD (assessment reference date - last day of the assessment period) of March 27, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. Review of Resident 58's Quarterly MDS with ARD of June 27, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic. During a staff interview on August 17, 2023, at 1:32 PM, Employee 2 confirmed that Resident 58's MDS assessments with ARD of March 27, 2023, and June 27, 2023, should have included antibiotic medication for seven days and were coded incorrectly. Interview with DON on August 17, 2023, at 1:40 PM, revealed it was the facility's expectation that resident assessments are coded accurately. Review of Resident 71's clinical record on July 13, 2023, revealed diagnoses that included dry eye syndrome, dementia, and dysphagia. Review of Resident 71's physician orders revealed an order for Ciprofloxacin HCl Ophthalmic Solution 0.3 % Instill two drops in both eyes, three times a day for blepharitis (eye inflammation), for seven Days from June 16, 2023, to June 23, 2023. Further review of Resident 71's physician orders revealed no order for an anticoagulant medication between the dates of June 16, 2023, and June 22, 2023. Review of Resident 71's Quarterly MDS with ARD of June 22, 2023, revealed under Section N - Medications, Resident 58 was marked 0 of 7 days for receiving an antibiotic, and was marked 7 of 7 days for receiving an anticoagulant. Email correspondence with DON on August 16, 2023, at 4:01 PM, revealed Resident 71 was on antibiotic eye drops during look-back for ARD June 22, 2023, and that Employee 2 should not have coded anticoagulant and should have coded antibiotic. Interview with DON on August 17, 2023, at 11:51 PM, revealed it was the facility's expectation that the resident assessment would be coded accurately. Review of Resident 110's clinical record revealed diagnoses that included dementia with behavioral disturbance and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Review of Resident 110's June 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order, effective June 1, 2023, for Risperdal (antipsychotic medication) at bedtime, and an order for Risperdal daily, effective June 3, 2023. Review of psychiatric service provider progress notes dated April 20, 2023, revealed that a gradual dose reduction of Resident 110's psychoactive medication (to include Risperdal) was not recommended at that time due to ongoing clinical treatment for anxiety and delusional disorder. Review of Resident 110's June 7, 2023, and June 26, 2023, quarterly MDS assessments revealed that neither assessment was coded to indicate that the practitioner had documented that a gradual dose reduction of antipsychotic medication was contraindicated. During an interview with the DON on August 17, 2023, at 11:56 AM, she deferred to the MDS coordinator. During an interview with Employee 2 on August 17, 2023, at 12:40 PM, she acknowledged that the progress note written by the psychiatric provider on April 20, 2023, could be interpreted as meeting the criteria to be coded on the MDS that the practitioner documented that an antipsychotic gradual dose reduction was contraindicated. 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided, in accordance with professional standards of practice, that would meet each resident's physical, mental, and psychosocial needs for four of 28 residents reviewed (Residents 12, 50, 54, and 63). Findings Include: Review of Resident 12's clinical record revealed diagnoses that included history of traumatic brain injury (an external mechanical force such as a violent blow to the head, which causes the brain to not function properly) and abnormal posture. Review of Resident 12's physician orders revealed an order, dated December 10, 2022, for gerisleeves (cloth sleeves worn on the arms to prevent skin irritation or injury) to bilateral arms when up in wheelchair. Review of Resident 12's current care plan revealed an intervention, dated August 23, 2022, for Resident 12 to wear gerisleeves on both arms when in her wheelchair. Observations on August 15, 2023, at 9:34 AM and at 1:34 PM, and on August 16, 2023, at 11:59 AM and at 1:20 PM, revealed Resident 12 was in her wheelchair. Resident 12 was not wearing gerisleeves. During an interview with the Director of Nursing (DON) on August 17, 2023, at 11:56 AM, she revealed the expectation that Resident 12 should have been wearing the gerisleeves. Review of Resident 50's clinical record revealed diagnoses that included pressure ulcer of right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure), osteomyelitis (infection of the bone), and diabetes mellitus (DM - a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 50's physician orders revealed an order for Strict pressure relief to BLE [bilateral lower extremities]. Bilateral multipodus boots when in bed every shift related to nonpressure chronic ulcer of unspecified heel and midfoot with unspecified severity, with a start date of May 18, 2023. Review of Resident 50's care plan revealed a focus area: [Resident 50] is at risk for skin breakdown related to impaired mobility, DM, incontinence, pressure ulcers, noted osteomyelitis to right ankle with actual skin breakdown, initiated May 15, 2023, and last revised on August 4, 2023, with an intervention for Bi-lateral multipodus boots while in bed, initiated May 16, 2023. Observation of Resident 50 in his room on August 15, 2023, at 1:15 PM, revealed the Resident was laying in bed and his multipodus boots were sitting in his wheelchair, beside his bed. Interview with Resident 50 on August 15, 2023, at 1:17 PM, revealed he does not refuse to wear his boots, but, depending on which nurse aide is working, they sometimes take them off before he gets into bed. Interview with the DON on August 17, 2023, at 11:51 AM, revealed she would expect Resident 50 to be wearing his multipodus boots in bed per physician order and per his care plan. Review of Resident 54's clinical record revealed diagnoses that included hypertension (elevated blood pressure), Type 2 Diabetes Mellitus, and end stage renal disease (ESRD- when the kidneys no longer work as they should to meet the body's needs). Review of Resident 54's physician orders revealed an order dated July 17, 2023, for hipsters at all times (impact-absorbing pads over the critical hip fracture area minimize potential damage that can occur from a fall). Review of Resident 54's current care plan revealed an intervention dated July 17, 2023, for hipsters at all times, may remove for care. Observation of Resident 54 on August 14, 2023, at 1:11 PM, revealed Resident 54 in his room alone, in bed, asleep, wearing only a shirt and a brief. Resident 54 was not observed to be wearing hipsters. Observation of Resident 54 on August 15, 2023, at 9:30 AM, revealed Resident 54 in his room alone, in bed, wearing only a brief. Resident 54 was not observed to be wearing hipsters. During an interview with Employee 5 (Licensed Practical Nurse) on August 16, 2023, at 10:13 AM, Employee 5 stated that she is unsure why Resident 54 was not wearing his hipsters on August 14 or 15, 2023. She stated they may have been soiled, as some of the hipsters were being laundered. On August 16, 2023, at 1:45 PM, the Nursing Home Administrator (NHA) and DON were made aware of Resident 54 not wearing his hipsters on the aforementioned dates and times. In a follow-up interview with the NHA and DON on August 17, 2023, at 11:42 AM, the DON stated that Resident 54's hipsters got soiled during an incontinence episode, and they were being laundered. When asked if the facility had extra hipsters to be provided during a situation like that, she stated the facility does have extra hipsters, but they were all used up. No additional information was provided. Review of Resident 63's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients needed for health), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 63's care plan revealed a focus area: nutritional risk related to mechanical diet, reflux, dementia, hyperlipidemia (high cholesterol), dysphagia (difficulty swallowing), depression, chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertension (high blood pressure), last revised May 19, 2023, with an intervention for provide a water pitcher at bedside to promote fluid intake, initiated March 24, 2022. Observation in resident 63's room on August 15, 2023, at 9:44 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Further observation in Resident 63's on August 15, 2023, at 12:39 PM, revealed Resident 63 during lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Observation in Resident 63's room on August 16, 2023, at 9:54 AM, revealed no water pitcher at bedside or anywhere in Resident 63's room. Further observation on August 15, 2023, at 12:45 PM, revealed Resident 63 during lunch meal, no water pitcher at bedside, and the only beverage was an 8-ounce (unit of measure) milk on the lunch tray. Interview with DON on August 17, 2023, at 11:48 AM, revealed she would expect the care plan to be followed and Resident 63 to have a water pitcher at bedside to promote fluid intake. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually, and that in-service education was provided based on the outcome of these reviews for five of five nurse aides reviewed (Employees 9, 10, 11, 12, and 13). Findings Include: Review of select facility documentation revealed that Employee 9 was hired on July 18, 2011; Employee 10 was hired on June 21, 2011; Employee 11 was hired on March 16, 2021; Employee 12 was hired on July 21, 2021; and Employee 13 was hired on December 30, 2021. During an interview with the Nursing Home Administrator on August 16, 2023, at 2:05 PM, he confirmed that no annual performance evaluations were completed for the aforementioned Employees since before June 2022. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy reviews, observations, completion of a meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were at an appetizing appearance, flavor, and temperature. Findings include: Review of facility document, titled Meal Service and Distribution last reviewed August 2, 2023, revealed Have hot food hot and cold food cold when the tray reaches that resident. Review of facility document, titled Dining and Food Service last reviewed August 2, 2023, revealed, The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve the provision of nourishing, palatable, attractive meals to meet the resident's daily nutritional and special dietary needs. Multiple resident interviews on August 14 and 15, 2023, revealed residents voiced concerns with the temperature and flavor of the food during meal service. During an interview with Resident 13 on August 14, 2023, at 10:35 AM, Resident 13 stated that sometimes the food is not always hot. Interview with Resident 30 on August 14, 2023, at 11:40 AM, revealed he is often served cold food. During an interview with Resident 34 on August 15, 2023, at 9:38 AM, Resident 34 stated that the food is not good. During an interview with Resident 36 on August 14, 2023, at 10:19 AM, Resident 36 indicated that the food was not too good; most of the time it is overcooked, and it is not always hot. Resident 36 further stated that condiments such as salt is not always on the tray. During an interview with Resident 82 on August 15, 2023, at 9:18 AM, when Resident 82 was asked about the food, he scrunched up his nose. Resident 82 stated the food was iffy and the temperature of the food is not good. Interview with Resident 84 on August 14, 2023, at 1:15 PM, revealed her family members bring her food often as facility food does not taste good and is often cold. Follow-up interview with Resident 84 on August 15, 2023, at 12:32 PM, during lunch meal, the Resident revealed the chicken was dry and salty. Immediate observation of the chicken on the plate revealed a dry appearance. During an interview with Resident 106 on August 14, 2023, at 11:02 AM, Resident 106 stated the food is not as good as it used to be. She further stated that the temperature of the food isn't to her liking, and the vegetables are often hard. Review of resident council meeting minutes from May 24, 2023, revealed residents voiced dietary concerns about potatoes and noodles needing to be cooked longer. Review of resident council meeting minutes from June 21, 2023, revealed residents voiced dietary concerns related to potatoes not being cooked long enough. Review of resident council minutes from July 18, 2023, revealed residents voiced concerns the iced tea needs more sugar, and the potatoes are still not being cooked long enough. Observation of dietary tray line service on August 16, 2023, at 11:46 AM, revealed chocolate pie portions stacked on top of each other causing pie served to residents to be smashed flat on the plate with an unattractive appearance. Observation of dietary tray line service on August 16, 2023, at 12:10 PM, revealed butter parsley noodles were running low and replaced with plain, not seasoned noodles. Interview with Employee 3 (Dietary Manager) on August 16, 2023, at 12:29 PM, revealed it is the facility's expectation that hot foods and beverages are served at or above 140 degrees Fahrenheit (unit of measure), and cold foods and beverages as served at or below 41 degrees Fahrenheit. A Test Tray was completed on August 16, 2023, at 12:34 PM, utilizing lunch tray served from tray line in the main facility kitchen. A test tray was served and placed in closed food cart for approximately two minutes prior to being delivered to third floor dining room area (other trays for room service being delivered here also at this time). The Test Tray included: meatballs with mushroom gravy, noodles, broccoli and cauliflower, chocolate pie, coffee, and milk. Temperatures taken by Employee 3 revealed the following: meatballs were 136 degrees Fahrenheit, not acceptable temperature broccoli and cauliflower were 132 degrees Fahrenheit, not acceptable temperature chocolate pie was 58 degrees Fahrenheit milk was 52 degrees Fahrenheit, not acceptable temperature, and coffee was 135 degrees Fahrenheit, not acceptable temperature The test tray included the plain noodles that were bland in taste, and the chocolate pie that was smashed flat on the plate with an unattractive appearance. Interview with Employee 3 on August 16, 2023, at 12:37 PM, revealed food and beverages should be served at attractive appearance, flavor, and temperatures. Interview with the Nursing Home Administrator on August 16, 2023, at 1:57 PM, revealed it is the facility's expectation that food and beverages are served at attractive appearance, flavor, and temperatures. 28 Pa. Code 211.6 (d) Dietary services

Based on personnel file review, facility policy review, job descriptions, and staff interviews, it was determined that the facility failed to implement written policies and procedures by not completing criminal background checks prior to hire for five of five personnel records reviewed (Employees 4, 5, 6, 7, and 8); and verifying professional licensure for three of three personnel records reviewed. Findings include: Review of the facility's current policy, titled Abuse Prevention & Reporting Policy revealed in the section, titled Policy Statement that the facility will comply with all Federal, State, and local regulations regarding the prevention, recognition, and reporting of abuse, neglect, and/or misappropriation of property. Review of section of the policy, titled Procedure indicated 1) Individuals functioning in an 'employee' status .will have a State Criminal Background Check completed at the time of employment; and 2) [in part] Persons hired as part of the professional staff .are required to have and maintain a valid current license or certification .and must submit a copy of their license on or before their first day of orientation. Review of the policy in its entirety did not reveal that the facility would complete a license or certification verification prior to hire. Review Employee 4's (Speech Language Pathologist) personnel file revealed that their date of hire was August 1, 2023; that their criminal background check was completed on August 2, 2023, at 11:40 AM; and that there was no licensure verification present. Review of Employee 5's (Licensed Practical Nurse) personnel file revealed that their date of hire was June 27, 2023; that their criminal background check was completed on June 29, 2023, at 8:13 AM; and that their license verification was completed June 29, 2023. Review of Employee 6's (Registered Nurse) personnel file revealed that their date of hire was April 25, 2023; that their criminal background check was completed on April 27, 2023, at 10:12 AM; and that their license verification was completed on April 25, 2023. Review of Employee 7's (Nurse Aide) personnel file revealed that their date of hire was June 6, 2023; and that their criminal background check was completed on June 14, 2023, at 3:18 PM; and that there was no certification verification present. Review of Employee 8's (Cook) personnel file revealed that their date of hire was August 1, 2023; and that their criminal background check was completed on August 2, 2023, at 11:40 AM. During an interview on August 16, 2023, at 1:38 PM, the aforementioned concerns were shared with the Nursing Home Administrator (NHA) and the Director of Nursing, at which time additional information was requested. During an interview on August 17, 2023, at 9:30 AM, with the NHA, he indicated that the facility does not complete the criminal background checks until the employee shows up for their first day of employment, secondary to cost, because there are several times when the individual does not show up for their first day. He further indicated that on day one of orientation, which would also be the date of hire, that the team member would be in the classroom setting all day and that the team members do not have resident contact until day 2. He further indicated that he would provide additional information for review. On August 17, 2023, at 11:33 AM, the NHA provided additional information for review (time card reports for Employees 4, 5, 6, 7, and 8; license verification for Employee 4, and training information for Employee 7). Review of this additional information revealed the following: Employee 4 had worked on August 1, 2023, from 8:30 AM to 2:45 PM (orientation day); August 2, 2023, from 10:15 AM to 4:00 PM; and August 3, 2023, from 8:30 AM to 2:15 PM, and that their license verification was completed on August 16, 2023, with no disciplinary actions noted; Employee 5 had worked only on June 27, 2023 (orientation day); Employee 6 had worked only on April 25, 2023 (orientation day); Employee 7 had just completed nurse aide training on July 28, 2023, has not yet completed certification testing, and he worked on June 6, 2023, from 8:30 AM to 2:45 PM; June 9, 2023, from 10:00 AM to 6:00 PM; June 12, 2023, from 10:00 AM to 6:15 PM; June 13, 2023, from 10:00 AM to 6:15 PM; and June 14, 2023, from 10:00 AM to 6:00 PM, in the role of Helping Hands (a position that provides general support to the residents as needed and performs basic housekeeping duties as assigned); and Employee 8 had worked on August 1, 2023 from 8:30 AM to 2:45 PM (orientation day), and August 2, 2023, from 5:00 AM to 2:00 PM. During an interview on August 17, 2023, at 1:20 PM with the NHA, he confirmed that the background checks and license verifications were not completed prior to hire or on the day of hire. He further indicated that he would expect background checks and license verification to be completed at time of hire. During a final follow-up interview on August 17, 2023, at 1:43 PM, NHA confirmed that he had no additional information to provide. 28 Pa. Code 201.18(e)(1) Management

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for one of 26 residents reviewed (Resident 77). Findings include: Review of Resident 77's clinical record on August 14, 2023, revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension (high blood pressure). Observation in Resident 77's room on August 14, 2023, at 12:52 PM, revealed there was no call bell plugged into the wall or in reach. Interview with Employee 14 on August 14, 2023, at 12:52 PM, revealed she was unable to locate a call bell for Resident 77 in his room. Employee 14 stated she was unsure why he did not have a call bell, she left the room, and returned with a metal call bell to place at the Resident's bedside. Review of Resident 77's care plan on August 14, 2023, revealed a focus area: [Resident 77] is at risk for falls due to weakness with an intervention for call bell in reach, initiated October 17, 2022. Interview with the Director of Nursing on August 16, 2023, at 1:58 PM, revealed she would expect Resident 77's call bell to be in reach. 28 Pa code 201.29(d) - Resident Rights 28 Pa Code 211.12(d)(1) Nursing Services

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from sexual abuse for six of 22 residents reviewed (Residents R8, R15, R17, R18, R19, R22), resulting in the residents being placed at risk for sexual abuse and Immediate Jeopardy to the residents' safety. Findings include: The facility's policy regarding abuse, dated December 19, 2016, revealed that sexual abuse included non-consensual contact of any type, rape, molestation or other inappropriate sexual behavior against a resident, such as sexual harassment, sexual assault, or sexual coercion, and inappropriate sexual behaviors displayed by and/or toward an incapable resident. The policy indicated that all instances of alleged violations concerning abuse, neglect, or misappropriation of property were to be verbally reported immediately to the Facility Abuse Coordinator, the Nursing Home Administrator and to other officials in accordance with state law, including the State Survey and Certification Agency (Department of Health). The facility's behavior management policy, dated July 1, 2017, revealed that staff would incorporate behavior management techniques to assist residents in reaching or maintaining their highest physical, mental, and psychosocial well being. Individual resident routines were to be restructured as required to control or prevent future behavior episodes. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident R14, dated September 6, 2017, revealed that the resident had a Brief Interview for Mental Status (BIMS - a standardized interview to determine a resident's mental status) score of 8 (moderately impaired), could make his needs known, could understand others, had physical behaviors directed toward others, used a wheelchair, was able to move on his nursing unit with supervision, and had [DIAGNOSES REDACTED]. The plan included that staff were to intervene as necessary to protect the rights and safety of others, divert his attention and remove him from the situation, and take him to an alternate location as needed. Staff were also to monitor the resident's behavior episodes and attempt to determine the underlying cause, and document the behavior and potential causes. The resident could also watch adult movies as he desired. A quarterly MDS assessment for Resident R8, dated July 12, 2017, revealed that the resident was rarely understood, could rarely understand, had short and long-term memory problems, and had [DIAGNOSES REDACTED]. The resident's current care plan, dated September 19, 2016, indicated that she had a history of [REDACTED]. An admission MDS assessment for Resident R15, dated July 19, 2017, revealed that the resident was rarely understood, could rarely understand, had short and long-term memory problems, wandered daily, used a wheelchair for mobility, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident R17, dated August 14, 2017, revealed that the resident had a BIMS score of 3 (severely impaired), could sometimes make her needs known, could sometimes understand others, was not ambulatory, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident R18, dated August 14, 2017, revealed that the resident had a BIMS score of 2 (severely impaired), could sometimes make her needs known and could sometimes understand others, that she was not ambulatory and had [DIAGNOSES REDACTED]. A comprehensive significant change MDS assessment for Resident R19, dated August 8, 2017, revealed that the resident had a BIMS score of 10 (moderately impaired), could sometimes make her needs known and understand others, and was able to move on her nursing unit with limited assistance. A comprehensive annual MDS assessment for Resident R22, dated August 16, 2017, revealed that the resident had a BIMS score of 2 (severe impairment), could sometimes make her needs known and understand others, used a wheelchair, was able to move on her nursing unit with supervision, and had [DIAGNOSES REDACTED]. A social service note for Resident R14, dated June 7, 2017, revealed that the resident asked to be moved back to the third floor. The note indicated that the resident was deemed capable of making decisions about his care. A social service note, dated June 9, 2017, revealed that the social worker was asked to speak with Resident R14 about his inappropriate behaviors with incapable women on his floor, as he had been seen caressing their arms and hands without their permission. He stated that he would stop this behavior. A nursing note for Resident R14, dated June 11, 2017, revealed that the nurse talked with the resident about going into female residents' rooms. The resident was brought out of the neighboring room, and it was explained to him that he was not to go in there. On June 12, 2017, at 2:19 p.m. Resident R14 was found in Resident R8's room, touching her breast. He was removed from the room and was told his behaviors were inappropriate and that this kind of behavior would not be tolerated. A social service note for Resident R14, dated June 12, 2017, at 6:11 p.m. revealed that Resident R14 was spoken to about his behavior and its extreme inappropriateness, and he was to be seen by a mental health service related to his behaviors. Per his wishes, he also had some sex toys in his possession to provide an outlet for his physical/sexual needs. A nursing note for Resident R14, dated June 13, 2017, at 6:57 p.m. revealed that the nurse responded to a chair alarm and saw Resident R14 in another resident's room standing over the resident and attempting to touch her. The resident was immediately removed from the area. A nursing note for Resident R14, dated June 14, 2017, at 10:26 p.m. revealed that Resident R14 was found in Resident R22's room attempting to get close to her. When Resident R14 was removed from the room, he was laughing. A physician's orders [REDACTED]. A nursing note for Resident R14, dated July 2, 2017, at 7:53 a.m. revealed that the resident was found in Resident R8's room with his hands under the covers. Resident R14 was removed from the room and the social worker was notified. On July 6, 2017, at 2:03 p.m. Resident R14 was found in Resident R8's room standing over her. Resident R14 was not touching Resident R8 and he was redirected to his own room, as he had been told that he was not permitted in Resident R8's room. A social service note for Resident R14, dated July 6, 2017, at 5:08 p.m. revealed that it was reported to the social worker that Resident R14 was found in Resident R8's room on July 4 and July 6, 2017, and she had spoken to Resident R14 on multiple occasions in reference to staying out of female residents' rooms. The current plan was to have Resident R14 seen by a mental health service and if the behavior did not improve, a room change may be considered. A nursing note for Resident R14, dated July 10, 2017, at 10:23 p.m. revealed that Resident R14 continued to be non-compliant with transferring and was found in Resident R19's room attempting to touch her, and then he was also found attempting to touch Resident R18. Resident R14 was removed from the area. A nursing note for Resident R14, dated July 14, 2017, revealed that the resident was seen by a mental health service and 125 milligrams of [MEDICATION NAME] (medication used to treat mood disorders) was ordered twice a day. A note from the mental health service, dated July 26, 2017, revealed that Resident R14 had issues with impulsive behaviors towards female residents and he came with a box of pornographic tapes. A nursing note for Resident R14, dated August 7, 2017, at 10:44 p.m. revealed that the resident was found attempting to touch another female inappropriately while in the common area in front of the nursing station, and when attempting to redirect him, Resident R14 laughed and thought that trying to touch the resident was funny. The resident's care plan, dated August 8, 2017, was updated to include a stop sign on the doorway of his room. A nursing note for Resident R14, dated August 9, 2017, at 6:01 p.m. revealed that the resident was found kissing a female resident's arm, and was moving up the arm. Resident R14 was immediately removed from the situation and when re-educating him, he began to laugh and said that he was doing these women a favor. A mental health service note, dated August 9, 2017, indicated that Resident R14 had another incident of inappropriate sexual touching and the plan was to increase the [MEDICATION NAME] and consider an increase in [MEDICATION NAME]. physician's orders [REDACTED]. A nursing note for Resident R14, dated August 16, 2017, revealed that the resident was found attempting to touch multiple women, multiple times throughout the day. The resident was pulled away from the other residents, but was unable to be redirected, and when he was pulled away he would laugh. A nursing note for Resident R14, dated August 31, 2017, revealed that the resident was found kissing Resident R15. Resident R15 wandered into Resident R14's room through the stop sign on his door, and laid down in his bed. When Resident R15 laid down in his bed, Resident R14 started kissing the resident. The nurse aide was responding to Resident R14's bed alarm when she witnessed this. The note indicated that Resident R14 had multiple incidents of touching or attempting to touch women, the resident did not respond to re-education, and social services was made aware of the incident. A social service note, dated September 5, 2017, at 4:10 p.m. revealed that Resident R14 was evaluated related to sexual behavior toward another resident on August 31, 2017. Resident R14 stated that the other resident asked for him to kiss her, and that he did not think he hurt anybody. He also stated that she was in his bed, so he thought it was okay. Resident R14 stated that he would not do it anymore, and the plan was for the resident to see the mental health service to see if there was any medication that would curb his sexual behavior. A nursing note for Resident R14, dated September 5, 2017, at 10:25 p.m. revealed that the resident was found attempting to touch multiple women during the shift, and when re-directing the resident, he stated that he was only touching their arms, hands and thighs, and it was not like he was asking them to get naked, then he laughed. physician's orders [REDACTED]. A nursing note for Resident R14, dated September 13, 2017, at 8:44 a.m. revealed that the resident continued to have sexually inappropriate behaviors towards female peers and recently his [MEDICATION NAME] was increased. Observations on September 21, 2017, at 5:01 p.m. revealed that Resident R14 was in his room in his wheelchair and the stop sign barrier across his doorway was not in place. Interview with Licensed Practical Nurse 1 at this time confirmed that the barrier was to be across the doorway of Resident R14's room at all times. She indicated that Resident R14 liked to take off the barrier and lay it on his bed. On September 21, 2017, at 8:02 p.m. the Nursing Home Administrator was informed that the health and safety of residents who were not able to give consent for sexual activities were in Immediate Jeopardy due to the lack of supervision and monitoring of Resident R14. The facility submitted and implemented an immediate plan to ensure resident safety that included placing Resident R14 under direct observation, educating staff about the facility's abuse policy, prevention and reporting sexual behaviors, and updating Resident R14's care plan with interventions to prevent any further sexual behaviors and maintain a safe environment. The Immediate Jeopardy was removed on September 22, 2017, at 4:15 p.m. when it was confirmed that Resident R14 was under direct observation, and the majority of the facility's staff were educated regarding the prevention and reporting of sexual abuse. Interview with Licensed Practical Nurse 3 on September 21, 2017, at 2:05 p.m. revealed that Resident R14 could be sexually inappropriate at times, that he wandered into female residents' rooms, that Residents R8 and R15 wander into Resident R14's room, and they try to keep him in the common area. She indicated that Resident R14 inappropriately rubs their arms and has been talked to several times. She confirmed that the resident was seen by mental health services and was receiving medications, but there was no plan for monitoring in place. Interview with Social Worker 2 on September 21, 2017, at 4:18 p.m. revealed that Resident R14 touched the arms of women in a sexual manner, and that he was sneaky, very flirtatious and manipulative. She also thought that Resident R14 knew what he was doing and that his behaviors were the reason he was removed from the last place where he lived. Interview with Licensed Practical Nurse 3 on September 21, 2017, at 6:55 p.m. revealed that Resident R14 frequently grabbed the hands of female residents and kissed them, and a lot of times he would go to Resident R8 and kiss and rub her hands. Interview with Nurse Aide 7 on September 21, 2017, at 7:15 p.m. revealed that she saw Resident R14 rub Resident R17's and R18's hands and their legs from the knee to the thigh. Interview with Nurse Aide 6 on September 21, 2017, at 7:25 p.m. revealed that sometimes when she enters a room Resident R14 and Resident R8 or R15 will be making out, kissing and touching. Interview with Nurse Aide 5 on September 21, 2017, at 8:59 p.m. revealed that Resident R14 liked to touch women, kiss confused residents, and tried to get up their shirts. She indicated that about a week ago, the resident was rubbing Resident R18's leg, was told to stop, and they were separated. Interview with the Nursing Home Administrator on September 21, 2017, at 6:49 p.m. confirmed that Resident R14 was seen by mental health services and was ordered medications, but there was no monitoring of Resident R14 or interventions put into place to protect other residents from his inappropriate sexual behaviors. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/8/17, 7/26/17, 4/6/17, 11/22/16, 8/19/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 8/19/16. 28 Pa. Code 201.29(j) Resident rights. Previously cited 5/18/17, 2/9/17, 1/22/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/26/17, 2/9/17, 8/2/16, 1/22/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/26/17, 5/18/17, 2/9/17, 11/22/16, 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16.

Based on review of facility policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with timely emergency services in accordance with physician's orders [REDACTED]. Findings include: The facility's policy regarding clinical code, undated, revealed that if the person who found a medical emergency was a licensed nurse, and the resident had no pulse and was not breathing, staff were to determine the resident's code status and if the resident was a full code (start CPR when there is no pulse and no breathing), CPR (cardio-pulmonary resuscitation - an emergency procedure performed when someone's breathing or heart beat stops) was to be started. A physician's orders [REDACTED]. However, physician's orders [REDACTED]. Resident CR4's clinical record information, facility witness statements, and staff interviews revealed that the resident was found unresponsive and not breathing on [DATE], at 9:20 a.m. the resident's clinical record was checked for the code status, the first page inside the record where staff were to check for code status indicated that Resident CR4 was a DNR, and there was no CPR performed. The physician was notified and instructed the registered nurse to call the resident's time of death (pronounce the resident's death). The Assistant Director of Nursing (ADON) was called and was informed that Resident CR4 ceased to breathe and she thought that Resident CR4 was a full code. After reviewing the clinical record, it was found that physician's orders [REDACTED]. A witness statement from Registered Nurse 11, dated [DATE], revealed that Nurse Aide 10 found Resident CR4 unresponsive at approximately 9:20 a.m. The nurse then checked the code status page in the resident's chart and it indicated that the resident was a DNR. She notified the physician and ADON, and at that time the ADON thought that the resident was a full code. After verifying the code status in the physician order's, it was found that Resident CR4 was a full code. There was no documented evidence that CPR was performed according to the resident's advanced directives and physician's orders [REDACTED]. Interview with Registered Nurse 11 on [DATE], at 5:41 p.m. revealed that when she found Resident CR4 to have no pulse and unresponsive, she checked the resident's code status and it indicated that Resident CR4 was a DNR . She confirmed that CPR was not initiated at that time, and the physician was notified about the resident's condition and gave instructions to call the resident's time of death. She indicated that when she called the ADON to inform her about the resident's death, the ADON thought that Resident CR4 was a full code, and after verifying the physician's orders [REDACTED]. Interview with the Nursing Home Administrator on [DATE], at 3:31 p.m. confirmed that staff did not perform CPR as ordered for Resident CR4, and they should have. A [DIAGNOSES REDACTED]. A laboratory report, dated [DATE], revealed that the resident's potassium level was low at 2.9 millimols per liter (mmol/L) (normal level is 3XXX,[DATE].2). physician's orders [REDACTED]. Interview with the Director of Nursing on [DATE], at 5:10 p.m. confirmed that there was no evidence that staff administered Resident R1's 9:00 p.m. dose of potassium as ordered by the physician. physician's orders [REDACTED]. Interview with the Director of Nursing on [DATE], at 6:20 p.m. confirmed that staff should have administered only one dose of [MEDICATION NAME] to Resident R5, and the resident's MAR indicated [REDACTED]. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.11(d) Resident care plan. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the necessary treatment and services to prevent new pressure ulcers from developing for one of 10 residents reviewed (Resident R3), resulting in the development of two pressure ulcers for the resident. Findings include: The facility's policy regarding splints, dated June 21, 2017, revealed that it was important to keep all splints clean and to check the resident's hands regularly to ensure that no pressure ulcers developed. A therapy screening form for Resident R3, dated January 20, 2017, revealed that the resident had a tightly fisted left hand and would only allow the hand to be opened slightly. The form indicated that it appeared that the resident had Dupuytren's (a condition in which one or more fingers become permanently bent in a flexed position). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated May 23, 2017, revealed that the resident was confused, was dependent for activities of daily living, wore a splint, and was at risk for developing pressure ulcers. The resident's care plan, revised April 29, 2017, revealed that the staff were to check the resident's skin every shift and were to report red/open areas to the nurse. A revision to the care plan, dated June 9, 2017, revealed that the resident was to receive passive range of motion exercises (when someone else moves your joints) to the left hand/fingers prior to the application of the splint, as specified in the resident's restorative nursing care plan. An occupational therapy (OT) note for Resident R3, dated May 31, 2017, revealed that the resident was tolerating passive range of motion to the left hand, wrist, and fingers, to improve range of motion for hand hygiene and use of the splint. The resident was able to wear the finger separator splint up to four hours, and checks were continued without signs of irritation or skin breakdown. An OT note for Resident R3, dated June 2, 2017, revealed that the finger separator splint worked the best and was to be on after morning care and off at bedtime, with passive range of motion performed. The staff were trained on the purpose, care, and use of the splint for the left hand, and therapy discharge recommendations included an established splint/brace program using a left finger separator splint. physician's orders [REDACTED]. Resident R3's Treatment Administration Records (TAR's) for June 2017 revealed that the licensed nursing staff were signing that the splint was applied after a.m. care and removed at bedtime from June 3 to 25, 2017. Nurse aide flow records for June 14 to 25, 2017, revealed that Resident R3's left finger separator splint was to be applied after morning care and was to be removed at bedtime; however, there was no documented evidence that the splint was removed at bedtime after the evening of June 15, 2017. A nursing note for Resident R3, dated June 25, 2017, revealed that at approximately 9:00 p.m. it was noted that the resident had the left finger separator splint in place. The splint was removed and was noted to have a moderate amount of serosanguineous drainage (thin, watery, yellow drainage) on it, and the resident had active bleeding coming from the left hand. Open areas were noted on the bottom side of the left fourth and fifth fingers, the physician was notified, and an order was received to send the resident to the emergency room . Hospital records for Resident R3, dated June 26, 2017, revealed that the resident had contractures (a loss of joint motion due to structural changes in non-bony tissues such as muscle, ligaments or tendons) of all digits (fingers) of the left hand and had wounds at the bases of the fourth and fifth digits at about the level of the metacarpophalangeal joint (location where the fingers meet the palm of the hand), with exposed flexor tendons (tendons connect muscles to bones) within the wound bed. There was surrounding [DIAGNOSES REDACTED] (redness) and soft tissue swelling extending into the palm in the proximal (closest to the palm) portion of the fingers. The wound was in a very difficult location to access both secondary to the patient's discomfort and cooperation as well as the contractures involving her fingers. It was explained to the resident's family that wound care would be quite difficult given the contractures and the location of the wound, but was a potential option. A more definite treatment plan was discussed in the form of the left upper extremity forearm amputation, which would remove all infected tissue and cure the current problem. On June 29, 2016, the resident had surgery to amputate the left hand, including the left mid forearm. Interview with Registered Nurse 3 on July 17, 2017, at 8:00 a.m. revealed that she did not remove Resident R3's finger separator splint and observe the skin on the resident's hand during the evening shift on June 23, 2017. She indicated that the nurse aide reported to her that everything was fine, and that the nurse aide reapplied the splint after cleaning the resident for supper and the splint stayed on all night. Interview with Licensed Practical Nurse 2 on July 18, 2017, at 10:05 a.m. revealed that she did not remove Resident R3's finger separator splint and observe the resident's skin during the morning and evening of June 24, 2017, and during the morning of June 25, 2017. She reported that the night of June 25, 2017, the finger separator splint was still on the resident's hand, and when she removed it she saw the open areas. She indicated that the splint had drainage on it and when she removed the splint she had another staff member assist her with opening the resident's fourth and fifth fingers. The resident's hand was reddish-purple in color, swollen at the base, and had bone or tendon exposed. She also indicated that she did not receive any training regarding the resident's splint. Interview with Nurse Aide 6 on July 18, 2017, 10:41 a.m. revealed that when she arrived for her shift the morning of June 24, 2017, Resident R3's splint was already on her hand and she did not remove it. She indicated that she took it off during the evening shift but did not open the resident's fingers to check her skin because the resident was yelling when her fingers were moved. She stated that she reported to the licensed practical nurse that she could not get the resident's fingers open and was unable to see everything. She also indicated that she did not receive any training regarding the application of the resident's splint. Interview with Nurse Aide 8 on July 18, 2017, at 1:55 p.m. revealed that Resident R3 was on the night shift's (11:00 p.m. to 7:00 a.m.) list to wash up, but she never dealt with the splint, and she did not look at the resident's fingers on Sunday morning (June 25, 2017). Interview with Nurse Aide 9 on July 18, 2017, at 2:16 p.m. revealed that she did not wash Resident R3 during the night shift on June 24, 2017, and did not put the splint on the resident. Interview with Licensed Practical Nurse 5 on July 18, 2017, at 3:04 p.m. revealed that she thought that Resident R3's hand splint was not to be removed at night. Interview with Nurse Aide 10 on July 18, 2017, at 6:34 p.m. revealed that Resident R3's morning care on Sunday (June 25, 2017) was done before she started her shift that morning (7:00 a.m.). She revealed that on Saturday (June 24, 2017) she reported to one of the nurses that the resident's splint smelled. She also indicated that she did not remove the resident's splint and thought that the splint was to be on at all times. Interview with Occupational Therapist 7 on July 18, 2017, at 12:10 p.m. revealed that staff were to open Resident R3's hand to check the resident's skin each time the splint was applied or removed. He confirmed that the splint was to be applied in the morning and removed at bedtime, and that only four members of the nursing staff were educated about the use and care of the splint. Interview with the Nursing Home Administrator and the Director of Nursing on July 18, 2017, at 6:00 p.m. revealed that the day shift nurse aides indicated that Resident R3's splint was already on when they arrived for the shift on Saturday, June 24 and Sunday June 25, 2017. They confirmed that the day shift staff should have put the splint on and the evening shift staff should have removed the splint, and the resident's skin should have been checked each time the splint was put on and taken off. They indicated that the nurses, not the nurse aides, were responsible for checking the resident's skin. They confirmed that there was no documented evidence that the resident's splint was removed and that her skin was checked on the evening of June 23, the morning and evening of June 24, and the morning of June 25, 2017. 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 11/22/16. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 2/9/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 11/22/16, 8/2/16, 4/14/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/18/17, 2/9/17, 11/22/16, 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were provided with appropriate pain management for one of 26 residents reviewed (Resident R3) who had contractures. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated May 23, 2017, revealed that the resident was confused, was dependent for activities of daily living, and wore a splint. The resident's care plan, revised April 29, 2017, revealed that the staff were to check the resident's skin every shift and were to report red/open areas to the nurse. A physician's orders [REDACTED]. Interview with Nurse Aide 6 on July 18, 2017, 10:41 a.m. revealed that she took the splint off Resident R3's hand on the evening shift on June 24, 2017, but did not open the resident's fingers to check her skin due to the resident yelling when she moved her fingers. She stated that she reported to the licensed practical nurse that she could not get the resident's fingers open and was unable to see everything. An undated witness statement from Licensed Practical Nurse 12 revealed that a nurse aide had taken the resident's splint off and did range of motion and the splint caused the resident pain. An undated witness statement from Nurse Aide 13 indicated that there were times when she tried to do range of motion with Resident R3's hand and the resident would yell out. An undated witness statement from Nurse Aide 14 indicated that she would take the splint off Resident R3 and wash between her fingers and then bend the fingers as far as should could, but the resident would yell because of the contractures. An undated witness statement from Nurse Aide 15 indicated that she would take Resident R3's splint off, try to do range of motion by rubbing lotion on her hand, and the resident would yell, so she would stop. An undated witness statement from Nurse Aide 6 revealed that she took the splint off Resident R3's hand on June 24, 2017, and washed the resident's hand, and she was crying out in pain so she stopped. physician's orders [REDACTED]. A nursing note for Resident R3, dated June 25, 2017, revealed that at approximately 9:00 p.m. it was noted that the resident had the left finger separator splint in place. The splint was removed and was noted to have a moderate amount of serosanguinous drainage (thin, watery, yellow drainage) on it, and the resident had active bleeding coming from the left hand. Open areas were noted on the bottom side of the left fourth and fifth fingers, the physician was notified, and an order was received to send the resident to the emergency room . Resident R3's Medication Administration Records (MAR's) for June 2017 revealed that staff administered Tylenol to the resident one time, during the month, on June 25, 2017, at 9:31 p.m. for mild pain. There was no documented evidence that an individualized plan was developed to address Resident R3's pain when performing range of motion or applying the finger separator splint. Interviews with the Nursing Home Administrator and the Director of Nursing on July 18, 2017, at 6:00 p.m. confirmed that there was no individualized plan in place to address Resident R3's complaints and signs of pain with range of motion and applying the finger separator splint. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 8/2/16, 1/22/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 11/22/16, 8/2/16, 4/14/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/18/17, 2/9/17, 11/22/16, 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that individualized interventions were developed to protect the residents from further accidents and/or injury for two of 27 residents reviewed (Residents R4, R8), resulting in a fractured arm bone for Resident R4. Findings include: The facility's policy regarding assessing falls and their causes, dated December 29, 2016, indicated that when a resident falls, documentation should include completion of a fall risk assessment and appropriate interventions taken to prevent further falls. The facility's policy regarding fall and fall risk management, dated December 29, 2016, indicated that if a fall occurs despite initial interventions, staff were to implement additional or different interventions, or indicate why the current approach remained relevant. If the underlying cause(s) could not be corrected, staff were to try various interventions until falling was reduced or stopped. A [DIAGNOSES REDACTED]. (a progressive disease of the brain that causes cognitive loss). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated May 25, 2016, indicated that the resident was confused and required assistance with her care. A nursing note for Resident R4, dated June 16, 2016, indicated that the resident was found on the floor at the left side of her bed. She had been incontinent of bowel at that time and she had removed her pants. The resident obtained a wound to her left knee and left elbow. A report provided by the facility, dated June 16, 2016, indicated that the resident had increased confusion and increased incontinent episodes and that she was known to ambulate (walk) without assistance. A nursing note for Resident R4, dated July 15, 2016, indicated that at 2:00 p.m. the resident was found sitting on the floor, next to her bed, with her wheelchair next to her. She was unable to state what happened, had taken her shoes off and stood up in her bare feet, and she was incontinent of urine at that time. Following this fall, there was no documented evidence that any new individualized interventions were initiated in an attempt to prevent further falls and/or injury for the resident. A nursing note for Resident R4, dated July 17, 2016, indicated that at 7:15 p.m. on July 16, 2016, the resident was found lying on the floor, to the left side of her bed. She had no shoes, socks or shirt on. The resident had a 1.0 x 0.5 centimeter (cm) laceration to the posterior (back) right side of her head and she complained of pain to her hip and right hand. Resident R4 was sent to the hospital where an X-ray report, dated July 17, 2016, revealed that she had a fractured radius (a bone in the forearm). A nursing note dated July 17, 2016, indicated that when the resident returned from the hospital, she had two staples in the head laceration and a half cast on her right forearm. A physician's consultation note, dated July 18, 2016, confirmed that the resident had a fractured radius and a cast was applied, which was to be on for approximately six weeks. An interview with the Director of Nursing on February 8, 2017, at 3:20 p.m. confirmed that there were no new interventions put into place after Resident R4's fall on July 15, 2016, and no documented evidence regarding why a new intervention was not attempted. She confirmed that a new intervention to prevent falls and/or injury should have been attempted. A comprehensive admission MDS assessment for Resident R8, dated June 1, 2016, revealed that the resident was confused, required assistance with his care, wandered (aimlessly), used a wheelchair, and had diagnsoses that included Alzheimer's disease. Nursing notes for Resident R8 revealed that on July 28, 2016, the resident received a skin tear to his left elbow; on September 9, 2016, the resident received a skin tear on his left lateral (side) elbow; on September 28, 2016, the resident received a skin tear on his right forearm; on October 8, 2016, the resident received a skin tear to his left forearm; on October 27, 2016, the resident received a skin tear to his right wrist; on October 28, 2016, the resident received a skin tear to his left elbow; on November 17, 2016, the resident received a skin tear on the back of his left hand; on December 15, 2016, the resident received a skin tear on his left elbow; on December 19, 2016, the resident received a skin tear on his right elbow; on December 29, 2016, the resident received a skin tear on his left wrist; and on January 24, 2017, the resident received a skin tear on his left upper arm. There was no documented evidence that any interventions to prevent skin tears were initiated for Resident R8. An interview with the Director of Nursing on February 9, 2017, at 8:38 a.m. confirmed that there were no interventions initiated to prevent skin tears for Resident R8. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 8/2/16, 3/11/16. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/22/16, 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16, 9/29/15, 2/26/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to immediately notify the resident's physician when there was a change in condition for one of five residents reviewed (Resident R1), resulting in harm for the resident. Findings include: An admission assessment for Resident R1, dated October 4, 2016, revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. to be up (off the mattress) when in bed. An orthopedic physician (bone doctor) consultation for Resident R1, dated October 13, 2016, revealed that the resident was seen for a follow-up visit for his hip repair by Physician 2. Physician 2's findings and recommended treatment indicated that there was an approximately five centimeter (cm) pressure sore from skin irritation secondary to the immobilizer rubbing the skin raw on the right posterior lower extremity (the back of the right lower leg). The area was covered with an ABD pad (a cushion-like pad). The orthopedic physician indicated that this was the first time he was finding out about the area and that it was not acceptable patient care. He indicated that all braces should be removed by someone at the facility every day (at least) and the skin inspected for signs of irritation. If the brace was irritating the skin, the brace needed to be readjusted or padded as appropriate, and if a problem occurred, the doctor should be notified so that a small problem did not become a big one. The consultation report indicated that the orthopedic physician would discontinue the immobilizer and try to switch to an abduction pillow (a foam pillow with straps for holding a patient's legs in proper position for optimum healing after hip surgery), that he would ask the wound clinic to evaluate the resident, and to continue post hip precautions and recheck in one month. An addendum to the report indicated that early stages of pressure sores were developing on the sacrum (the area at the base of the spine) as well as the posterior (back side) hips and heels. The skin was only [DIAGNOSES REDACTED]tous (redness of the skin caused by injury, infection or inflammation) and the resident needs aggressive pressure sore [MEDICATION NAME] (prevention). There was no documented evidence that Resident R1's primary care physician was notified about the new pressure sore until October 18, 2016, at 10:55 p.m. when a nursing note indicated that the doctor was notified about the redness around the area where an open area was being treated. An order was given for the resident to receive 500 milligrams (mg) of Keflex (an antibiotic) three times a day, for ten days, for [MEDICAL CONDITION] (a skin infection) of the right posterior lower extremity and foot. There was no documented evidence that the resident's physician was notified about the recommendations for aggressive pressure sore [MEDICATION NAME] made by the orthopedic physician. A weekly wound assessment for Resident R1, dated October 20, 2016, revealed that the right posterior lower extremity pressure sore now measured 10.0 x 6.5 cm with light serous drainage (pale yellow transparent fluid), 60 percent thick adherent black necrotic tissue (dead cells), 20 percent thick adherent devitalized (dead tissue) necrotic tissue, and 20 percent granulation (new) tissue. The wound was now unstageable (a full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or (tan, brown or black) in the wound bed. There was also a right dorsal (the top of) foot Stage II pressure sore (a superficial open sore caused by pressure) measuring 1.2 x 1.0 cm. An order was written to treat both pressure sores with silver [MEDICATION NAME] (a topical antibacterial cream) with a dry protective dressing once daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the right posterior lower leg wound or the new area that was found on the right dorsal foot. A weekly wound assessment for Resident R1, dated October 27, 2016, revealed that the right posterior lower extremity pressure sore now measured 10.5 x 6.5 cm and remained unstageable with thick adherent black necrotic tissue. The right dorsal foot pressure sore measured 1.0 x 1.0 cm that showed deterioration and was now a Stage IV wound (large-scale destruction of tissue, muscle and skin) with black necrotic tissue. An order was written to continue treatment to both pressure sores with silver [MEDICATION NAME] with a dry protective dressing once daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the condition of the right posterior lower leg wound or the right dorsal foot wound. A weekly wound assessment for Resident R1, dated November 3, 2016, revealed that the right posterior lower extremity pressure sore measured 10.5 x 7.0 cm and was a Stage IV with thick adherent black necrotic tissue. The right dorsal foot pressure sore measured 1.2 x 1.0 cm and was a Stage III (full thickness tissue loss where subcutaneous fat and slough may be visible) with thick adherent devitalized necrotic tissue. An order was written to continue with the same dressings but change the frequency to twice daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the condition of the right posterior lower leg wound or the right dorsal foot wound. A wound assessment for Resident R1, dated November 4, 2016, revealed that there was a new Stage I pressure sore on the resident's right heel that measured 1.5 x 1.2 cm. An order was written for the resident to wear heelbows (padded heel sleeves that protect the heels from pressure) on both heels at all times. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the new pressure area. A wound assessment for Resident R1, dated November 5, 2016, revealed that there was a reddened area on the sacrum that measured 5.0 x 7.0 cm. No treatment was ordered, and there was no documented evidence in the clinical record that the resident's primary care physician was notified about the new area. A wound assessment for Resident R1, dated November 9, 2016, revealed that the area on the resident's sacrum was now a Stage I pressure ulcer (intact skin that remains red) that measured 3.5 x 5.0 cm. Orders were written for a bordered foam dressing, side-to-side positioning, and an air mattress. These orders were written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the pressure area. A wound assessment for Resident R1, dated November 10, 2016, revealed that Resident R1's right posterior lower leg pressure sore was a Stage IV that measured 11.2 x 5.5 cm and showed no change. There was thick adherent necrotic tissue. The pressure sore on the resident's right heel was now a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) measuring 3.0 x 3.2 cm, and the right dorsal foot pressure sore was a Stage III that measured 1.1 x 0.9 x 0.1 cm with thick adherent devitalized necrotic tissue and granulation tissue. An order was written to decrease the dressing changes to once daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the status of the resident's right heel wound. An interview with the facility's wound nurse on November 17, 2016, at 12:59 p.m. revealed that the facility had a wound protocol and that she writes orders for treatments based on the appearance and measurements of the wounds. She confirmed that she did not notify Resident R1's primary care physician about the resident's new pressure sores or when there were changes in the condition of the resident's wounds. 42 CFR 483.10(b)(11) Notify of Changes (Injury/Decline/Room, Etc.) Previously cited 8/19/16, 3/11/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16, 9/29/15, 2/26/15.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained and/or followed for pressure relief and for the care and treatment of [REDACTED]. Findings include: The facility's pressure ulcer protocol policy, most recently reviewed on October 19, 2016, revealed that the purpose of the policy was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The policy indicated that treatment orders were written by the registered nurse after an assessment of the wound(s), and if the wound(s) did not improve in two to three weeks, the physician was to be notified, a reevaluation of nutritional support was to be completed, off-loading/redistribution devices and advanced wound product changes were to be made. The facility's policy did not include that the resident's physician would be promptly notified about the development of new pressure ulcers or changes to existing pressure ulcers, or that a physician's order was required for the treatment of [REDACTED]. An admission assessment for Resident R1, dated October 4, 2016, revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Physician's orders, dated October 4, 2016, included orders for the resident to wear an immobilizer boot (a brace used to keep the leg in proper alignment while healing) to his right leg at all times, for the immobilizer to be removed every shift to check the skin integrity of his leg, and for the resident's heels to be up (off the mattress) when in bed. A skin assessment for Resident R1, dated October 4, 2016, revealed that the resident had a surgical incision on the right hip measuring 23.0 x 0.5 centimeters (cm) and a bruise on the right and left forearm, each measuring 1.0 x 1.0 cm. A nursing note for Resident R1, dated October 11, 2016, at 11:56 p.m. revealed that a bruise was found on the back of the resident's right leg and it appeared that the bruise resulted from the brace (immobilizer). The resident was to have an undergarment on the right leg before placing the brace. A wound assessment for Resident R1, dated October 13, 2016, at 11:18 a.m. revealed that his right posterior lower leg (the back of the right lower leg) showed a denuded area that measured 4.7 x 3.0 cm. The area was cleaned and triple antibiotic ointment (helps to prevent infection) and a bordered foam dressing (a soft silicone gel adhesive which minimizes trauma to the wound) was applied. An orthopedic physician (bone doctor) consultation for Resident R1, dated October 13, 2016, revealed that the resident was seen for a follow-up visit for his hip repair by Physician 2. Physician 2's findings and recommended treatment indicated that there was an approximately five centimeter (cm) pressure sore from skin irritation secondary to the immobilizer rubbing the skin raw on the right posterior lower extremity (the back of the right lower leg). The area was covered with an ABD pad (a cushion-like pad). The orthopedic physician indicated that this was the first time he was finding out about the area and that it was not acceptable patient care. He indicated that all braces should be removed by someone at the facility every day (at least) and the skin inspected for signs of irritation. If the brace was irritating the skin, the brace needed to be readjusted or padded as appropriate, and if a problem occurred, the doctor should be notified so that a small problem did not become a big one. The consultation report indicated that the orthopedic physician would discontinue the immobilizer and try to switch to an abduction pillow (a foam pillow with straps for holding a patient's legs in proper position for optimum healing after hip surgery), that he would ask the wound clinic to evaluate the resident, and to continue post hip precautions and recheck in one month. An addendum to the report indicated that early stages of pressure sores were developing on the sacrum (the area at the base of the spine) as well as the posterior (back side) hips and heels. The skin was only [DIAGNOSES REDACTED]tous (redness of the skin caused by injury, infection or inflammation) and the resident needs aggressive pressure sore [MEDICATION NAME] (prevention). There was no documented evidence that Resident R1's primary care physician was notified about the new pressure sore until October 18, 2016, at 10:55 p.m. when a nursing note indicated that the doctor was notified about redness around the area where an open area was being treated. An order was given for the resident to receive 500 milligrams (mg) of Keflex (an antibiotic) three times a day, for ten days, for [MEDICAL CONDITION] (skin infection) of the right posterior lower extremity and foot. There was no documented evidence that the resident's physician was notified about the recommendations for aggressive pressure sore [MEDICATION NAME] made by the orthopedic physician. Nursing notes for Resident R1, dated October 13 through October 18, 2016, revealed that the knee immobilizer continued to be used on his right leg every day in addition to the abduction pillow. Interview with Registered Nurse 1 on November 17, 2016, at 12:19 p.m. confirmed that Physician 2's order to discontinue Resident R1's knee immobilizer on October 13, 2016, was missed, and that the immobilizer continued to be used until October 18, 2016, when she called Physician 2. The nurse asked if the physician would discontinue the brace because it was rubbing the resident's skin and causing pressure sores. Physician 2 informed Registered Nurse 1 that the brace was to have been discontinued on October 13, 2016, due to a pressure sore on his right posterior lower leg that measured five centimeters. The brace was discontinued on October 18, 2016 (five days after the order). A weekly wound assessment for Resident R1, dated October 20, 2016, revealed that the right posterior lower extremity pressure sore now measured 10.0 x 6.5 cm with light serous drainage (pale yellow transparent fluid), 60 percent thick adherent black necrotic tissue (dead cells), 20 percent thick adherent devitalized (dead tissue) necrotic tissue, and 20 percent granulation (new) tissue. The wound was now unstageable (a full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or (tan, brown or black) in the wound bed). There was also a right dorsal (the top of) foot Stage II pressure sore (a superficial open sore caused by pressure) measuring 1.2 x 1.0 cm. An order was written to treat both pressure sores with silver [MEDICATION NAME] (a topical antibacterial cream) with a dry protective dressing once daily. This order was written by the facility's wound care nurse and there was no documented evidence that Resident R1's primary care physician was notified about the change in the right posterior lower leg wound or the new area that was found on the right dorsal foot. A weekly wound assessment for Resident R1, dated October 27, 2016, revealed that the right posterior lower extremity pressure sore now measured 10.5 x 6.5 cm and remained unstageable with thick adherent black necrotic tissue. The right dorsal foot pressure sore measured 1.0 x 1.0 cm that showed deterioration and was now a Stage IV wound (large-scale destruction of tissue, muscle and skin) with black necrotic tissue. An order was written to continue treatment to both pressure sores with silver [MEDICATION NAME] (a topical antibacterial cream) with a dry protective dressing once daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the condition of the right posterior lower leg wound or the right dorsal foot wound. A weekly wound assessment for Resident R1, dated November 3, 2016, revealed that the right posterior lower extremity pressure sore measured 10.5 x 7.0 cm and was a Stage IV with thick adherent black necrotic tissue. The right dorsal foot pressure sore measured 1.2 x 1.0 cm and was a Stage III (full thickness tissue loss where subcutaneous fat and slough may be visible) with thick adherent devitalized necrotic tissue. An order was written to continue with the same dressings but change to twice daily. There was no documented evidence in the clinical record to indicate that R1's primary care physician was notified about the change in condition to the right posterior lower leg wound or the right dorsal foot wound. An order was written to continue treatment to both pressure sores with silver [MEDICATION NAME] (a topical antibacterial cream) with a dry protective dressing twice daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in condition to the right posterior lower leg wound or the right dorsal foot wound. A wound assessment for Resident R1, dated November 4, 2016, revealed that there was a new Stage I pressure sore on the resident's right heel that measured 1.5 x 1.2 cm. An order was written for the resident to wear heelbows (padded heel sleeves that protect the heels from pressure) on both heels at all times. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the new pressure area. A wound assessment for Resident R1, dated November 5, 2016, revealed that there was a reddened area on the sacrum (triangular bone at the base of the spine) that measured 5.0 x 7.0 cm. No treatment was ordered, and there was no documented evidence in the clinical record to indicate that the resident's primary care physician was notified about the new area. A wound assessment for Resident R1, dated November 9, 2016, revealed that the area on the resident's sacrum was now a Stage I pressure ulcer (skin that remains intact but red) that measured 3.5 x 5.0 cm. Orders were written for a bordered foam dressing, side-to-side positioning and an air mattress. These orders were written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the pressure area. A wound assessment for Resident R1, dated November 10, 2016, revealed that Resident R1's right posterior lower leg pressure sore was a Stage IV that measured 11.2 x 5.5 cm and showed no change. There was thick adherent necrotic tissue. The pressure sore the resident's right heel was now a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) measuring 3.0 x 3.2 cm, and the right dorsal foot pressure sore was a Stage III that measured 1.1 x 0.9 x 0.1 cm with thick adherent devitalized necrotic tissue and granulation tissue. An order was written to decrease the dressing changes to once daily. This order was written by the facility's wound care nurse, and there was no documented evidence that Resident R1's primary care physician was notified about the change in the status of the resident's right heel wound. A nursing note for Resident R1, dated November 14, 2016 at 7:02 a.m. revealed that the resident had a follow-up appointment with Physician 2 and would be leaving at 7:15 a.m. A nursing note for Resident R1, dated November 14, 2016 at 1:15 p.m. revealed that the resident was being admitted to the hospital for wound evaluation and wound disorder. An interview with the facility's wound nurse on November 17, 2016, at 12:59 p.m. revealed that the facility had a wound protocol and that she writes orders for treatments based on the appearance and measurements of the wounds. She confirmed that she did not notify Resident R1's primary care physician when new pressure sores were identified or when there were changes in the condition of his wounds. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/19/16, 8/2/16, 4/14/16, 3/11/16, 1/22/16, 9/29/15, 2/26/15.