Every finding on record at Southwestern Manor Nursing and Rehabilitation

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the a medication cart for one of two carts observed (First Floor Short Hall).Findings include: Review of the facility policy Medication - Storage of reviewed 12/5/25, indicated all medications and biologicals are stored in a secure manner that is consistent with Federal and State guidelines and current standards of practice. Medications and biologicals are to be stored in a secure and orderly manner under proper temperatures and are to be accessible only to licensed nursing and pharmacy personnel. During an observation on 7/22/26, at 11:00 a.m. a medication cart was unlocked, unattended, and pushed up against the wall on the first-floor short hall nursing unit. Two residents were noted to be within ten feet of the medication cart talking to each other. During an interview on 7/22/26, at 11:02 a.m. Licensed Practical Nurse Employee E1 confirmed the medication cart should be secured if unattended. During an interview on 7/22/26, at 11:35 a.m. the Director of Nursing confirmed the medication cart should be secured when unattended.28 Pa Code205.28(c)(3)(4)Nurses' Station28 Pa Code 211.9(a)(1)()h)(k)(l)(1)Pharmacy Services28 Pa Code211.12(d)(1)(2)(3)(5)Nursing Services

Based on observations, review of facility policy, clinical record review, and a staff interview, it was determined that the facility failed to assess and conduct ongoing assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with enabler bar usage for three of four residents (Residents R34, R44, and R48).Findings include: Review of facility policy Policy on Bed Enablers/Side Rails dated 12/5/25 with a previous review date of 1/16/25, indicated Therapy will assess and determine if the need for enablers is warranted on an individualized bases. Review of the clinical record indicated Resident R34 was originally admitted to the facility on [DATE]. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), diabetes mellitus (body cannot properly use or make insulin causing high blood sugar), and depression (persistent feeling of sadness, emptiness and loss of interest in life). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R34 on 2/19/26 at approximately 10:00 a.m., Resident R34 had two top enabler bars in use on Resident R34's bed. Review of Resident R34's clinical record on 2/19/26, failed to include an assessment for the resident's enabler bar usage. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R44 on 2/19/26 at approximately 10:00 a.m., Resident R44 had two top enabler bars in use on Resident R44's bed. Review of Resident R44's clinical record on 2/19/26, failed to include an assessment for the resident's enabler bar usage. Review of the clinical record indicated Resident R48 was originally admitted to the facility on [DATE]. Review of Resident R48's MDS dated [DATE], indicated diagnoses of seizure disorder (sudden bursts of abnormal electrical activity in the brain), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R48 on 2/19/26 at approximately 10:00 a.m., Resident R48 had two top enabler bars in use on Resident R48's bed. Review of Resident R48's clinical record on 2/19/26, failed to include a current assessment for the resident's enabler bar usage, last assessment completed on 8/21/24. During an interview on 2/18/26, at 2:18 p.m. the Director of Nursing confirmed that the facility failed to conduct assessments and ongoing assessments to ensure that enabler bars were used to meet residents' needs and the risks associated with enabler bar usage. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record, and staff interviews, it was determined that the facility failed to make certain consistent dialysis communication was maintained for three of four residents (Residents R8, R15 and R29). Findings include: Review of the facility policy Hemodialysis Catheters – Access and Care of dated 12/5/25 with a previous review date of 1/16/25, indicated Agreements between the facility and the contracted ESRD facility to include aspects of how the residents' care will be managed, including the following: How information will be exchanged between the facilities, i.e. dialysis communication forms. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of end stage renal disease (kidneys no longer function normally), diabetes (body cannot properly use or make insulin causing high blood sugar), high blood pressure, dementia (progressive decline in mental ability-specifically memory, thinking, and behavior that can interfere with daily life). Review of Resident R8's dialysis communication forms indicated the following: 1/29/26, dialysis communication forms were not completed by the dialysis unit before the resident returned to the facility and no information was obtained by the facility concerning pre- and post-weight, vital signs pre- and post-procedure or any special instructions if needed. 1/15/26 and 2/5/26 post-dialysis weights were not completed. 1/3/26, 1/8/26, 1/31/26 and 2/3/26 dialysis communications are missing various pre- and post-dialysis vital signs. 1/3/26, 1/15/26, 1/27/26, 1/29/26, 1/31/26, and 2/3/26 dialysis communication forms were not signed off by a registered nurse. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS dated [DATE], indicated diagnoses of end stage renal disease, high blood pressure and cerebral palsy (a group of permanent, non-progressive motor disorders caused by abnormal brain development or damage before, during, or shortly after birth). Review of Resident R15's dialysis communication forms indicated the following: 12/16/25, 12/27/25, 1/31/26, and 2/7/26 dialysis communication forms were not completed by the dialysis unit before the resident returned to the facility and no information was obtained by the facility concerning pre- and post-weight, vital signs pre- and post-procedure or any special instructions if needed. 11/18/25, 11/20/25, 11/22/25, 12/2/25, 12/4/25, 12/11/25, 12/24/25, 12/31/25, 1/3/26, 1/8/26, 1/20/26, 1/27/26, 1/29/26, 2/3/26, 2/14/26 dialysis communication forms are missing pre-, post- or pre- and post-dialysis weights. 11/11/25, 12/4/25, 12/31/25, 1/8/26, 2/3/26, 2/14/26 dialysis communication records are missing various vital signs. 11/18/25, 11/20/25, 12/6/25, 12/27/25, 1/3/26, 1/20/26, 1/22/26, 1/27/26, 1/31/26, 2/3/26, 2/7/26, and 2/12/26 dialysis communication forms were not signed off by a registered nurse Review of the clinical record indicated Resident R29 was originally admitted to the facility on [DATE]. Review of Resident R29's physician orders, indicated dialysis: at [dialysis center], Dialysis days: Tuesday- Thursday- Saturday Pick up Time: 8am pick up for 9am chair time Review of Resident R29's baseline care plan completed on 2/5/26 does not indicate the resident has been care planned for dialysis treatments including pre and post evaluation or dialysis line care (tube in a large vein that allows blood from you to be taken to the dialysis machine cleaned and returned to you). Review of Resident R29's comprehensive care plan initiated on 2/9/26 does not indicate the resident had been care planned for dialysis treatments or dialysis line care. Review of Resident R27's dialysis communication forms indicated the following: 2/7, 2/10, and 2/12 dialysis communication forms were not on the medical record and not available for review. The facility staff searched for the documents that were reportedly found in a drawer in the resident's room. 2/14 dialysis communication form was incomplete, absent of the pre and post dialysis weight, vital signs. Review of Resident R29's Minimum Data Set, dated [DATE], indicated diagnoses of end stage renal disease, respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), and diabetes mellitus. Review of Resident R29's physician orders, indicated dialysis: at [dialysis center], Dialysis days: Tuesday- Thursday- Saturday Pick up Time: 8am pick up for 9am chair time Review of Resident R29's baseline care plan completed on 2/5/26 does not indicate the resident has been care planned for dialysis treatments including pre and post evaluation or dialysis line care (tube in a large vein that allows blood from you to be taken to the dialysis machine cleaned and returned to you). Review of Resident R29's comprehensive care plan initiated on 2/9/26 does not indicate the resident had been care planned for dialysis treatments or dialysis line care. Review of Resident R29's dialysis communication forms indicated the following: 2/7, 2/10, and 2/12 dialysis communication forms were not on the medical record and not available for review. The facility staff searched for the documents that were reportedly found in a drawer in the resident's room. 2/14 dialysis communication form was incomplete, absent of the pre and post dialysis weight, vital signs. During an interview on 2/20/26, at approximately 9:40 a.m. the Director of Nursing confirmed that the facility failed to make certain consistent dialysis communication was maintained. 28 Pa. Code: 211.5(f) Clinical records. 28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for two of six residents (Resident R34, and R44).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that Section O: Special Treatments, Procedures, and Programs, Question O0100 Check all of the following treatments, procedures, and programs that were performed. For Respiratory Treatments section C1 should be marked as X if the resident receives oxygen therapy with sub-sections C2 Continuous, C3 Intermittent, and C4 High concentration, D1 Suctioning sub-sections D2 Scheduled and D3 As needed, E1 Tracheostomy care, F1 Invasive Mechanical Ventilator, G1 Non-invasive Mechanical Ventilator with sub-sections G2 BIPAP and G3 CPAP. Review of the clinical record indicated Resident R34 was originally admitted to the facility on [DATE].Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), diabetes mellitus (body cannot properly use or make insulin causing high blood sugar), and depression (persistent feeling of sadness, emptiness and loss of interest in life).Resident R34 MDS, Review of Section O: Special Treatments, Procedures, and Programs, Question O0100 Section G1 Non-invasive Mechanical Ventilator with sub-sections G2 BIPAP was not marked as receiving any respiratory treatments. Sections Z1 was marked as None of the above (indicating the resident was not receiving any special treatments, procedures, or programs). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R34 on 2/19/26 at approximately 10:00 a.m., Resident R34 had a Bilevel Positive Airway Pressure (BIPAP) device at her bedside it was confirmed that Resident R34 utilized the BIPAP. R34 stated she has used a BIPAP for years at the facility. Review of Resident R34's care plan reveals a BIPAP care plan was initiated on 9/29/22 and continues to be active. Review of Residents R34's physician orders, did not reveal an order for the BIPAP. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar).Resident R44 MDS, Review of Section O: Special Treatments, Procedures, and Programs, Question O0100 Section C1 Oxygen Treatments was not marked as receiving any respiratory treatments. Sections Z1 was marked as None of the above (indicating the resident was not receiving any special treatments, procedures, or programs). During an observation and interview with Employee E2 Nurse Manager and an interview with Resident R44 on 2/19/26 at approximately 10:00 a.m., it was confirmed that Resident R44 had oxygen in use at 4 liters. Review of Residents R44's physician orders revealed an order on 8/27/25 for oxygen at 4 liters to keep Peripheral Oxygen Saturation (SPO2) at greater than 90%. During an interview on 2/20/26, at approximately 8:47 a.m. Employee E1 RNAC confirmed the MDS periodic assessment failed to identify the respiratory treatments required and utilized by Residents R34 and R44. During an interview on 2/20/26, at approximately 9:40 a.m. the Director of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of eight residents reviewed (Residents R8, and R44). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Nursing Care of the Older Adult with Diabetes Mellitus reviewed 1/16/26, indicated diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. For further education and guidelines refer to the provider orders and instructions as well as the American Diabetes Association Standards of Medical Care in Diabetes. For glycemic targets use a glucometer for capillary blood sampling to measure current blood glucose levels. Target range for healthy older adults is considered 90-130 mg/dL (fasting or pre-prandial glucose). Glycemic targets for older adults with chronic illnesses, functional decline, or cognitive impairment may be less stringent. The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. Manage hypoglycemia according to protocols and provider orders. Establish provider notification protocols, follow physician orders for parameters. Review of the clinical record indicated Resident R8 was re-admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of end stage renal disease (kidneys no longer function normally), diabetes (body cannot properly use or make insulin causing high blood sugar), high blood pressure, dementia (progressive decline in mental ability-specifically memory, thinking, and behavior that can interfere with daily life). Review of a physician's order dated 1/20/26, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale, no parameters given as to when to notify MD (doctor). Review of physician's orders dated 12/18/25, indicated to administer glucose oral gel 40% if CBG below 60 and symptomatic or asymptomatic but conscious and able to swallow. Repeat CBG in 10-15 minutes and if CBG still less than 60 to notify MD. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 12/5/25: 67 1/7/26: 57 2/16/26: 69 Review of Resident R8's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), depression (persistent feeling of sadness, emptiness and loss of interest in life), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar). Review of a physician ' s order dated 12/1/25, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours). Review of a physician ' s order dated 12/1/25, indicated to inject Glargine (long-acting insulin that starts to work about 1 to 2 hours after injection and keeps working for up to 22 hours). Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the residents' CBG's were as follows: 2/3/25: 475 2/5/26: 461 Review of Resident R44's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. During an interview on 2/19/26, at approximately 9:00 a.m. Licensed Practical Nurse (LPN) Employee E3 stated if the blood glucose was under 70, they would call the doctor and follow orders. If the blood glucose was greater than 400, they would notify the supervisor and call the doctor. They would document in the MAR and progress notes. During an interview on 2/19/24, at approximately 9:05 a.m. LPN Employee E4 stated if the blood glucose was less than 70, they would give glucose gel, notify the supervisor, recheck blood glucose in 15 minutes, and call the doctor. If blood glucose was over 400, they would administer the ordered insulin and call the doctor. They would document in the progress notes. During an interview on 2/19/24, at approximately 9:10 a.m. Registered Nurse (RN) Employee E5 stated she would follow protocol for glucoses less than 70, notify the MD and recheck the CBG, if greater than 400 would administer medication as ordered, notify MD and Nursing supervisor. They would then document their actions in the progress notes. During an interview on 2/19/24, at 10:10 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R8, and R44. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline or comprehensive care plan that included dialysis care and interventions needed to provide effective and person-centered care for one of three residents (Resident R29).Findings include: The facility policy Care Plans - Baseline dated 12/5/25 with a previous review date of 1/16/25, indicated a baseline care plan includes but is not limited to the following: The stated goals and objectives of the resident.A summary of the residents' medications and dietary instructions.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.Any updated information based on the details of the comprehensive care plan a necessary. The facility policy Care Plans, Comprehensive Person - Centered dated 12/5/25 with a previous review date of 1/16/25, indicated a comprehensive, person - centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well - being, including, Reflects currently recognized standards of practice for problem areas and conditions. Review of the clinical record indicated Resident R29 was originally admitted to the facility on [DATE].Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/26, indicated diagnoses of end stage renal disease (kidneys no longer function normally), respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), and diabetes mellitus (body cannot properly use or make insulin causing high blood sugar).Review of clinical records revealed, Resident R29 was sent to dialysis on 2/7/26, 2/10/26, 2/12/26, 2/14/26 and 2/17/16 R29 receives dialysis, at [Dialysis Center] three times a week. Dialysis days are Tuesday, Thursday and Saturday with a chair time of 9:00 am. Review of Resident R29's baseline care plan completed on 2/5/26 does not indicate the resident has been care planned for dialysis treatments including pre and post evaluation or dialysis line care (tube in a large vein that allows blood from you to be taken to the dialysis machine cleaned and returned to you). Review of Resident R29's comprehensive care plan initiated on 2/9/26 does not indicate the resident had been care planned for dialysis treatments or dialysis line care. During an interview on 2/20/26, at approximately 8:47 a.m. Employee E1 RNAC confirmed the base line or comprehensive care plan failed to identify the dialysis treatments required and utilized by Residents R29. During an interview on 2/20/26, at approximately 9:40 a.m. the Director of Nursing confirmed that the facility failed to make certain the baseline or comprehensive care plan was accurate, addressing any services and treatments received by the resident. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on observations and a staff interview, it was determined the facility failed to post contact information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building on three of three locations where postings are (first floor lobby, second, and third floor nursing units). Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. During an observation completed on 2/18/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency posted or accessible to residents or resident representatives. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations and a staff interview, it was determined the facility failed to ensure the availability of the most recent survey results and any plan of correction were accessible to residents and visitors. Findings Include: The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. During an observation completed on 2/18/26, at approximately 11:30 a.m., the facility binder containing the Department of Health's survey results revealed the binder was last updated on 6/13/24. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the Nursing Home Administrator confirmed the facility failed to make the Department of Health's most recent survey results readily accessible to residents and visitors. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building, on three of three locations where postings are (first floor lobby, second, and third floor nursing units). Findings include: The facility must display in the facility, written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an observation completed on 2/18/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed that facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During an observation and an interview with the Nursing Home Administrator (NHA) on 2/19/26, at 9:00 a.m., the Nursing Home Administrator confirmed the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations and staff interviews it was determined that the facility failed to verify the dish washing temperature and staff education on the use of chemical sanitation to prevent the potential for cross contamination and failed to store food products in a manner to prevent foodborne illness in the main kitchen. Findings include: During an observation on 1/21/25 beginning at approximately 10:15 a. m., of the Main Kitchen the following concerns were identified: The dish machine was identified as high temperature, however, according to Dietary Aide(DA) Employee E3 who was assisting in running the dish machine with DA Employee E4 stated that the dish machine elements were not working and the machine was currently functioning as a low temp with chemicals used for sanitation. During an interview on 1/21/25, at 10:20 a.m., Dietary Aides were asked to run a strip through the machine to show the level of sanitation. Neither employee stated that they were not trained how to run the strips and had not done so prior to using the machine. During an interview on 1/21/25, at 10:45 a.m., District Manager Dietary Employee E5 stated that the dish machine had not been functioning since 1/20/25 evening and that EcoLab (dishmachine vendor) staff had set the machine up for chemical use. The District Manager Employee E5 confirmed that staff had not been trained to perform test strip chemical testing. During an interview on 1/21/25, at 11:00 a.m., the Nursing Home Administrator confirmed that the staff were not trained how to perform necessary tasks to prevent the potential for cross contamination while using the dish machine. During an observation on 1/21/25 at 10:55 a. m., of the refrigerator leading to he deep freezer identified a gray fuzzy substance on the fan blades and cover and on the ceiling with food stored underneath which had the potential for food borne illness. During an interview on 1/21/25, at 11:00 a.m., the District Manager confirmed that the substance in the fans and ceiling had the potential for contamination of food which could cause potential for food borne illness. Pa Code: 211.6(c)(d)(f) Dietary services.

Based on review of staff education records and interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of four nurse aides (Employees E6, E7, E8, and E9). Finding include: Review of education records for Employees E6, E7, E8, and E9 revealed the following: Nurse Aide (NA) Employee E6 had a hire date of 9/16/21, with approximately 10.25 hours of in-service education between 9/16/23, and 9/16/24. NA Employee E7 had a hire date of 10/4/12, with approximately 9.75 hours of in-service education between 10/4/23, and 10/4/24. NA Employee E8 had a hire date of 10/14/13, with approximately 10.00 hours of in-service education between 10/14/23, and 10/14/24. NA Employee E9 had a hire date of 8/15/22, with approximately 6.75 hours of in-service education between 8/15/23, and 8/15/24. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for four of four nurse aides. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.20(c) Staff development.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for seven of eight residents without a BIMS assessment completed (Resident R7, R21, R22, R24, R38, R43, and R60). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing MDS Assessments dated October 2018, and updated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. -Resident R7 had an MDS completed on 12/13/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R7 is sometimes understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R7 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R21 had an MDS completed on 11/14/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R21 is usually understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R21 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R22 had an MDS completed on 1/2/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R22 is understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R22 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R24 had an MDS completed on 1/7/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R24 is sometimes understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R24 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R38 had an MDS completed on 10/16/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R38 is sometimes understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R38 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R43 had an MDS completed on 12/27/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R43 is sometimes understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R43 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. -Resident R60 had an MDS completed on 12/19/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R60 is sometimes understood. Review of Section C: Cognitive Patterns, and Section D: Mood were indicated that Resident R60 is rarely understood, and the BIMS assessment and Resident Mood Interview were not completed. During an interview on 1/24/25, at 11:26 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that the above MDS assessments were not accurate. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate for seven of eight residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on abuse and neglect prevention for three of nine staff members (Employee E9, E13, and E14). Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on abuse and neglect prevention. Nurse Aide (NA) Employee E9 had a hire date of 8/15/22, failed to have abuse and neglect prevention in-service education between 8/15/24, and 8/15/24. Registered Nurse Employee E13 had a hire date of 10/6/22, failed to have abuse and neglect prevention in-service education between 10/6/23, and 10/6/24. Licensed Practical Nurse Employee E14 had a hire date of 9/6/22, failed to have abuse and neglect prevention in-service education between 9/6/23, and 9/6/24. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on abuse and neglect prevention for three of nine staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for three of the eight residents reviewed (Resident R41, R75, and R77). Findings Include: A review of the facility policy Advanced Directives last reviewed 11/5/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R41 was readmitted to the facility on [DATE], with diagnoses that included muscle weakness, high blood pressure, and heart failure (heart cannot pump or fill adequately). A review of the clinical record failed to reveal an advance directive or documentation that Resident R41 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R75 was admitted to the facility on [DATE], with diagnoses that included dyspnea (difficult or labored breathing), muscle weakness, and epilepsy (nerve cells in the brain are disturbed, causing seizures). A review of the clinical record failed to reveal an advance directive or documentation that Resident R75 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R77 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, dysphagia (difficulty swallowing), muscle weakness, and liver transplant status. A review of the clinical record failed to reveal an advance directive or documentation that Resident R77 was given the opportunity to formulate an Advanced Directive. During an interview on 1/24/25, at 9:39 a.m. the Director of Nursing (DON) confirmed that the clinical record did not include documentation that Resident R41, R75, and R77 were not afforded the opportunity to formulate Advance Directives, it was confirmed again with the Admissions Director on 1/24/25 at 10:42 a.m 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R27). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2024, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record indicated that Resident R27 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Wernicke's encephalopathy (a neurological disorder caused by thiamine deficiency, and marked by mental confusion, abnormal eye movements, and unsteady gait) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Section O: Special Treatments, Procedures, and Programs revealed at the time of the MDS, Resident R27 did not receive hospice services. Review of a physician order dated 11/27/24, indicated Resident R27 was admitted to hospice care (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care). Review of Resident R27's MDS assessments revealed a MDS significant change was not completed to include hospice services. During an interview on 1/22/25, at 2:01 p.m. the Director of Nursing confirmed that a Significant Change MDS assessment for Resident R27 was not completed. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to complete a Significant Change Minimum Data Set for one of four residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services after hospitalization for one of three residents (Resident R27). Review of the facility policy, Resident Hydration and Prevention of Dehydration dated 11/5/24, previously dated 11/30/23, indicated the facility will strive to provide adequate hydration and to prevent dehydration. Review of the clinical record indicated that Resident R27 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/14/24, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Wernicke's encephalopathy (a neurological disorder caused by thiamine deficiency, and marked by mental confusion, abnormal eye movements, and unsteady gait) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Resident R27's plan of care for problem/potential problem with nutrition and/or hydration status dated 2/1/22, with a revision on 9/23/24, failed to include interventions related to hydration status. Review of Resident R27's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff, failed to include instructions on hydration status. Review of hospital discharge paperwork dated 6/13/24, indicated Resident R27 had been admitted for acute metabolic encephalopathy (alteration in consciousness caused by a chemical imbalance affecting the brain, often caused by infections or dehydration) and hypernatremia (high sodium levels in the blood, often caused by dehydration), and a urinary tract infection. The paperwork indicated that while in the hospital, Resident R27 was treated with intravenous fluids for dehydration with hypernatremia, and it was noted: Hypernatremia, secondary to dehydration. Overall, she is not eating and drinking adequately which is contributing to dehydration. Upon discharge nursing will be asked to push oral fluids. It is thought she is having poor intake of food, water. Review of Resident R27's progress notes after her hospitalization with treatment for dehydration failed to reveal any notes related to fluid status. Review of Resident R27's physician's orders after hospitalization with treatment for dehydration failed to reveal any orders related to monitoring fluid status. Review of Resident R27's plan of care failed to reveal any interventions after her hospitalization with treatment for dehydration related to monitoring fluid status. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide care and services after hospitalization for one of three residents. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa Code: 211.10(c)(d) Resident rights. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. (Resident R23). Findings include: Review of the facility policy, Medication Use: Psychotropic dated 11/5/24, indicated; Residents will not receive medications that are not clinically indicated to treat a specific condition. Review of Resident R23's admission record indicated she was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R23's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of multiple sclerosis (a disease that affects central nervous system), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) without behaviors, and anxiety. Review of Section N: Medications revealed Resident R23 received antipsychotic medications in the seven days prior to the assessment. Review of a physician order dated 1/16/25, indicated Resident R23 received Seroquel (an anti-psychotic medication) 25 mg twice per day for anxiety. Review of Resident R23's care plan for the use of psychotropic behaviors initiated 8/13/24, indicated Resident R23 received psychotropic medication related to dementia. Review of Resident R23's progress notes from 7/1/24, through 1/24/25, failed to include documentation of unwanted behaviors. Review of behavior monitoring documentation for November 2024, December 2024, and January 2025 (through 1/24/25), failed to reveal any documented behaviors. During an interview 1/24/25, at approximately 1:00 p.m. Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.2(a)(c) Physician services. 28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services. 28 Pa. Code: 211.12(c)(d)(5) Nursing services.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on infection control for one of nine staff members (Employee E13). Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on infection control. Registered Nurse Employee E13 had a hire date of 10/6/22, failed to have infection control in-service education between 10/6/23, and 10/6/24. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on infection control for eight of nine staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of the facility's admission and financial agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. Findings include: Review of facility's Admission Agreement packet, which contained the document Admission and Financial Agreement indicated that the Indemnification statement in the agreement indicated that the facility will not be indemnified or held harmless from injury to or death of any person or other resident, or for any damage to or loss of the property of any person or resident, caused by the acts or omissions of Resident to the fullest extent of the law. The facility's admission and financial agreement failed to identify the indemnification statement as an arbitration agreement and provide for the selection of a neutral arbitrator agreed upon by both parties as one is designated in the facility arbitration agreement, in accordance with S483.70(n)(2)(iii). Regulatory guidance defined a neutral Arbitrator as an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute. To ensure a neutral arbitrator is selected, the facility should avoid even the appearance of bias, partiality, or a conflict of interest, and should promptly disclose to the resident or his or her representative the extent of any relationship which exists with an arbitrator or arbitration services company, including how often the facility has contracted with the arbitrator or arbitration service, and when the arbitrator or arbitration service has ruled for or against the facility. During an interview on 1/22/25, at 3:20 p.m. the Nursing Home Administrator confirmed the language of the admission/ financial agreement may appear to not identify the indemnification statement as arbitration and does not to afford a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a)(j) Resident rights.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on effective communication for eight of nine staff members (Employee E6, E7, E8, E9, E10, E11, E13, and E14). Findings include: Review of facility provided documents and training records revealed the following staff members did not have documented training on effective communication. Nurse Aide (NA) Employee E6 had a hire date of 9/16/21, failed to have effective communication in-service education between 9/16/23, and 9/16/24/24. NA Employee E7 had a hire date of 10/4/12, failed to have effective communication in-service education between 10/4/23, and 10/4/24. NA Employee E8 had a hire date of 10/14/13, failed to have effective communication in-service education between 10/14/23, and 10/14/24/24. NA Employee E9 had a hire date of 8/15/22, failed to have effective communication in-service education between 8/15/24, and 8/15/24. Central Supply Employee E10 had a hire date of 11/3/21, failed to have effective communication in-service education between 11/3/23, and 11/3/24. Activities Assistant Employee E11 had a hire date of 1/12/22, failed to have effective communication in-service education between 1/12/24, and 1/12/25. Registered Nurse Employee E13 had a hire date of 10/6/22, failed to have effective communication in-service education between 10/6/23, and 10/6/24. Licensed Practical Nurse Employee E14 had a hire date of 9/6/22, failed to have effective communication in-service education between 9/6/23, and 9/6/24. During an interview on 1/24/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for eight of nine staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policies clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure that residents received care and treatment by failing to identify signs and symptoms of constipation in one of five residents reviewed (Resident R28), resulting in actual harm by admissions to the hospital and failed to provide prescribed treatment and services related to the care of wounds for four of six residents (Resident R4, R11, R12, and R29). Findings include: Review of the facility policy Bowel Regimen Protocol dated 11/30/23, indicated the following will be instituted for constipation: (1) bowel movements are to be recorded by nursing staff in the electronic health care record. (2) if there is no bowel movements by the completion of the third day: (a) Milk of Magnesia (MOM- laxative) will be administered at bedtime. (b) if there is no bowel movement following administration of MOM, Dulcolax suppository (solid medication that enters the body through the rectum to help produce a bowel movement) will be given as per MD (doctor) order. (c) if there is no bowel movement after administration of Dulcolax suppository, Fleets enema (liquid inserted through the anus into the large intestine to empty contents of the bowel) will be administered as per MD order. (d) MD will be notified if there is no bowel movement after administration of Fleets enema. The Director of Nursing or designee will review the dashboard each morning at the clinical meeting to identify residents who have not had a bowel movement in the last three days. The bowel protocol will begin. Review of the facility Bowel Regimen Protocol dated 11/30/23, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living, including hygiene, mobility, toileting, dining, and communication. Review of the facility policy, Dressings, Dry/Clean dated 11/30/23, indicated staff should review the resident's current orders. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R28 was readmitted to the facility on [DATE], with diagnoses that included obesity, depression, and muscle weakness. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS revealed a BIMS score or 12, indicating moderate impairment. Review of the physician orders dated 4/14/24, and remained active, indicated the following orders: MOM 30 milliliters (ml) every 24 hours as needed for constipation if no bowel movement in 3 days, give at bedtime. Dulcolax suppository 10 mg, insert one suppository rectally every eight hours as needed for constipation, administer if no BM (bowel movement) after MOM was administered. Administer fleets enema if no result from administering Dulcolax suppository (laxative). If no bowel movement post fleets, notify MD. Review of a doctor's note dated 4/17/24, indicated Resident R28 was admitted to the hospital on 4/8/24,for fecal impaction with history of constipation, and we will continue aggressive bowel regimen. Review of the clinical record indicated from 5/1/24 - 5/4/24, Resident R28 went four days without a bowel movement. Review of the eMAR revealed a Dulcolax suppository was administered on 5/3/24, at 9:00 p.m. and was ineffective. MOM and fleets enema was not administered per protocol. Review of a progress note dated 5/4/24, at 5:02 a.m. resident observed with large coffee ground emesis, abdomen extremely distended and firm, resident had large episode of diarrhea. Doctor notified and resident sent to the hospital for evaluation. Review of the care plan most recently updated 5/13/24, failed to reveal interventions for prevention of constipation. Review of a doctor's note dated 5/14/24, indicated Resident R28 was admitted to the hospital from 5/4/24 through 5/10/24, for acute abdominal pain with small bowel obstruction. Review of the eMAR revealed a fleets enema was administered on 5/26/24, at 9:45 a.m. and was effective. Review of the clinical record indicated from 5/28/24, through 6/2/24, Resident R28 went six days without a bowel movement. Resident R28's last documented bowel movement was 5/27/24, at 1:27 a.m. Review of the June eMAR failed to indicate Resident R28 received medication per facility bowel protocol. During an interview on 6/2/24, at 12:05 p.m. Resident R28 stated she did not have a bowel movement in one week. During an interview on 6/2/24, at 3:30 p.m. Licensed Practical Nurse (LPN) Employee E5 stated the facility has a bowel protocol, if residents do not have bowel movement in three days afternoon shift gives MOM. If that's not effective in 24 hours, afternoon shift will give a suppository. If that's not effective in 24 hours, afternoon shift gives an enema. During an interview on 6/2/24, at 3:32 p.m. Nurse Aide (NA) Employee E10 stated if residents don't have a bowel movement in two or three days, they tell the charge nurse. During an interview on 6/2/24, at 3:34 p.m. NA Employee E11 stated if residents don't have bowel movements in three days, they tell the charge nurse. During an interview on 6/2/24, at 3:37 p.m. Registered Nurse (RN) Employee E12 stated residents that did not have a bowel movement is given in shift report so they can be monitored. During an interview on 6/2/24, at 3:42 p.m. LPN Employee E4 stated the facility has a bowel protocol, if residents do not have bowel movement in three days afternoon shift gives MOM. If that's not effective in 24 hours, afternoon shift will give a suppository. If that's not effective in 24 hours, afternoon shift gives an enema. During an interview on 6/2/24, at 3:55 p.m. NA Employee E13 stated if resident does not have a bowel movement in three days, she tells the nurse and monitors the resident. During an interview on 6/2/24, at 4:00 p.m. LPN Employee E14 stated for residents that have not had a bowel movement in three days they are given MOM on day shift, if that wasn't effective then afternoon shift administers a suppository, and if that wasn't effective midnight shift administers an enema. During an interview on 6/2/24, at 4:12 p.m. the Director of Nursing confirmed the facility failed to recognize the signs and symptoms of constipation, failed to implement interventions to prevent constipation, and failed to prevent actual harm by preventing hospital admissions for Resident R28. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/15/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and necrotizing fasciitis (also known as flesh-eating disease, is a bacterial infection that affects the skin and the tissue under it). Review of the physician's orders for the treatment of Resident R14's right lateral calf wound from 4/17/24, through 6/2/24, indicated to Cleanse with wound cleanser. Apply Halobetasol 0.05% cream to base of wound and peri wound. on mon/thurs. Apply collagen matrix to wound bed then Hydrofera blue (antibacterial foam dressing) to wound bed. Cover with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrap with rolled gauze daily and as needed. Review of the physician's orders for the treatment of Resident R14's right lateral foot wound from 5/16/24, through 6/2/24, indicated to Cleanse with Dakins 0.25% solution and pat dry. Apply 40% zinc to periwound then Dakin's moistened gauze to wound bed and cover with abd pad, wrap with rolled gauze 2 times daily and as needed. Review of the Wound Nurse Practitioner's (Wound NP) report dated 4/17/24, indicated that Resident R4's right lateral calf wound treatment should be: 1. Cleanse with 0.25% Dakin's solution (a diluted solution of sodium hypochlorite bleach used to disinfect wounds). 2. apply Hydrofera Blue foam, Collagen, Halobetasol cream MR (steroid cream to treat redness, itching, swelling), Collagen to base of the wound. 3. secure with Super absorbent, ABD (large gauze pad to absorb discharge from heavily draining wounds), Rolled gauze, Ace Wrap. 4. change Daily, and PRN (as needed). During an interview on 5/31/24 at 1:30 p.m., Resident R4 stated that he had not had his dressing changed on 5/30/24. Observation of Resident R4's right lateral calf wound at this time revealed the dressing to be dated 5/29/24, 2200 (10:00 p.m.). The dressing was noted to be saturated with drainage. During an interview on 5/31/24, at 1:31 p.m. RN Employee E1 confirmed that Resident R4's right lateral calf dressing should have been changed on 5/30/24, and right later foot dressing should have been changed twice on 5/30/24. Review of a hospital transfer for dated 6/5/24, indicated that Resident R4 was being transferred to the hospital due to an abnormal white blood count (high). Review of a progress note dated 6/6/24, at 4:52 a.m. indicated that Resident R4 was admitted to the hospital with a diagnosis of a diabetic foot infection. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R11 dated 3/30/24, included diagnoses of hemiplegia (paralysis on one side of the body), Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior), and aftercare following surgery for neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer). Review of a progress note dated 3/28/24, at 7:00 a.m. indicated Resident R11 was transported to the hospital for a scheduled right mastectomy (surgical removal of the breast). Review of a clinical admission assessment dated [DATE], indicated that Resident R24 had a surgical dressing to the right breast. Review of surgical discharge instruction dated 3/27/24, indicated -Use ice for 20 minutes on and off for the next 48 hours. -Do not remove dressing on 3/27/24. -Do not remove dressing until Thursday 3/28. Then, remove top dressing. Allow steri-strips (wound closure strips) to remain and fall off naturally. During an interview with Oncology office nurse on 6/3/24, at 10:44 a.m. she stated that when Resident R11 returned to her post-operative appointment on 4/3/24, her original dressing was still in place. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included the diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and lymphedema (the build-up of fluid in soft body tissues). Review of Resident R12's TAR for May 2024, failed to reveal any wound care documentation for 5/23/24, 5/24/24, and 5/25/24. Review of facility census information indicated Resident R12 was present in the facility. Review of progress notes from 5/23/24, through 5/25/24, failed to reveal a reason for the lack of wound care documentation. Review of a physician's order dated 3/14/24, through 6/2/24, indicated Resident R12's right trochanter wound cleansed with NSS and pat dry. Pack with silver alginate and cover with bordered gauze daily and prn. Review of the Wound Nurse Practitioner's report dated 3/27/24, indicated Resident R4's right trochanter wound order was cleanse with wound cleanser, pack with calcium alginate, cover with bordered gauze, daily and prn. Review of a physician's order dated 6/2/24, revealed the update to the right trochanter wound, changing the packing from silver alginate to calcium alginate. Review of the clinical record revealed Resident R29 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and senile degeneration of the brain. Section O: Special Treatments, Procedures, and Programs revealed Resident R29 received hospice services. Review of a physician's order dated 3/14/24, indicated Resident R29's left lower extremity wound should be cleansed with normal saline, Xeroform gauze, cover with ABD pad. Change daily and PRN. Review of the Wound Nurse Practitioner's report dated 3/14/24, indicated Resident R29's left lower extremity wound should be cleansed with wound cleanser. Review of the Wound Nurse Practitioner's report dated 5/22/24, indicated Resident R29's left lower extremity wound should start being changed every other day, and as needed. Review of Resident R29's TAR (treatment administration record) beginning on 5/22/24, through 6/2/24, revealed that wound care was ordered and provided daily. During an interview on 6/2/24, at approximately 1:00 p.m. the Director of Nursing and the Corporate Nurse stated that orders from hospice providers take precedence over Wound NP and facility physician orders. At this time, the request was made to the facility for confirmation of wound care hospice orders. This information was not provided by the facility by the end of the survey on 6/12/24. Review of a physician's order dated 6/2/24, revealed the update to the left lower extremity wound, changing the frequency to every other day. During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of six residents.

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of seven residents (Resident R1, R12, R13, and R14) and failed to prevent avoidable pressure ulcer development that resulted in the actual harm of a new pressure ulcer for one of seven residents (Resident R1). Findings include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays and increased morbidity and mortality. Three critical components in preventing pressure ulcers were listed: comprehensive skin assessments, standardized pressure ulcer risk assessments, and care planning and implementation to address areas of risk. Review of the National Library of Medicine, The Braden Scale for Predicting Pressure Sore Risk indicated the scale was developed to foster early identification of patients at risk for forming pressure ulcers. The scale consists of six subscales and the total range from 6-23, with the following distributions: -Severe Risk: Less than or equal to 9. -High Risk: 10-12. -Moderate Risk: 13-14. -Mild Risk: 15-18. The facility policy Prevention of Pressure Injuries dated 11/30/23, indicated the facility will use this procedure to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Listed in the Prevention Section was the following: -Mobility/Repositioning: 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3. Teach residents who can change positions independently the importance of reposition. Provide support devices and assistance as needed. Remind and encourage residents to change position. -Device Related Injuries: 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device. 2. Monitor regularly for comfort and signs of pressure-related injury. 3. For prevention measures associated with specific devices, consult current clinical practice guidelines. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/20/24, included diagnoses of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), peripheral vascular disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section M: Skin Conditions, indicated Resident R1 was at risk of pressure ulcer development, and at the time of the assessment had one Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia (collagen-based connective tissue under the skin), muscle, tendon, ligament, cartilage or bone in the ulcer) and two unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue that needs to be removed for wound to heal) or eschar (dry, dark scab or falling away of dead skin)). Review of Resident R1's Braden Scale assessments dated 8/4/23, indicated Resident R1 was at low risk (score of 21) for pressure ulcer development. Assessments completed on 11/15/23, 2/29/24, and 3/5/24, all indicated Resident R1 was at risk (score 15) for pressure ulcer development. Review of a physician order dated 9/12/23, and remained current, indicated for Resident R1 to have a PRAFO (pressure relieving ankle foot orthosis, cushioned bootie worn on the calf, ankle, and foot, used for patients who spend a significant amount of time in bed. Assists in the prevention of pressure ulcers) to the left foot while in bed. No interventions were documented to assess the status of the skin under the PRAFO. Review of a physician order dated 11/15/23, and remained current, indicated for Resident R1 to be assisted to turn and reposition Q2 hour (every two hours), elevate heels with heel elevator boots. Review of a physician order dated 11/21/23, and remained current, indicated that Resident R1 was to receive wound care to his left heel (apply betadine and cover with ABD (large gauze pad to absorb discharge from heavily draining wounds) daily. Review of Resident R1 plan of care for Potential for skin breakdown last updated 2/22/24, included the goals of using the left heel elevator boot (PRAFO) and to turn and reposition every 2-3 hours for comfort. Review of the nurse aide Kardex (paper or electronic document that outlines the patients' activities of daily living - ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) for Resident R1 as of 2/28/24, indicated for staff to Left heel elevator boot (PRAFO) and Right heel elevated on pillow when in bed. Turn and reposition q 2-3 hours for comfort. Review of Resident R1's Wound Nurse Practitioners (Wound NP) report dated 2/28/24, indicated a new wound, left Achilles (area on the back of the ankle, above the heel) pressure ulcer, unstageable, with measurements of 1.2 cm (centimeters) x 1.6 cm x 0.2 cm. The report further stated the new left Achilles wound was likely from the PRAFO boot. Review of the previous four weeks of wound care documentation (2/1/24, through 2/28/24) of the left heel wound already present revealed missing documentation on 2/1/24, 2/2/24, 2/5/24, 2/7/24, 2/12/24, 2/16/24, 2/21/24, 2/22/24, and 2/27/24. Review of physicians' orders from November 2023, through June 2024, failed to reveal an order directing staff to assess the skin under the PRAFO boot. Review of monthly wound measurements and assessments to the left Achilles wound since development were as follows: 2/28/24: 1.2 cm x 1.6 cm x 0.2 cm, classified as unstageable. 3/06/24: 2.0 cm x 1.9 cm x 0.0 cm, classified as unstageable. 3/13/24: 2.0 cm x 1.5 cm x 0.0 cm, classified as unstageable. 3/20/24: 2.0 cm x 1.5 cm x 0.0 cm, classified as unstageable. 3/27/24: 1.5 cm x 3.5 cm x 0.2 cm, classified as unstageable, malodorous. 4/03/24: 2.0 cm x 2.0 cm x 0.2 cm, classified as unstageable, malodorous. 4/10/24: 3.0 cm x 2.0 cm x 0.3 cm, classified as unstageable, malodorous. 4/17/24: 3.0 cm x 2.0 cm x 0.3 cm, classified as unstageable, malodorous, status worsening. 4/24/24: 2.5 cm x 1.8 cm x 0.3 cm, classified as unstageable. 5/01/24: 2.5 cm x 2.0 cm x 0.3 cm, classified as unstageable. 5/08/24: 4.5 cm x 2.5 cm x 0.3 cm, classified as unstageable, malodorous. 5/15/24: 4.0 cm x 2.5 cm x 1.5 cm, classified as unstageable, malodorous, status worsening. 5/22/24: 3.5 cm x 2.5 cm x 1.0 cm, classified as unstageable, malodorous. 5/29/24: 3.5 cm x 2.0 cm x 0.6 cm, classified as unstageable, malodorous. During an interview on 5/31/24 at 1:21 p.m., Resident R1 stated I don't get my protein drink. Unless [RN Employee E1] or [LPN Employee E5] is here, I don't get nothing done, gesturing to his lower legs that had multiple dressings on them. Observation of Resident R1's Left Achilles wound at this time revealed the dressing to be dated 5/29/24, 2200 (10:00 p.m.). Observation of Resident R1's Right heel wound at this time revealed the dressing to be dated 5/29/24. Observation of Resident R1's Left Heel wound at this time revealed the dressing to be dated 5/29/24. During an interview on 5/31/24, at 1:25 p.m. RN Employee E1 confirmed that Resident R1's left Achilles dressing should have been changed on 5/30/24 on both day and evening shift, and that his left and right heel should have been changed on 5/30/24. Review of the of wound care documentation from 5/1/24, through 6/6/24, revealed the following dates without documentation of wound care completed: -Left Achilles: 5/2/24, 5/21/24 (evening), 5/24/24 (day), 5/30/24 (day and evening). -Left heel: 5/24/24, 5/30/24. -Right heel: 5/24/24, 5/30/24. During an interview on 6/2/24, at approximately 1:00 p.m. the Director of Nursing confirmed that for the left heel wound dressing change, the PRAFO boot would have been removed, allowing visualization of left Achilles area. Review of the wound report dated 6/7/24, indicated that the left heel wound, and the left Achilles wound joined together with measurements of 6.0 cm x 2.0 cm x 0.6 cm, classified as unstageable, malodorous, status worsening. Additionally, the wound report dated 6/7/24, revealed the development of a new right Achilles wound, 1.0 cm x 0.8 cm x 0.1 cm, classified as unstageable. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included the diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and lymphedema (the build-up of fluid in soft body tissues). Review of Section M: Skin Conditions, indicated Resident R12 was at risk of pressure ulcer development, and had one Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). Review of Resident R12's Braden Scale assessments dated 1/3/24, and 4/4/24, indicated Resident R12 was at high risk (scores of 11, 12) for pressure ulcer development. Review of Resident R12's plan of care for Wound Management updated on 3/14/24, included the intervention of Provide wound care per treatment order. Review of a physician's orders provided by the facility Medical Director for Resident R12's right buttock wound, revealed the following: -1/25/24: Cleanse with NSS (normal saline solution) and pat dry. Apply collagen and calcium alginate and cover with bordered gauze daily and as needed. -3/20: Cleanse with NSS and pat dry. Apply collagen and cover with bordered gauze daily and as needed. -4/11/24, indicated, Flush with 20cc (cubic centimeters, equivalent to milliliters) NSS and pat dry. Pack with collagen and calcium alginate and cover with bordered gauze daily and as needed. This order was active at the time of the survey. Review of the Wound NP's reports and included orders for Resident R12's right buttock wound, revealed the following: -1/31/24: Cleanse with wound cleanser. Treat with collagen, calcium alginate, apply skin prep to periwound (skin around the outer edges of the wound), cover with bordered gauze. Daily and as needed. -2/21/24: Cleanse with wound cleanser. Treat with calcium alginate, cover with bordered gauze. Daily and as needed. -3/20/24: Cleanse with wound cleanser. Treat with collagen, cover with bordered gauze. Daily and as needed. -3/27/24: Cleanse with wound cleanser. Treat with collagen, cover with bordered gauze. Every other day and as needed. -4/3/24: Cleanse with wound cleanser. Treat with collagen, calcium alginate, cover with bordered gauze. Every other day and as needed. -4/10/24, indicated, Flush with 20cc NSS and pat dry. Pack with collagen and calcium alginate and cover with bordered gauze. Every other day and as needed. This order was active at the time of the survey. 4/17/24: Cleanse with soap and water, pat dry. Treat with collagen, calcium alginate, cover with bordered gauze. Every other day and as needed. Review of Resident R12's TAR (treatment administration record) beginning on 3/27/24, through 6/10/24, revealed that wound care was ordered and provided daily. Wound NP orders indicated wound care to be provided every other day and as needed, beginning 3/27/24. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included the diagnoses of atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls) and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Section M: Skin Conditions, indicated Resident R13 was at risk of pressure ulcer development, and had no unhealed pressure ulcers. Review of Resident R13's Braden Scale assessments dated 3/1/24, 3/21/24, 4/1/24, and 4/23/24, all indicated Resident R13 was at risk (score of 16 for each) for pressure ulcer development. Review of Resident R13's plan of care for Risk for Skin Breakdown initiated on 3/4/24, indicated Resident R13 was at risk for skin breakdown due to incontinence and immobility. Review of a Wound NP's note on 3/8/24, indicated Resident R13 was known to their service from a previous facility, had an unstageable pressure wound to her right heel, and further documented that Resident R13 was receiving hospice care. Treatment orders on this date indicated to cleanse the wound with soap and water, pat dry, apply Betadine to the base of the wound, leave open to air, and change twice daily. Review of a Wound NP's note on 4/3/24, treatment orders on this date indicated to cleanse the wound with normal saline, apply Betadine to the base of the wound, leave open to air, and change twice daily. Review of a Wound NP's note on 5/8/24, treatment orders on this date indicated to cleanse the wound with normal saline, apply Betadine to the base of the wound, leave open to air, and change daily. Review of a physician's order dated 3/8/24, and discontinued on 6/2/24, indicated for Resident R13's right heel wound to apply betadine and leave open to air, every day and evening shift. Review of Resident R13's TAR (treatment administration record) beginning on 5/8/24, through 6/2/24, revealed that wound care was ordered and provided twice daily. Wound NP orders as of 5/8/24 indicated wound care to be provided once daily, beginning on 5/8/24. During an interview on 6/2/24, at approximately 1:00 p.m. the Director of Nursing and the Corporate Nurse stated that orders from hospice providers take precedence over Wound NP and facility physician orders. At this time, the request was made to the facility for confirmation of wound care hospice orders. This information was not provided by the facility by the end of the survey on 6/12/24. Review of a physican's order dated 6/3/24, revealed the update to the right heel wound, changing the frequency to once daily. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included the diagnoses of hemiplegia (paralysis on one side of the body) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section M: Skin Conditions, indicated Resident R14 was at risk of pressure ulcer development, and had four Stage 3 pressure ulcers (full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue. Slough and/or eschar may be visible). Review of Resident R14's Braden Scale assessments dated 10/21/23 (score of 10), 1/30/24 (score of 11), and 5/7/24 (score of 12), all indicated Resident R14 was at high risk for pressure ulcer development. Review of Resident R14's plan of care for Pressure Injuries left foot initiated on 2/9/24, indicated for staff to monitor/document/report as needed any changes in skin status. Review of a Wound NP's note on 5/15/24, indicated Resident R14's left medial foot wound had resolved. Review of a Wound NP's note on 5/29/24, indicated Resident R14's left medial foot wound had reopened. Treatment orders indicated to cleanse with normal saline, apply calcium alginate to base of wound, secure with bordered gauze, and to change daily and as needed. Review of a Resident R14's physician's order on 6/2/24, failed to include treatment orders for Resident R14's left medial foot wound. During an interview on 5/31/24, at approximately 2:00 p.m. the Medical Director confirmed that orders from the Wound NP should take precedence over his orders as it is her area of expertise. During an interview on 6/2/24, at approximately 1:00 p.m. the Director of Nursing and the Corporate Nurse were advised that no treatment orders were in place. Review of Resident R14's physician's orders revealed a new order for Resident R14's left medial foot, dated 6/2/24, at 2:55 p.m. During an interview on 6/14/24, at approximately 11:00 a.m. the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of seven residents and failed to prevent avoidable pressure ulcer development that resulted in the actual harm of a new pressure ulcer for one of seven residents. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and documents, clinical records and documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R2), that resulted in actual harm of a low leg skin tear. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 11/30/23, indicated that residents have the right to be free from abuse and neglect. Review of facility policy Activities of Daily Living (ADL), Supporting dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. Review of the facility provided Certified Nurse Aide (nurse aide) job description indicated that nurse aides would provide daily nursing care and services in accordance with the resident's assesment and care plan. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 3/27/24, included diagnoses of macular degeneration (vision loss in the center of the field of vision) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair) and for Lower body dressing (the ability to dress and undress below the waist, including fasteners) Resident R2 was Dependent on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity). Review of a physician's order dated 10/4/22, and remains current, indicated Transfer status: Transfer assist of 1 with wheeled walker. Assist of 2 with care. Review of Resident R2's plan of care for ADL Self Care Performance Deficit related to Dementia active on 5/28/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. The care plan was not updated to reflect the physician's order for transfer and assistance. Review of Resident R2's plan of care for ADL Self Care Performance Deficit related to dementia updated on 6/2/24, indicated TRANSFER: resident requires total assistance with transfers. Further review of the updated care plan failed to include interventions related to what level of staff assistance Resident R2 required for dressing/undressing. Review of Resident R2's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated as of 5/27/24, indicated ADL - Transferring assist times 1 with wheeled walker; Assist of 2 with care. Review of a progress note written by Registered Nurse (RN) Employee E2 dated 5/28/24, at 10:52 p.m. indicated RN supervisor notified by LPN (licensed practical nurse) that resident sustained a skin tear to left shin during care. Per LPN the CNA (nurse aide) providing care for the resident reported that the resident sustained a skin tear to her left shin, and RN supervisor was contacted. Upon entering the room, the resident was observed lying on her bed turned slightly on her right side. Resident did not appear to be in any distress. Resident alert and disoriented at baseline. Resident assessed and wound care provided. Wound measured 6.5 centimeters (cm) x 5.5 cm x 0.3 cm. Resident tolerated wound care well. RN assessment, skin tear measured, cleansed with wound cleanser, patted dry, wound approximated and steri-strips (wound closure strips) applied, in area wound could not be approximated Xeroform (fine mesh gauze) was applied to the wound bed, wound covered with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrapped with Kerlix (absorbent rolled bandage), secured with tape. Notification made to [medical provider], [hospice provider], and resident's daughter. CNA staff reeducated on ensuring safety of resident, disengaging from resident during period of agitation, allowing for resident to have a cool down period prior to reapproaching or having someone else attempt to approach, and reporting of behaviors to nurse for documentation and appropriate treatment of behaviors. Review of a written statement by Nurse Aide (NA) Employee E2 dated 5/28/24, indicated, I was getting her in bed and she was fighting me. I went to pull her pants down and she was trying to kick at me and in the process, she got a skin tear to her lower left leg. Nurse [LPN Employee E4] aware. During an interview on 6/2/24, at 3:32 p.m. NA Employee E10 stated she reviews the resident Kardex to learn the transfer and care status. During an interview on 6/2/24, at 3:34 p.m. NA Employee E11 stated she reviews the resident chart, point of care documentation system, Kardex, or ask the charge nurse to learn the transfer and care status. During a follow-up interview on 6/4/24, at 7:15 p.m. NA Employee E2 confirmed that she provided care alone to Resident R2. When asked why she provided care alone when Resident R2 is ordered two people for care, NA Employee E2 confirmed she was aware Resident R2 was ordered two person for care, and stated that Resident R2 is usually not combative. During an interview on 6/14/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from neglect for one of four residents, that resulted in actual harm of a low leg skin tear. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents (Resident R2 and R10). Findings include: Review of facility policy Safety and Supervision of Residents date d 11/30/23, indicated that, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of facility policy Activities of Daily Living (ADL), Supporting dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 3/27/24, included diagnoses of macular degeneration (vision loss in the center of the field of vision) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair) and for Lower body dressing (the ability to dress and undress below the waist, including fasteners) Resident R2 was Dependent on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity). Review of a physician's order dated 10/4/22, indicated Transfer status: Transfer assist of 1 with wheeled walker. Assist of 2 with care. Review of Resident R2's plan of care for ADL Self Care Performance Deficit related to dementia active on 5/28/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. Review of Resident R2's plan of care for ADL Self Care Performance Deficit related to dementia updated on 6/2/24, indicated TRANSFER: resident requires total assistance with transfers. Further review of the updated care plan failed to include interventions related to what level of staff assistance Resident R2 required for dressing/undressing. Review of Resident R2's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated as of 5/27/24, indicated ADL - Transferring assist times 1 with wheeled walker; Assist of 2 with care. Review of a progress note written by Registered Nurse (RN) Employee E2 dated 5/28/24, at 10:52 p.m. indicated RN supervisor notified by LPN (licensed practical nurse) that resident sustained a skin tear to left shin during care. Per LPN the CNA (nurse aide) providing care for the resident reported that the resident sustained a skin tear to her left shin, and RN supervisor was contacted. Upon entering the room, the resident was observed lying on her bed turned slightly on her right side. Resident did not appear to be in any distress. Resident alert and disoriented at baseline. Resident assessed and wound care provided. Wound measured 6.5cm x 5.5cm x 0.3cm. Resident tolerated wound care well. RN assessment, skin tear measured, cleansed with wound cleanser, patted dry, wound approximated and steri-strips (wound closure strips) applied, in area wound could not be approximated Xeroform (fine mesh gauze) was applied to the wound bed, wound covered with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and wrapped with Kerlix (absorbent rolled bandage), secured with tape. Notification made to [medical provider], [hospice provider], and resident's daughter. CNA staff reeducated on ensuring safety of resident, disengaging from resident during period of agitation, allowing for resident to have a cool down period prior to reapproaching or having someone else attempt to approach, and reporting of behaviors to nurse for documentation and appropriate treatment of behaviors. Review of a written statement by Nurse Aide (NA) Employee E2 dated 5/28/24, indicated, I was getting her in bed and she was fighting me. I went to pull her pants down and she was trying to kick at me and in the process, she got a skin tear to her lower left leg. Nurse [LPN Employee E4] aware. During a follow-up interview on 6/4/24, at 7:15 p.m. NA Employee E2 confirmed that she provided care alone to Resident R2. When asked why she provided care alone when Resident R2 is ordered two people for care, NA Employee E2 stated that Resident R2 is usually not combative. Review of Resident R10's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R10's MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section G: Functional Abilities and Goals revealed that for Chair/bed-to-chair transfer Resident R10 required Substantial/maximal assistance meaning that the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of a progress note dated 5/15/24, at 10:56 a.m. indicated, CNA alerted this nurse that resident obtained a skin tear to her left shin while transferring resident OOB (out of bed) into w/c (wheelchair). It was reported that resident was resistant during transfer and was not following simple commands. Resident remains in stable condition and VS WNL (vital signs within normal limits). Review of a facility provided incident report dated 5/15/24, indicated CNA (nurse aide) alerted nurse that resident obtained a skin tear to left shin while transferring OOB into w/c. The Resident Description section indcated, Unable to give accurate accout, resident is a poor historian. During a follow-up interview on 6/14/24, at 10:48 a.m. NA Employee E17 stated that Resident R10 is confused, and was initially holding onto the wheelchair tightly. Confirmed that she was nervous, but eventually did comply with requests to let go of the wheelchair. During an interview on 6/14/24, at approximately 11:30 a.m., the Nursing Home Administrator confirmed that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 93 residents (Resident R1). Findings include: A review of the State Operations Manual (SOM) defines elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge. A review of the facility policy Elopement/ Missing Resident reviewed 10/31/22, states that the facility will provide a safe environment for all residents regardless of orientation status and to supervise those residents at risk for elopement based on the comprehensive assessment and specific care plan for each resident. Policy also states the person identifying that a resident is missing or unaccounted for immediately notifies the charge nurse or the RN supervisor. A review of the Resident Assessment Instrument 3.0 User's Manual (tool used for the completing the Minimum Data Set (MDS- periodic assessment of care needs) effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment A review of the MDS dated [DATE], indicated that the diagnoses remained current and that Resident R1 had a BIMS score of 6, which indicated severe impairment. Section GG of this MDS, which defines functional abilities, indicated resident was able to utilize a walker with assistance. Resident is mobile in a wheelchair. A review of the Admission Record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral atherosclerosis ( a condition of the arteries in the brain becoming hard, thick, and narrow decreasing the blood flow to the brain) and Vascular Dementia (brain damage caused by multiple strokes). Resident admission was scheduled as a hospice respite stay due to increased behaviors, wandering at home, and Resident R1's family having difficulty taking care of Resident R1. Resident R1 then was admitted to long term care on 3/7/23. A review of the Elopement Assessment Form dated 2/23/23, indicated that Resident R1 had zero of nine total factors/contributors indicating elopement risk. Elopement form instructions indicated that just one factor identified the resident at risk for elopement. Factors that are reviewed are: 1. Does the resident have a history of or an attemped elopement while at home? 2. Does the resident have a history of or attempted leaving the facility without informing staff? 3. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit or door? 4. Does the resident wander? 5. Is the wandering behavior a pattern, goal directed (i.e. specific destination mind, going home ect)? 6. Does the resident wander aimlessly or non-goal directed (i.e. confused, moves without purpose, may enter others' rooms and explore others' belongings)? 7. Is the residents wandering behavior likely to affect the safety or well being of self/others? 8. Is the residents wandering behavior likely to affect the privacy of others? 9. Has the resident been recently admitted or readmitted (within the past 30 days) and is not accepting the situation? A review of the resident admission documents and history indicated that the resident did have at least one factor that triggered the resident as an elopement risk, despite the facility indicating there were 0. This was indicated upon admission for the initial stay for respite care prior to the decision to stay long term. A Nurse Practitioner note dated 3/4/23, indicated Resident R1 was very confused at baseline. A review of the clinical record on 4/19/23 at 10:00 a.m. indicated that the nurse practitioner saw Resident R1 on a monthly review dated 3/24/23 and revealed Resident R1's status as very confused at his baseline. A review of Resident R1's care plan dated 2/28/23, failed to show documented risks, goals or interventions related to elopement or wandering. A review of Resident R1's physician order dated 2/23/23 through the elopement date of 4/3/23, failed to show any documented orders or protocols to follow for Resident R1 in case of elopement or wandering behaviors. A review of Resident R1's progress notes dated 4/1/23 indicated: Resident does not follow commands. A review of facility provided documents, dated 4/3/23, indicated that on 4/3/23, at 10:07 a.m. the facility had a resident elopement. A review of a statement from Registered Nurse Employee E2 dated 4/3/23, indicated that Therapy Employee E1 was looking for Resident R1 for therapy. RN Employee E2 looked around the second floor nursing station then down the halls and then into the second floor rooms. Resident R1 was not able to be located. Then Registered Nurse Employee E2 went to the third floor to see if the Resident R1 was at activities. Once Resident R1 was not able to be located, RN Employee E2 notified the Assistant Director of Nursing (ADON) as directed in the policy. A review of the facility Elopement Sheet documentation dated 4/3/23, indicated that the elopement code was called at 10:07 a.m. This documentation also indicated that the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified at 10:15 a.m. A call was placed to 911 at 10:32 a.m. when Resident R1 was still unable to be located. Documentation stated that Resident R1 was found at 10:42 a.m. in the hallway between the locked second floor doors and the kitchen. Directly outside these coded doors is a long hallway that is not part of the physical layout of the nursing home. A left out of these doors would lead to a set of double doors that would exit to a back parking lot; a right would lead down a long hallway, past a set of staff lockers, an exit to an enclosed courtyard that is staff access only, and then the kitchen. A person in this area may not come into contact with any staff until the next meal or if the nursing center would call the kitchen for a food request. During an interview on 4/19/23, at 2:00 p.m. RN Employee E2 indicated on 4/3/23, Resident R1was last seen at the end of the short hall and was brought back to the second floor nursing station and on 4/3/23, RN Employee E2 also indicated that it was witnessed that NA Employee E3 was talking with Resident R1 at 9:40 a.m. by the nurses station. During an interview on 4/19/23, at 2:45 p.m., the NHA indicated the facility does not have a wander guard system in place just locking doors that are coded and the doors do not have alarms. During an interview on 4/19/23, at 3:50 p.m., the Maintenance Director Employee E4 stated that the second floor doors that lead to the hallway that Resident R1 exited was slow closing. Maintenance Director Employee E4 also stated that after the elopement the doors were adjusted to close faster. A review of the maintenance log from 4/1/23 through 4/3/23 shows the facility did daily checks and indicated the maintenance department just checks that the doors lock; not how long the doors take to close. A review of a written statement from Nurse Aide (NA) Employee E5 dated 4/3/23, indicated they did not see Resident R1. A review of a written statement from Nurse Aide (NA) Employee E6 dated 4/3/23, indicated they did see Resident R1 by the nurses station at 8:30 a.m. A review of a written statement from Nurse Aide (NA) Employee E7 dated 4/3/23, indicated they did not see Resident R1 at all. A review of a written statement from NA Employee E8 dated 4/3/23, indicated they observed Resident R1 at 7:30 a.m., before starting to give care in a different room. During an interview on 4/20/23, at 12:00 p.m. with Resident Family RF1 indicated that she was notified on 4/3/23, by phone stating Resident R1 was missing; Resident Family RF1 was worried about Resident R1 getting into a stairwell. Resident Family RF1 also stated that this was one of the reasons why the hospice respite stay was given, due to the increased confusion. During an interview on 4/20/23, at 1:20 p.m., the NHA stated the facility did an investigation into the elopement and found the incident happened due to one of the kitchen/dietary staff going through the door and not making sure the door closed and the door not closing fast enough to limit the risk of residents eloping out of the doors. During an interview on 4/19/23, at 11:20 a.m. the NHA confirmed the facility failed to provide adequate supervision for Resident R1 resulting in elopement. This failure created an immediate jeopardy situation. During an interview on 4/19/23, at 4:18 p.m. the NHA and the DON were made aware that Immediate Jeopardy (IJ) existed for one of six residents (Resident R1) residing in the facility. The IJ template was provided to facility administration at that time and a corrective action plan was requested. Notification on 4/19/23, at 7:52 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R1 was assessed after the elopment to determine any injury, none at that time. Resident R1 elopement assessment was updated and care plan was updated accordingly. Resident Family RF1 was offered alternate placement but refused for Resident R1. Residents: Facility will re evaluate all residents to ensure elopement behaviors are identified; update the care plan as needed. Audit will be completed by 4/19/23. Facility will ensure adequate supervision/monitoring of residents identified at risk for elopement by educating staff on potential risk factors and implementing interventions per residents care plan. Education will be completed with all in house staff by 4/20/23, and all new hires and contracted staff prior working their next shift. Facility will review and/or revise elopement policy with all staff. Whole house audit was conducted by the NHA and DON on elopement risk with updated assessments done on every resident. No further residents identified to be at risk. System correction: Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, social services, and activities, also to include agency and hospice staff was conducted and completed regarding elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. The maintenance department updated daily work sheet on door functioning. Education was conducted by DON or designee via telephone or in person meetings. In person education was completed on 4/19/23 through 4/20/23, with any remaining staff getting a voice message to see the DON or designee before starting shift. Elopement policy and elopement binder was updated on 4/19/23. Monitoring: Audits and timed closing of the doors were initiated by Maintenance staff and documented daily. Audits and monitoring, supervision, and interventions will be completed daily for five days, weekly for three weeks, and monthly for two months. Results and audits will be presented at the Quality Assurance Improvement Committee meeting for review and recommendations. A review of Resident R1's care plan on 4/20/23, indicated the plan of care was updated on 4/3/23, after the incident. Continued review of ten sampled charts verified the part of the plan that residents were re-evaluated for identifying elopement behaviors. During an interview with RN Employee E2 on 4/20/23 at 10:00 a.m. it was confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview with RN Employee E4 on 4/20/23 at 10:05 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview with RN Employee E5 on 4/20/23 at 10:10 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview with RN Employee E6 on 4/20/23 at 10:15 a.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During a phone interview with License Practical Nurse (LPN) Employee E7, that works overnight 7:00 p.m. to 7:00 a.m. shift, on 4/20/23 at 1:00 p.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During a phone interview with NA Employee E8, that works on the 3:00 p.m. to 11:00 p.m. shift, on 4/20/23 at 1:10 p.m. confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During interviews on 4/20/23, from 9:00 a.m. through 2:00 p.m. 42 total staff employees confirmed they had received education on elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. Total of nine staff members was called for phone interviews and all staff interviewed by phone confirmed they had received the education via phone call. Facility provided documentation and sign in sheets verifying 80 staff members have received the education in person and 41 staff members received a phone call about the education . The IJ was lifted on 4/20/23, at 2:38 p.m. when the action plan implementation was verified. During an interview on 4/20/23, at 3:00 p.m. the NHA confirmed the facility failed to provide adequate supervision for one resident resulting in elopement. This failure created an immediate jeopardy situation for one of 93 residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation, review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to accurately assess, monitor, and provide timely interventions for treatment of [REDACTED]. Findings include: The facility policy titled, "Wound Care Protocol" dated 1/28/13, indicated the risk for skin breakdown is assessed on admission and weekly, for four weeks, using the Braden Scale (an analysis of risk of development of a pressure ulcer). The facility policy titled, "Weekly Skin Assessment" dated 1/28/13, indicated the resident will be assessed by the unit charge nurse on shower/bath days, treatment orders will be obtained for areas of impairment, a Weekly Wound Care Progress Note will be initiated, and the Wound Care Nurse will be informed. Licensed nurses will monitor the wounds and document any change each shift. Review of the clinical face sheet indicated Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 6/12/13, indicated Resident R1 had no cognitive impairment, required two persons for bed mobility assistance, was frequently incontinent of urine, and was at risk for development of pressure ulcers. Review of the Nursing Admission Evaluation dated 6/05/13, indicated that Resident R1 was assessed to be at moderate risk level on the Braden Scale, was incontinent of urine, and had a reddened intact area of the sacral/coccyx area (lower back/tailbone). Review of the nursing assistant "Shower Sheets" dated 6/21/13, indicated an area of soft eschar (brown/black dead tissue) measuring 2.5 centimeters (cm) by 2.6 cm. by undetermined depth, was initially discovered on Resident R1's sacral/coccyx area. This assessment was reviewed and signed by a licensed nurse. Review of the Interdisciplinary Progress Notes dated 6/21/13 through 6/24/13, did not include documentation for the new sacral/coccyx wound and/or a Braden Scale reassessment for Resident R1. Review of the Interdisciplinary Progress Notes dated 6/24/13, indicated the Wound Care Registered Nurse (RN), Employee E1, documented on the open area, as Unstageable (slough and/or eschar (dead tissue) covering the wound base) on Resident R1's coccyx and indicated that she notified the family and the physician and stated, "will monitor weekly." Review of the physician orders, indicated the initial orders for the sacral wound treatments were implemented on 6/24/13, three days after the initial observation of the wound and an order for [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the physician orders, indicated that Resident R1 was ordered to be turned and repositioned every two hours on 6/28/13, seven days after the initial observation of the coccyx wound. Review of the physician progress notes [REDACTED]." Review of the physician orders [REDACTED]. Review of the hospital physician notes indicated that Resident R1 was admitted on [DATE], with three wounds, including a deep infected sacral pressure ulcer and underwent surgery on 7/09/13, for debridement (removal of dead/infected tissue) and a diverting [MEDICAL CONDITION] (surgical diversion of the intestine to an artificial opening in the abdomen). During an interview on 7/23/13, at 1:20 p.m., Employee E1 confirmed that Resident R1's wound was discovered on 6/21/13, but no interventions were instituted and/or notification of the family and physician was done until 6/24/13. Employee E1 also confirmed that the Braden Scale for risk assessment was not completed after 6/05/13, and no further documentation of the wound was completed in the Interdisciplinary Notes for the period from 6/25/13 through 7/08/13. During an interview on 7/25/13 at 2:15 p.m., the Director of Nursing confirmed that Resident R1 was not accurately assessed for risk, the wounds were not adequately monitored, and treatment and interventions were not provided in a timely manner. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 4/19/13, 3/6/13, 5/31/12, 5/11/12. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 4/19/13, 5/31/12, 5/11/12. 28 Pa. Code: 201.18(e)(1) Management. Previously cited 4/19/13, 5/31/12. 28 Pa. Code: 211.5(f) Clinical records. Previously cited 4/19/13, 5/11/12. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 4/19/13. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/19/13, 1/31/13, 5/11/12.