Every finding on record at Squirrel Hill Wellness and Rehabilitation Center

Based on the review of facility policy, clinical records, observations, and resident and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers (PU/PI - injuries to the skin and underlying tissues resulting from prolonged pressure on the skin) for four of seven residents (Resident R1, R2, R3, and R4).Findings include: Review of the facility policy, Prevention of Pressure Ulcers/Injuries date ad 7/13/26, previously dated 2/14/25, indicated the Facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. 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 care needs) dated 6/25/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section M: Skin Conditions indicated Resident R1 did not have a pressure ulcer at the time of the assessment. Review of a Predicting Pressure Ulcer Risk Evaluation dated 6/25/26, indicated Resident R1 was at very high risk for the development of pressure ulcers. Review of the plan of care for Potential or actual skin impairment revised on 4/2/26, indicated for staff to administer treatments as ordered and monitor for effectiveness and to follow facility policies/protocols for the prevention/treatment of skin breakdown. Further review of the care plan failed to reveal information on the use of bunny boots. Review of a physician's order dated 7/23/26, indicated Offloading boots to bilateral foot/heels while in bed. every shift for skin integrity. Review of the Treatment Administration Record (TAR) indicated that this was in informational order for licensed nurses. Review of Resident R1'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 indicated instruction to assist Resident R1 with her bunny boots was not included until 7/30/26. Review of a practitioner progress note dated 7/22/26, at 8:14 p.m. indicated Resident R1 was seen per facility request to evaluation Resident R1's heels. Staff report that patient has been complaining of pain of her heels. The note indicated, the skin has identifiable open wound/breakdown; blanching discoloration. The note recommendations included side to side offloading while in bed and to Offload heels per facility protocol. Review of a progress note dated 7/30/26, at 12:31 p.m. indicated, Facility wound nurse conducted a skin check on resident. Resident had been c/o (complaining of) heel discomfort. Bilateral bunny boots (cushioned foot and heel protectors to prevent and treat pressure ulcers) order was already in place due to boggy heels (an early sign of a pressure injury where the skin feels soft, mushy, or spongy instead of firm). Resident was not wearing bunny boots. Heels checked. Resident right heel still boggy. Resident left heel DTI's (deep tissue injury: persistent non-blanchable deep red, maroon or purple discoloration) measuring 1.3x1.3x0 (centimeters). Order for skin prep placed. Care provided. Bunny boots placed. No other wounds or skin issues present. During an interview on 7/31/26, at 10:10 a.m. Wound Care Nurse Employee E1 confirmed that Resident R1 began complaining of heel pain a couple weeks ago. During wound rounds with the wound practitioner and herself, Resident R1's heels were found to be soft, and an order was placed for Resident R1 to wear bunny boots while in bed. Wound Care Nurse Employee E1 stated during wound rounds on 7/30/26, Resident R1 was found to have a DTI. Wound Care Nurse Employee E1 stated that on 7/30/26, she added a viewable task for the nurse aides to inform them of the need for Resident R1 to have bunny boots on while in bed. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease (gradual loss of kidney function). Review of Section M: Skin Conditions indicated Resident R2 had an unstageable pressure ulcer at the time of the assessment. Review of a Predicting Pressure Ulcer Risk Evaluation dated 5/22/26, indicated Resident R2 was at moderate risk for the development of pressure ulcers. Review of the plan of care for Potential for or has impaired skin integrity revised on 7/21/26, indicated, The resident needs assistance to turn/reposition at least every 2 hours, more oftenas needed or requested. Review of physician's order dated 7/14/26, indicated Resident R2 is to wear bunny boots to bilateral heels at all times while in bed and to turn and reposition every two hours. Review of Resident R2's Kardex, as of 7/30/26, failed to include instruction for staff to assist Resident R2 with his bunny boots. During an interview and observation on 7/31/26, at approximately 11:20 a.m. Resident R2 was observed laying in bed on his back. Resident R2 had slid so low in the bed that Resident R2's heels were directly atop the wooden footboard that had a width of approximately one inch. At this time, Resident R2 said his heels hurt like hell. The surveyor requested staffs to assist Resident R2 to be pulled up in bed. Resident R2 stated to the surveyor, Thanks. I've been asking since 9:30. During a second observation on 7/31/26, at approximately 1:30 p.m., Resident R2 was observed to still be positioned on his back. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and hemiplegia (paralysis on one side of the body) following a stroke. Review of Section G: Functional Abilities indicated Resident R3 is totally dependent on staff to assist him to roll left and right in bed. Review of Section M: Skin Conditions indicated Resident R3 had one Stage 3 pressure injury (full-thickness skin loss), one Stage 4 pressure injury (full-thickness skin and tissue loss) and three deep tissue pressure injuries (persistent non-blanchable deep red, maroon or purple discolorations) at the time of the assessment. Review of a Predicting Pressure Ulcer Risk Evaluation dated 6/18/26, indicated Resident R3 was at high risk for the development of pressure ulcers. Review of the plan of care for Resident has impaired skin integrity revised on 6/29/26, indicated, encourage/assist as needed to elevate heels off the mattress as tolerated and Assist resident with turning and repositioning as needed. Review of physician's order dated 6/18/26, indicated Resident R3 is to Float heels while in bed; bunny boots on at all times. Review of Resident R3's Kardex, as of 7/30/26, indicated for staff to assist Resident R3 to elevate his heels off the mattress as tolerated. Further review failed to include instruction for staff to assist Resident R3 with his bunny boots. Review of a progress note dated 7/27/26, at 2:50 p.m. indicated Resident R3 had a Stage 3 pressure injury to his left great toe and a Stage 4 pressure injury on his sacrum (lower back, below the waistline). During an observation on 7/31/26, at approximately 11:20 a.m. Resident R3 was observed laying in bed on his back. Resident R3 had slid so low in the bed that Resident R3's left foot (with a bandage on the left great toe) pressed directly against the footboard. A bunny boot was present only on Resident R3's right foot. When during the above request for staff to reposition Resident R2, after doing so, the staff walked past the bed of Resident R3 and did not assist him to relieve pressure on his foot. During a second observation on 7/31/26, at approximately 1:30 p.m., Resident R3 was observed to still be positioned on his back. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the facility diagnosis list included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), muscle wasting, and a leg fracture. Review of a progress note dated 7/24/26, at 7:40 a.m. indicated, Bilateral heels appear to have DTIs (deep tissue injuries). Review of a progress note dated 7/27/26, at 7:49 a.m. indicated Resident R4 had a Stage 2 pressure injury on his left heel and a DTI on his right heel. Review of physician's order dated 7/28/26, indicated Resident R4 is to Offload b/l (bilateral) heels on heels up ( Heelz Up device, a specialized cushion placed under the lower legs which allows the heels to be elevated off the bed to prevent pressure injury development) pillow while in bed. Review of Resident R4's Kardex, as of 7/30/26, failed to include instruction for staff to assist Resident R4 with the use of a Heelz Up pillow or regular pillow. During an observation on 7/31/26, at 11:58 a.m. Resident R4 was observed to have his left heel wound open to air with no sock on, and his right foot to have a sock on. Resident R4's heels were directly on the mattress without a Heelz Up pillow or other pillow in use. No additional pillow was observed in the room for use to elevate Resident R4's heels. When during the above request for staff to reposition Resident R2, after doing so, the staff walked past the bed of Resident R4 and did not assist him to relieve pressure on his foot. During a second observation on 7/31/26, at approximately 1:40 p.m., Resident R4 was observed to not have his heels elevated. During staff interviews completed on 7/31/26, nurse aides (NAs) confirmed that information related to elevating a resident's heels or the use of bunny boots is not viewable on their point of care system.NA Employee E2: If I see them in their room, I make sure I put them on them.NA Employee E3: Nurses are supposed to relay the message.NA Employee E4: We tell the agency aides if we know the resident needs them.NA Employee E5: We don't have any way of knowing unless the resident tells us. During an interview on 7/31/26, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers for four of seven residents. 28 Pa. Code: 211.10(d) Resident Care Policies28 Pa. Code: 211.12(d)(5) Nursing Services.

Based on review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for food borne illness.Findings include:Review of the facility policy Sanitation Inspection dated 6/9/26, previously reviewed 2/14/25, indicated, All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents.During an observation of the Main Kitchen tour on 6/6/26, at approximately 12:00 p.m., the following was identified:Fruit flies present above the food preparation areas.Storage shelves under food preparation counters had spilled food residue, boxes of dry goods on their sides with contents spilling out, disposable food service items not in wrappings.Food preparation counters had items placed haphazardly, cup lids, sweetener packets, coffee grounds spilled, open containers of beverages, wet boxes of gloves with loose gloves, trays of bowls, and other serving items.Observation of a plastic tray holding clean food service utensils at the tray line revealed collected water in the bottom of the container, visibly soiled with food waste.Main Kitchen floors were soiled with debris underneath the food preparation counters. Observation of the room corners revealed mouse droppings to be present. Multiple adhesive mouse traps were present in the Main Kitchen.The walls of the Main Kitchen were noted to have food waste adhered to them, particularly close to the floor.Observation of the ice machine drain revealed it to be extremely soiled with cup lids and other refuse around it and the floor very soiled. Observation of the coffee machine revealed ripped paper and multiple spills of liquid dried to the counter surface.Review of the storage shelves revealed large bowls and pans not inverted allowing the collection of water and debris.Observation of a clear plastic container labeled flour revealed dates of 6/20/25, and 9/20/25, to be written on pieces of tape affixed to the container. The container was loosely cover with clear plastic wrap. Visible areas of dried liquid were present on the plastic wrap.Observation the walk-in freezer revealed packages of food to be spilled on the floor and the floor soiled with food residue.Observation of the dishroom revealed food waste, disposable food items, and other debris on the floor, with no delineation from the soiled side to the clean side.Observation of the racks for clean utensil and dish storage revealed refuse under the racks.Observation of the food service workers revealed three of the four employees present during the Main Kitchen observation to have no hair coverings on.During an interview on 6/9/26, at approximately 3:45 p.m. the Nursing Home Administrator the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for food borne illness.28 Pa Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were documented accurately for four of six residents (Resident R1, R2, R3, and R4).Findings include: The facility policy Medication Administration dated 6/9/26, previously reviewed 2/14/25, indicated Sign MAR (medication administration record) after administered. If medication is a controlled substance, sign narcotic book. Review of Resident R1's MAR (medication administration record) for May and June 2026, revealed an order for oxycodone 10mg (a narcotic pain medication used to treat moderate to severe pain) to be given every four hours as needed for severe pain. Twenty-six administrations were documented on the MAR from 5/31/26, through 6/5/26. Review of Resident R1's Controlled Drug Record indicated that eleven additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 6/1/26, 6/2/26 x two doses, 6/3/26 x two doses, 6/4/26 x two doses, 6/5/26 x three doses, and 6/6/26. Review of Resident R2's MAR for May and June 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for pain. Fourteen administrations were documented from 5/25/26, through 6/5/26. Review of Resident R2's Controlled Drug Record indicated that eight additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 5/26/26, 5/28/26, 5/29/26 x three doses, 6/1/26, 6/3/26, and 6/4/26. Review of Resident R3's MAR for June 2026, revealed an order for oxycodone 5mg to be given every four hours as needed for severe pain. Zero administrations were documented from 6/1/26, through 6/5/26. Review of Resident R3's Controlled Drug Record indicated that two doses of oxycodone were signed out without corresponding documentation of administration to the resident on 6/2/26, and 6/4/26. Review of Resident R4's MAR for May 2026, revealed an order for Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) to be given every twelve hours as needed. Eleven administrations were documented on the MAR from 5/12/26, through 5/31/26. Review of Resident R4's Controlled Drug Record indicated that seven additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 5/15/26, 5/16/26, 5/17/27, 5/19/26, 5/20/26, 5/21/26, and 5/31/26. During an interview on 6/9/26, at approximately 3:45 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain controlled substances were accounted for accurately for four of six residents. 28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three nursing units (6th floor).Findings include:Review of the facility policy Safe and Homelike Environment dated 6/9/26, previously reviewed 2/14/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment.During an observation on 6/6/26, beginning at 11:15 a.m., the following was identified:Medication cart unlocked, allowing unsafe access to residents.Large bag of soiled linen in the hallway open, with soiled linen falling out onto the floor.Bag of clothing on resident room floor, with clothing falling out onto the floor.Nightlight without a cover, allowing access to the bulb and wiring.Soiled linen on resident room floors (multiple rooms).Staff restroom unlocked, without call light functionality, allowing unsafe access to residents.A breakfast tray on the counter with fruit flies swarming above it, and used gloves on the tray and dirty dishes.A deli-meat sandwich in plastic wrapping on the counter, unrefrigerated. The date on the bag was 6/5/26.Shower room had used gloves on the floor in multiple areas, refuse in the shower area, paper towels on the floor, and the trash can was overflowing onto the floor.Souled utility room unlocked, allowing unsafe access to the residents. Within the soiled utility room were unlidded trash containers, bags of trash on the floor, multiple sharps containers, the hopper (specialized plumbing fixture used to safely dispose of human waste, biohazardous fluids, or other heavy clinical waste) half full with soiled water, and the linen chute open access door open. The opening of the linen chute was approximately two feet by two feet square. Review of grievances received by the facility from March 2026, through May 2026, revealed two grievances filed on behalf of residents relating to cleanliness of their rooms. During an interview on 6/9/26, at approximately 3:45 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three nursing units (6th floor).28 PA. Code 201.14(a) Responsibility of Licensee28 PA. Code 201.18(b) Management

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of four residents (Residents R5).Findings include: Review of the facility policy Pharmacy Services dated 6/9/26, previously reviewed 2/14/25, indicated that the facility willprovide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of the clinical record indicated Resident R4 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/22/26, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and vitreous hemorrhage (leakage of blood into the clear, gel-like substance that fills the space between the eye's lens and the retina). Review of a physician's order dated 4/1/26, discontinued on 5/6/26, indicated Resident R5 was to receive Humalog insulin (injectable medication to treat high blood sugar / diabetes) on a sliding scale at 2:00 a.m. daily. Review of the May 2026 medication administration record (MAR) failed to reveal documentation of a blood sugar check or administration of Humalog insulin on 5/4/26. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omission. Review of a physician's order dated 5/9/26, (order entered into the electronic medical record 5/9/26, at 7:12 p.m.) reordered on 5/21/26, indicated Resident R5 was to receive Lantus insulin (injectable medication to treat high blood sugar / diabetes) four units at bedtime, scheduled for 9:00 p.m. Review of the May 2026 MAR failed to reveal documentation of administration of Lantus insulin on 5/9/26, at 9:00 p.m. The MAR was documented that the medication was withheld. Review of Resident R5's progress notes failed to reveal documentation of a reason for the medication to be held. Review of the May 2026 MAR failed to reveal documentation of administration of Lantus insulin on 5/24/26, at 9:00 p.m. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omission. Review of a physician's order dated 5/9/26, (order entered into the electronic medical record 5/9/26, at 7:19 p.m.) discontinued on 5/21/26, indicated Resident R5 was to receive atorvastatin (medication to treat high cholesterol) 80 mg (milligrams) at bedtime, scheduled for 9:00 p.m. Review of the May 2026 MAR failed to reveal documentation of administration of atorvastatin on 5/9/26, at 9:00 p.m. The MAR was documented that the medication was withheld. Review of Resident R5's progress notes failed to reveal documentation of a reason for the medication to be held. Review of a physician's order dated 5/10/26, (order entered into the electronic medical record 5/9/26, at 7:21 p.m.) indicated Resident R5 was to receive Humalog insulin on a sliding scale at 5:00 a.m. daily. Review of the May 2026 MAR failed to reveal documentation of a blood sugar check or administration of Humalog insulin on 5/10/26. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omission. Review of a physician's order dated 5/21/26, indicated Resident R5 was to receive brimonidine tartrate ophthalmic solution, one drop in the left eye three times per day for dry eyes, schedule at 8:00 a.m., 12:00 p.m., and 8:00 p.m. Review of the May 2026 MAR failed to reveal documentation of administration of brimonidine eyedrops on Sunday 5/24/26, at 8:00 a.m. and 12:00 p.m. and on Thursday 5/28/26, at 8:00 a.m. and 12:00 p.m. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omissions. Review of a physician's order dated 5/23/26, indicated Resident R5 was to receive amlodipine (a medication to treat high blood pressure) 10 mg one time per day on Tuesday, Thursday, Saturday, and Sunday. Review of the May 2026 MAR failed to reveal documentation of administration of amlodipine on Sunday 5/24/26, at 9:00 a.m. and on Thursday 5/28/26, at 9:00 am. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omissions. Review of a physician's order dated 5/23/26, indicated Resident R5 was to receive carvedilol (a medication to treat high blood pressure) 25 mg one time per day on Tuesday, Thursday, Saturday, and Sunday. Review of the May 2026 MAR failed to reveal documentation of administration of carvedilol on Sunday 5/24/26, at 9:00 a.m. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omissions. Review of a physician's order dated 5/23/26, indicated Resident R5 was to receive isosorbide (a medication to chest pain) 30 mg one time per day on Tuesday, Thursday, Saturday, and Sunday. Review of the May 2026 MAR failed to reveal documentation of administration of isosorbide on Sunday 5/24/26, at 9:00 a.m. and on Thursday 5/28/26, at 9:00 am. Review of Resident R5's progress notes failed to reveal documentation of a reason for the omissions. Review of the facility provided inventory of medications included in the automatic dispensing system included Humalog, Lantus, amlodipine, atorvastatin, carvedilol, and isosorbide. Review of facility census information confirmed that Resident R5 was present in the facility during the times the medications were omitted. During an interview on 6/9/26, at approximately 3:45 p.m. the Nursing Home Administrator confirmed that the facility failed to implement procedures to ensure availability of prescribed medications for one of four residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on three of three nursing units (4th floor, 5th floor, and 6th floor). Findings include:Review of the facility policy Safe and Homelike Environment dated 2/14/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment.During an observation on 4/21/2026, from 11:12 a.m., through 12:25 p.m., the following was identified:Hallway on 4th floor had an overwhelming urine scent.Ceiling fans along the 5th floor hallway had a white dusty substance covering the filtering area.Dining room on the 5th floor has loose floor strip at center of room, causing a potential tripping hazard.Additional resident rooms with broken blinds include:Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER] During an interview on 4/21/26, at 1:25 p.m., Nursing Home Administrator confirmed the above findings and that the facility failed to provide a safe, clean, comfortable, and homelike environment on three of three nursing units (4th floor, 5th floor, and 6th floor).

Based on observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include:During an observation of the main kitchen on 4/8/26, from 8:45 a.m., through 9:10 a.m., the following was observed:The dish machine wash and rinse cycle temperature gauges were not functioning; the dish machine is a low temperature machine with chemicals.During an interview on 4/8/26, at 8:50 a.m., Dietary [NAME] Employee E4 stated that the gauges have not worked consistently since the machine was put in.During an interview on 4/8/26, at 9:10 a.m., the Nursing Home Administrator confirmed that the facility failed to ensure the dish machine was in proper working order. 28 Pa Code: 207.2(a) Administrator's Responsibility

Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 1of 1 month (March 19, 2026 through April 2026).Findings include:During an interview on 4/8/26, at approximately 11:00 a.m., the Corporate Dietary Manager Employee E1 stated the facility currently has no certified dietary manager and that the Dieticians are not employed full time in the facility. The Corporate Dietary Manager Employee E1 confirmed that the facility failed to provide documented evidence that any staff met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.Pa Code: 211.6(c)(d) Dietary Services.

Based on review facility documents, grievance logs, and individual resident interviews, it was determined that the facility failed to serve food that was palatable and attractive. Findings include:Review of facility documentation on 4/7/26, identified that the food served was not adequate.Review of the February 2026, grievance log identified a resident stating that the food is subpar and food on the list are not provided for lunch and dinner.During individual resident interviews on 4/8/26 from 9:10 a.m. through 11:40 a.m., residents indicated that meals are tasteless, except for the orange chicken and sometimes spaghetti. The male residents indicated that they often do not get enough and sometimes do not get extra even when asking. Trays are almost always late.During an observation of cart delivery on 4/8/26, from 12:00 p.m., through 12:45 p.m., identified meal carts were delivered approximately 20 minutes late.During an interview on 4/8/26, at approximately 1:00 p.m., the Corporate Dietary Manager Employee E1 stated that the facility does not have a dietary manager and staffing in the kitchen is not often adequate to make certain foods are done as they should be and delivered timely. She confirmed that the facility failed to serve food that was palatable and attractive.28 Pa. Code 211.6(c)(d)(f) Dietary Services.

Based on observations, and staff interviews, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen). Findings include:During an observation of the kitchen on 4/8/26, from 8:45 a.m., through 9:10 a.m., the following was observed:Dietary Aide (DA) Employee E2 was observed eating food in the dish machine room. The dish machine wash and rinse cycle temperature gauges were not functioning; the dish machine is a low temperature machine with chemicals.The cooler had a cart of undated fruit cups, unsealed bread cubes and undated cooked carrots.The ice machine drainpipe was sitting directly on the floor draining and the drain was approximately four inches away with a cover over it.During an interview on 4/8/26, at 8:50 a.m., Dietary [NAME] Employee E4 stated that the gauges have not worked consistently since the machine was put in.Observation of a prep table identified a pink staff neck cooling collar on top of the prep table and an opened crate of cereal on the second shelf. DA Employee E3 indicated that it was hers.The prep table near the tray line area had a cell phone on a tray, DA Employee E3 stated it was hers.During an interview on 4/8/26, at 9:10 a.m., the Nursing Home Administrator confirmed that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.6(b)(c)(d) Dietary services.

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).Findings include: Review of the facility policy Abuse, Neglect, & Exploitation dated 2/14/25, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, 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 intact8-12: moderately impaired0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/15/25, included diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C revealed Resident R1's BIMS score to be 01. Review of a physician's order dated 3/11/25, indicated Resident R1 received lorazepam (Ativan, an anti-anxiety medication) 0.5 mg three times per day. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and an anxiety disorder. Review of Section C revealed Resident R2's BIMS score to be 15. Review of a physician's order dated 11/24/25, indicated Resident R2 received clonazepam (Klonopin, an anti-anxiety medication) 1.0 mg two times per day. Review of facility submitted documentation on 12/29/25, indicated that on 12/28/25, Two controlled substances were identified as missing/unaccounted for during routine narcotic count reconciliation. One tablet of Lorazepam 0.5 MG belonging to [Resident R1] and one tablet of Clonazepam 1 MG belonging to [Resident R2]. The discrepancy was discovered on 12/28/25. The nurse in charge of the medication cart was Licensed Practical Nurse (LPN) Employee E1. The medications had been stored in a secured/locked medication cart on the 6th floor of the facility. A review of narcotic count records and MAR (medication administration record) documentation identified a discrepancy in the recorded quantity. Facility leadership was notified, an investigation was initiated, and appropriate steps were taken to secure remaining controlled substances. [LPN Employee E1] was given a drug screen and sent home pending investigation. There is concern of two missing narcotics and a potential diversion concern. Review of documentation of a verbal statement dated 12/28/25, indicated, A verbal statement was obtained from LPN Employee E1 via telephone on 12/28/25, at 2pm regarding two narcotic discrepancies identified on the 6th floor medication carts. LPN Employee E1 stated, The count was wrong this morning when I counted with [LPN Employee E4]. When asked why she assumed responsibility for the medication cart despite the incorrect count, LPN Employee E1 stated, I forgot my reading glasses so I couldn't see. I didn't know the count was wrong. As part of the investigation into the narcotic discrepancies identified on the 6th floor medication carts, LPN Employee E1 was requested to submit a urine drug screen. Following the request LPN Employee E1 was instructed to leave the facility and was placed on suspension pending completion of the investigation. The urine drug screen result was negative. During a follow-up statement provided by LPN Employee E1 on 12/31/25, indicated, Error.On Sunday morning [DATE] I was counting off the cart with LPN Employee E2 not LPN Employee E3 when I did not have my reading glasses on and the Ativan and Klonopin was not the right count. Review of and employee statement written by LPN Employee E2 on 12/31/25, indicated, On the morning of Sunday, 12/28/25, I, LPN Employee E2, counted out the narcotic drawer with LPN Employee E1 who was coming in to work at 7am to relieve me after I worked the 11p-7a shift. When we counted the drawer, all counts matched perfectly to the records, there was no discrepancy whatsoever on paper and nothing was questioned verbally. Review of a facility provided investigation document stated, Two controlled substances were identified as missing during routine narcotic count reconciliation. The missing medications include one tablet of Lorazepam 0.5 mg prescribed to Resident R1 and one tablet of clonazepam 1 mg prescribed to Resident R2. The discrepancy was discovered on 12/28/25. At the time of discovery, the medication card was assigned to LPN Employee E1. The medications had been stored in a secured, locked medication card on the sixth floor of the facility. A review of narcotic count sheets revealed the discrepancy and the recorded quantities. Facility leadership was immediately notified, and investigation was initiated, and appropriate measures were taken to secure all remaining controlled substances. LPN Employee E1 was administered a drug screen and sent home pending the outcome of the investigation. The situation raised concerns for missing narcotics and potential diversion. Statements were obtained from LPN Employee E1and LPN Employee E2 who handed off the medication card to LPN Employee E1 at 7:00 a.m. on 12/28/25. Both nurses reported that the narcotic count was accurate at the time of shift change and then no discrepancies were noted. LPN Employee E1 stated that she was unaware of any issue with the narcotic count, noting that she did not have her reading glasses at the time. During the course of the investigation, a perpetrator was identified. On 1/3/26. Registered Nurse (RN) Employee E3 (the Assistant Director of Nursing) was found to be in possession of an extra set of medication cart keys. RN Employee E3 was working in the facility during the time frame of the identified discrepancy on 12/28/25. The keys are immediately suspended, and RN Employee E3 was suspended pending further investigation. During an interview on 12/31/25, at approximately 11:00 a.m. the Director of Nursing (DON) provided a copy of the investigation into Resident R1 and Resident R2's missing medication. Review of the investigation documents failed to reveal if the possibility of misappropriation was investigated for any other residents. During this interview, the following Individual Patient Controlled Substance Administration Record (narcotic sign-out sheets) were provided for view to the Director of Nursing: Resident R3's narcotic sign-out sheet indicated additional doses of hydromorphone (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/23/25: 2 mg at 8:00 a.m.12/24/25: 2 mg at 8:00 a.m.12/26/25: 2 mg at 12:30 p.m.12/28/25: 2 mg at 2:00 p.m.12/29/25: 2 mg at 12:32 a.m.12/27/25: 2 mg at 11:00 a.m. Resident R4's narcotic sign-out sheet indicated additional doses of Tramadol (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/17/25: 50 mg at 9:00 p.m.12/18/25: 50 mg at 8:00 p.m.12/19/25: 50 mg at 8:00 p.m.12/23/25: 50 mg at 5:21 p.m.12/24/25: 50 mg at 10:00 a.m.12/27/25: 50 mg at 11:00 a.m. Resident R5's narcotic sign-out sheet indicated additional doses of oxycodone (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/25/25: 5 mg at 9:00 p.m.12/26/25: 5 mg at 9:00 p.m.12/28/25: 5 mg at 9:00 a.m.12/28/25: 5 mg at 9:00 p.m.Illegible entry.12/29/25: 5 mg at 9:00 p.m. Resident R6's narcotic sign-out sheet indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR:12/28/25: 5 mg written over illegibly.Three doses were signed out on 12/30/25, between 12:20 a.m. and 5:00 a.m. Resident R5's was scheduled to only have one dose at 1:00 a.m. Resident R7's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:10/19/25: 25 mg at 9:50 a.m.10/28/25: 25 mg at 7:00 p.m. Resident R8's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:9/16/25: 50 mg at 8:00 a.m.9/17/25: 50 mg at 2:00 p.m.9/18/25: 50 mg at 8:30 a.m.9/19/25: 50 mg at 6:30 p.m.9/20/25: 50 mg at 8:00 a.m. Resident R9's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:12/17/25: marked as error, not cosigned by a second nurse.12/18/25: 50 mg at 8:00 a.m.12/18/25: 50 mg at 9:00 p.m.12/27/25: 50 mg at 9:00 a.m. Resident R10's narcotic sign-out sheet indicated a dose of Tramadol was signed out on paper, and not documented in the electronic medical record MAR on 12/27/25, at 9:00 a.m. Review of the physician's orders indicated the order for Tramadol was discontinued on 12/15/25. Resident R11's narcotic sign-out sheet indicated additional doses of alprazolam (Xanax, an anti-anxiety medication) signed out on paper, and not documented in the electronic medical record MAR:12/30/25: 1.0 mg at 2:00 p.m. (two 0.5 mg tablets). Resident R12's narcotic sign-out sheet indicated additional doses of oxycodone/acetaminophen (Tylenol) signed out on paper, and not documented in the electronic medical record MAR:12/22/25: 5-325 mg at 6:36 p.m.12/24/25: 5-325 mg at 8:00 p.m.12/25/25: 5-325 mg at 12:30 p.m.12/25/25: 5-325 mg at 8:34 p.m.12/26/25: 5-325 mg at illegible time12/26/25: 5-325 mg at 12:00 p.m.12/28/25: 5-325 mg at 8:00 p.m.12/29/25: 5-325 mg at illegible time12/29/25: 5-325 mg at 10:45 a.m.12/29/25: 5-325 mg at 7:00 p.m.12/30/25: 5-325 mg at 11:30 a.m. Resident R13's narcotic sign-out sheet indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR:(3) doses wasted on 12/25/25.12/25/25: 5 mg at 11:00 p.m.12/26/25: 5 mg at 3:00 a.m.12/26/25: 5 mg at 10:00 p.m.12/27/25: 5 mg at illegible time12/27/25: 5 mg at 9:00 a.m.12/27/25: 5 mg at 5:00 p.m.12/28/25: 5 mg at 8:00 a.m.12/29/25: 5 mg at 12:50 p.m.12/30/25: 5 mg at 11:45 a.m. Resident R14's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:12/18/25: 100 mg at 9:30 p.m.12/20/25: 100 mg at 8:00 a.m. (order no longer active).12/20/25: 100 mg at 9:30 p.m. (order no longer active).12/23/25: 50 mg at 9:00 a.m. (order no longer active). During the interview on 12/31/25, at approximately 11:00 a.m. the DON confirmed that the investigation into misappropriation failed to include audits of other residents' medication records, narcotic sign-out sheets, or resident interviews to ascertain if the misappropriation included other residents. During an interview on 1/8/25, at approximately 11:00 a.m. the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents (Resident R3, R4, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38).Findings include: Review of the facility policy, Isolation - Notices of Transmission-Based Precautions dated 6/1/25, indicated, Notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Review of the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit dated 11/24/25, indicated, The LTCF (long-term care facility) should encourage masking of HCP (health care personnel), residents, and visitors during any respiratory virus outbreak. Masks help to prevent the spread of illness. This provides protection for the wearer (if using a fitted N95 or KN95) and protection for others (some surgical and N95/KN95). When a resident is suspected or confirmed to have a respiratory viral infection, additional precautions are needed to protect HCP during resident care. These precautions should be used in addition to standard precautions, source control, and proper hand hygiene. Proper institution of TBP (transmission-based precautions) includes placement in a private room, if available. The toolkit further stated that for SARS-CoV-2 (Covid-19) airborne, contact, and eye protection should be used, per the United States Department of Health and Human Services, Centers for Disease Control and Prevention, guidelines: Airborne Precautions indicated everyone must:Clean their hands, including before entering and when leaving the room.Put on a fit-tested N-95 or higher-level respirator before room entry.Remove respirator after exiting the room and closing the door.Door to room must remain closed.Contact Precautions indicated everyone must:Clean their hands, including before entering and when leaving the room.Put on gloves before room entry. Discard gloves before room exit.Put on gown before room entry. Discard gown before room exit.Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of facility provided documentation on 12/20/25, revealed that 41 of the 109 current residents were being treated for active Covid-19 infections. During an observation on 12/30/25, at 2:11 p.m. the following was observed on the Five South nursing unit:Room door for Resident R15 and R16 was open. Both residents had active Covid-19 infections.Room door for Resident R17 and R18 was open. Both residents had active Covid-19 infections.Room door for Resident R4 and R19 was open.Room door for Resident R20 and R21 was open. Both residents had active Covid-19 infections.Room door for Resident R22 and R23 was open. Resident R23 had an active Covid-19 infection.Room door for Resident R24 was open. Resident R24 had an active Covid-19 infection. During the observation, Licensed Practical Nurse (LPN) Employee E5 noted the surveyor writing down rooms numbers and she began closing the room doors. During an interview and observation on 12/30/25, at 2:13 p.m. LPN Employee E5 confirmed that none of the three PPE (personal protective equipment) caddies located in the Five South nursing unit had N-95 masks available to staff who would choose to wear them. During an observation on 12/30/25, at approximately 2:37 p.m. the following room doors of Covid-19 positive residents were open on the Sixth Floor nursing unit, allowing airborne virus to spread.Resident R25 and R26.Resident R27 and R3.Resident R28 and R29.Resident R30 and R31.Resident R32. During an observation on 12/30/25, at approximately 2:40 p.m. the following room doors of Covid-19 positive residents were open on the Fifth Floor nursing unit, allowing airborne virus to spread.Resident R36 and R14.Resident R37 and R38.Resident R16. During an observation on 12/30/25, at approximately 2:45 p.m. the following room doors of Covid-19 positive residents were open Fourth Floor nursing unit, allowing airborne virus to spread.Resident R33 and R34.Resident R35. During an interview on 12/30/25, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents. 28 Pa. code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(a)(d) Resident Care Policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services.

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to report a misappropriation of resident property 12 of 14 residents (Resident R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).Findings include: Review of the facility policy Abuse, Neglect, & Exploitation dated 2/14/25, indicated the facility will report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment During an interview on 12/31/25, at approximately 11:00 a.m. the following Individual Patient Controlled Substance Administration Record (narcotic sign-out sheets) were provided for view to the Director of Nursing (DON), and a physical copy of the narcotic sign-out sheets was provided to the Nursing Home Administrator on 12/31/25, at approximately 11:15 a.m. Resident R3's narcotic sign-out sheet indicated additional doses of hydromorphone (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/23/25: 2 mg at 8:00 a.m.12/24/25: 2 mg at 8:00 a.m.12/26/25: 2 mg at 12:30 p.m.12/28/25: 2 mg at 2:00 p.m.12/29/25: 2 mg at 12:32 a.m.12/27/25: 2 mg at 11:00 a.m. Resident R4's narcotic sign-out sheet indicated additional doses of Tramadol (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/17/25: 50 mg at 9:00 p.m.12/18/25: 50 mg at 8:00 p.m.12/19/25: 50 mg at 8:00 p.m.12/23/25: 50 mg at 5:21 p.m.12/24/25: 50 mg at 10:00 a.m.12/27/25: 50 mg at 11:00 a.m. Resident R5's narcotic sign-out sheet indicated additional doses of oxycodone (a narcotic pain medication) signed out on paper, and not documented in the electronic medical record MAR:12/25/25: 5 mg at 9:00 p.m.12/26/25: 5 mg at 9:00 p.m.12/28/25: 5 mg at 9:00 a.m.12/28/25: 5 mg at 9:00 p.m.Illegible entry.12/29/25: 5 mg at 9:00 p.m. Resident R6's narcotic sign-out sheet indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR:12/28/25: 5 mg written over illegibly.Three doses were signed out on 12/30/25, between 12:20 a.m. and 5:00 a.m. Resident R5's was scheduled to only have one dose at 1:00 a.m. Resident R7's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:10/19/25: 25 mg at 9:50 a.m.10/28/25: 25 mg at 7:00 p.m. Resident R8's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:9/16/25: 50 mg at 8:00 a.m.9/17/25: 50 mg at 2:00 p.m.9/18/25: 50 mg at 8:30 a.m.9/19/25: 50 mg at 6:30 p.m.9/20/25: 50 mg at 8:00 a.m. Resident R9's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:12/17/25: marked as error, not cosigned by a second nurse.12/18/25: 50 mg at 8:00 a.m.12/18/25: 50 mg at 9:00 p.m.12/27/25: 50 mg at 9:00 a.m. Resident R10's narcotic sign-out sheet indicated a dose of Tramadol was signed out on paper, and not documented in the electronic medical record MAR on 12/27/25, at 9:00 a.m. Review of the physician's orders indicated the order for Tramadol was discontinued on 12/15/25. Resident R11's narcotic sign-out sheet indicated additional doses of alprazolam (Xanax, an anti-anxiety medication) signed out on paper, and not documented in the electronic medical record MAR:12/30/25: 1.0 mg at 2:00 p.m. (two 0.5 mg tablets). Resident R12's narcotic sign-out sheet indicated additional doses of oxycodone/acetaminophen (Tylenol) signed out on paper, and not documented in the electronic medical record MAR:12/22/25: 5-325 mg at 6:36 p.m.12/24/25: 5-325 mg at 8:00 p.m.12/25/25: 5-325 mg at 12:30 p.m.12/25/25: 5-325 mg at 8:34 p.m.12/26/25: 5-325 mg at illegible time12/26/25: 5-325 mg at 12:00 p.m.12/28/25: 5-325 mg at 8:00 p.m.12/29/25: 5-325 mg at illegible time12/29/25: 5-325 mg at 10:45 a.m.12/29/25: 5-325 mg at 7:00 p.m.12/30/25: 5-325 mg at 11:30 a.m. Resident R13's narcotic sign-out sheet indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR:(3) doses wasted on 12/25/25.12/25/25: 5 mg at 11:00 p.m.12/26/25: 5 mg at 3:00 a.m.12/26/25: 5 mg at 10:00 p.m.12/27/25: 5 mg at illegible time12/27/25: 5 mg at 9:00 a.m.12/27/25: 5 mg at 5:00 p.m.12/28/25: 5 mg at 8:00 a.m.12/29/25: 5 mg at 12:50 p.m.12/30/25: 5 mg at 11:45 a.m. Resident R14's narcotic sign-out sheet indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR:12/18/25: 100 mg at 9:30 p.m.12/20/25: 100 mg at 8:00 a.m. (order no longer active).12/20/25: 100 mg at 9:30 p.m. (order no longer active).12/23/25: 50 mg at 9:00 a.m. (order no longer active). Review of documentation submitted by the facility to the State Survey Agency failed to include reports of possible misappropriation for the above residents. During follow-up review of documentation submitted by the facility to the State Survey Agency indicated that on 1/4/25, information was submitted, On 01/03/2025, a discrepancy was identified in the narcotic inventory for resident [Resident R13], with 4 1/2 tablets of Oxycodone 5 mg unaccounted for. The prior documented count at 7AM was 29 1/2 tablets, with 25 1/2 tablets remaining at 10:15 AM. No medication was administered to [Resident R13]. Review of activity indicated that [Registered Nurse Employee E3] accessed the narcotic drawer of the medication cart shortly before the discrepancy was noted. During an interview on 1/8/25, at approximately 11:00 the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to report possible misappropriation of resident property for 12 of 14 residents. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for three of seven residents (Resident R1, R2, and R3).Findings include: Review of the facility policy Abuse, Neglect, & Exploitation dated 2/14/25, previously defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/15/25, included diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C revealed Resident R1's BIMS score to be 01. Review of a physician's order dated 3/11/25, indicated Resident R1 received lorazepam (Ativan, an anti-anxiety medication) 0.5 mg three times per day. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and an anxiety disorder. Review of Section C revealed Resident R2's BIMS score to be 15. Review of a physician's order dated 11/24/25, indicated Resident R2 received clonazepam (Klonopin, an anti-anxiety medication) 1.0 mg two times per day. Review of facility submitted documentation on 12/29/25, indicated that on 12/28/25, Two controlled substances were identified as missing/unaccounted for during routine narcotic count reconciliation. One tablet of Lorazepam 0.5 MG belonging to [Resident R1] and one tablet of Clonazepam 1 MG belonging to [Resident R2]. The discrepancy was discovered on 12/28/25. The nurse in charge of the medication cart was Licensed Practical Nurse (LPN) Employee E1. The medications had been stored in a secured/locked medication cart on the 6th floor of the facility. A review of narcotic count records and MAR (medication administration record) documentation identified a discrepancy in the recorded quantity. Facility leadership was notified, an investigation was initiated, and appropriate steps were taken to secure remaining controlled substances. [LPN Employee E1] was given a drug screen and sent home pending investigation. There is concern of two missing narcotics and a potential diversion concern. Review of documentation of a verbal statement dated 12/28/25, indicated, A verbal statement was obtained from LPN Employee E1 via telephone on 12/28/25, at 2pm regarding two narcotic discrepancies identified on the 6th floor medication carts. LPN Employee E1 stated, The count was wrong this morning when I counted with [LPN Employee E4]. When asked why she assumed responsibility for the medication cart despite the incorrect count, LPN Employee E1 stated, I forgot my reading glasses so I couldn't see. I didn't know the count was wrong. As part of the investigation into the narcotic discrepancies identified on the 6th floor medication carts, LPN Employee E1 was requested to submit a urine drug screen. Following the request LPN Employee E1 was instructed to leave the facility and was placed on suspension pending completion of the investigation. The urine drug screen result was negative. During a follow-up statement provided by LPN Employee E1 on 12/31/25, indicated, Error.On Sunday morning [DATE] I was counting off the cart with LPN Employee E2 not LPN Employee E3 when I did not have my reading glasses on and the Ativan and Klonopin was not the right count. Review of and employee statement written by LPN Employee E2 on 12/31/25, indicated, On the morning of Sunday, 12/28/25, I, LPN Employee E2, counted out the narcotic drawer with LPN Employee E1 who was coming in to work at 7am to relieve me after I worked the 11p-7a shift. When we counted the drawer, all counts matched perfectly to the records, there was no discrepancy whatsoever on paper and nothing was questioned verbally. Review of a facility provided investigation document stated, Two controlled substances were identified as missing during routine narcotic count reconciliation. The missing medications include one tablet of Lorazepam 0.5 mg prescribed to Resident R1 and one tablet of clonazepam 1 mg prescribed to Resident R2. The discrepancy was discovered on 12/28/25. At the time of discovery, the medication card was assigned to LPN Employee E1. The medications had been stored in a secured, locked medication card on the sixth floor of the facility. A review of narcotic count sheets revealed the discrepancy and the recorded quantities. Facility leadership was immediately notified, and investigation was initiated, and appropriate measures were taken to secure all remaining controlled substances. LPN Employee E1 was administered a drug screen and sent home pending the outcome of the investigation. The situation raised concerns for missing narcotics and potential diversion. Statements were obtained from LPN Employee E1and LPN Employee E2 who handed off the medication card to LPN Employee E1 at 7:00 a.m. on 12/28/25. Both nurses reported that the narcotic count was accurate at the time of shift change and then no discrepancies were noted. LPN Employee E1 stated that she was unaware of any issue with the narcotic count, noting that she did not have her reading glasses at the time. During the course of the investigation, a perpetrator was identified. On 1/3/26. Registered Nurse (RN) Employee E3 (the Assistant Director of Nursing) was found to be in possession of an extra set of medication cart keys. RN Employee E3 was working in the facility during the time frame of the identified discrepancy on 12/28/25. The keys are immediately suspended, and RN Employee E3 was suspended pending further investigation. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and end stage renal disease (ESRD, an inability of the kidneys to filter the blood). Review of Section C revealed Resident R3's BIMS score to be 09. During an employee statement written by LPN Employee E1 on 12/31/25, indicated, On the morning of December 27 while counting off the cart there was a stack of cards with rubber bands around it. I asked [LPN Employee E4] what it was and he said they belong to [Resident R39] and never mentioned anything about any money, money was never seen or mentioned so there was never any money counted. Review of an employee statement written by LPN Employee E2 on 12/31/25, indicated, The last time this writer (LPN Employee E2) noticed [Resident R3's] money inside the narcotic drawer on the 6 north cart was Friday morning (12/26/25) between the hours of 7a-8:45a. The money was visible through the side of a clear plastic ziplock bag. The money was not counted, but a hundred dollar bill was clearly visible. When I noticed the money was no longer visible through the bag when I counted said drawer Saturday night (12/27/25) at 11 PM, I immediately notified the acting supervisor. Review of an employee statement written by LPN Employee E4 on 1/1/26, indicated, On 12/27/25. I, [LPN Employee E4], advised [LPN Employee E1] that [Resident R3] had the following in the narc box on the sixth floor north hall: 1 wallet , a stack of different credit cards , and money totaling $145. I even picked up the bundle that was in a plastic bag with his name on it, and showed it to her just to make sure that she knew it was in that particular box. Review of facility submitted documentation on 12/29/25, indicated that on 12/28/25, Credit cards (2 debit cards, Access card, state ID, Aetna insurance cards) and cash ($145) belonging to [Resident R3] were being stored in a locked drawer of the medication cart located on the 6th floor of the facility. It was due to be taken to the business office the following business day but was being secured in the medication cart over the weekend. On 12/28/2025, it was reported that the resident's money was missing. LPN Employee E1 was in charge of the medication cart. The funds had previously been secured in the locked drawer, and there is concern regarding the loss or possible misappropriation of resident property. Review of a facility entered Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property submitted on 1/7/25, included the information, During the course of the investigation, it was discovered that RN/ADON Employee E3 was in possession of a set of keys that provided access to the medication carts and locked narcotic drawers. RN/ADON Employee E3 was working in the facility at the time the money was reported missing. Due to more than one nurse having access to the locked narcotic drawer of the medication cart during the relevant timeframe, the investigation is inconclusive and cannot be substantiated or unsubstantiated. The missing funds in the amount of $145.00 will be reimbursed to the resident by the facility. During an interview on 1/8/25, at approximately 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents are free from misappropriation of property for three of seven residents. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

Based on review of facility provided documents and and staff interviews, it was determined that the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents (Resident R3).During an interview on 12/30/25, at approximately 1:30 p.m. the (former) Nursing Home Administrator was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an interview on 12/31/25, at approximately 11:30 a.m. the Director of Nursing was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During a telephone interview on 1/2/26, at 1:05 p.m. the (former) Nursing Home Administrator was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an electronic communication on 1/5/26, at 10:43 a.m. the Director of Nursing was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an electronic communication on 1/7/26, at 10:08 a.m. the Director of Nursing was requested to provide the investigation documents related to the possible misappropriation of resident property for Resident R3.During an electronic communication on 1/7/25, at 5:46 p.m. the investigation documents related to the possible misappropriation of resident property for Resident R3 were received.During an interview on 1/8/26, at approximately 11:00 a.m. the Nursing Home Administrator confirmed the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents.28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide information regarding how to file a grievance and information on the grievance official on two of three nursing units (Fourth Floor and Fifth Floor) and failed provide and make accessible grievance forms to residents and visitors on three of three nursing units (Fourth Floor, Fifth Floor, and Sixth Floor).Review of the facility policy, Resident and Family Grievances dated 2/14/25, indicated, Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. During an observation of the Fourth Floor nursing unit on 12/5/25, at approximately 1:55 p.m. the grievance box was not easily observed. During an interview on 12/5/25, at approximately 2:00 p.m. Licensed Practical Nurse (LPN) Employee E1 and Nurse Aide (NA) Employee E2 were unable to state where the grievance box was located on the unit. During an interview and observation on 12/5/25, at 2:04 p.m. NA Employee E3 was able to show the surveyor where the grievance box was. The grievance box was located in a vending machine room, attached to the wall. No words or signage were displayed to indicate that the box was for filing grievances. No grievance forms were available for resident and/or the representative to fill out. No information was posted to indicate the Grievance Official or the process for filing a grievance. During an observation on 12/5/25, at 2:07 p.m. the Fifth Floor grievance box was located in the resident dining room/lounge. The box was attached to the wall and labeled Grievance Box. No grievance forms were available for resident and/or the representative to fill out. No information was posted to indicate the Grievance Official or the process for filing a grievance. During an observation on 12/5/25, at 2:11 p.m. the Fifth Floor grievance box was located in the resident dining room/lounge. The box was attached to the wall. No words or signage were displayed to indicate that the box was for filing grievances. No grievance forms were available for resident and/or the representative to fill out. Posted in a separate area of the nursing unit, near the elevators, was information on the Grievance Official. During an interview on 12/5/25, at approximately 3:20 p.m. the Director of Nursing confirmed the facility failed to provide information regarding how to file a grievance and information on the grievance official on two of three nursing units and failed provide and make accessible grievance forms to residents and visitors on three of three nursing units.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to investigate a resident-to-resident abuse incident for one of four residents (Resident R1).Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. 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 8/12/25, 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). Review of Section C: Cognitive Patterns revealed a BIMS score of 07. Review of Resident R1's clinical record indicated that her child was her emergency contact and responsible party. Review of Resident R1's plan of care initiated 5/9/25, indicated Resident has an impaired mood status related to anxiety, dementia, admission to a skilled nursing facility, and a recent CVA (cardiovascular accident stroke). Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia. Review of Section C: Cognitive Patterns revealed a BIMS score of 04. Review of Resident R2's clinical record indicated that her child was her emergency contact and responsible party. Review of Resident R2's plan of care initiated 10/14/25, indicated Resident R2 has behaviors of combativeness, resisting care, anxiety, and wandering. Review of a progress note dated 10/15/25, at 9:10 p.m. indicated, Resident (Resident R2) witnessed standing over roommate (Resident R1) stating I need to change you Roommate (Resident R1) witnessed crying saying she's scared. Attempted to redirect pt (patient) when she became irate saying she is trying to work. Review of Resident R1's progress notes failed to reveal any documentation of the incident or notification to Resident R1's representative of the incident. Further review of the clinical record failed to reveal any actions taken to prevent a recurrence of the incident or an offer to move the resident to a different room. Review of a progress note dated 11/4/25, at 11:13 a.m. indicated, Resident (Resident R2) observed standing over her roommate (Resident R1) who was in her bed yelling at her stating that she stole her belongings. Resident extremely difficult to redirect. Review of Resident R1's progress notes failed to reveal any documentation of the incident or notification to Resident R1's representative of the incident. Further review of the clinical record failed to reveal any actions taken to prevent a recurrence of the incident or an offer to move the resident to a different room. During an interview on 12/5/25, at approximately 12:00 p.m. the facility was asked to provide documentation of an investigation into the incidents on 10/15/25, and 11/4/25. The Director of Nursing confirmed that the facility did not complete an investigation into the incidents to prevent recurrence. During an interview on 12/5/25, at approximately 3:20 p.m. the Director of Nursing confirmed the facility failed to investigate a resident-to-resident abuse incident for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, nursing unit observations, and staff interviews, it was determined that the facility failed to provide a clean and homelike environment on one of four nursing units (Fourth Floor nursing unit).Findings include: Review of the facility policy, Safe and Homelike Environment dated 2/14/25, indicated, The facility will provide a safe, clean, comfortable, and homelike environment. During an observation of the Fourth Floor dining room/lounge on 12/5/25, at approximately 12:35 p.m. the sink was noted to have refuse in it, partially uses bottles of shampoo and lotion were on a shelf above the sink, and a drawer had a broken handle. In the drawer was one sock, a soiled Ziploc bag, and a soiled disposable cup lid. The sink in the dining room/lounge only had a handle for hot water. The outlet on the wall next to the television had no faceplate, allowing access to the wires. In the lounge was a resident reclining chair with one arm cushion missing, exposing the metal frame. A brown substance was dried to the side of the chair, multiple substances appeared to have dried while dripping down the side, food residue was dried to the chair, and the reclining food rest was broken. During an observation on 12/5/25, at approximately 12:42 p.m. a restroom door (not designated as staff/visitor/resident) was unlocked and accessible to residents. No call light system was installed in the restroom. Personal hygiene items were noted to be stored on top of the paper towel dispenser. An interior door was noted to have silver duct tape covering the locking mechanism, not allowing it to engage. Upon opening the door, an electrical room was noted, allowing access to multiple circuit breakers and loose wires. During an interview on 12/5/25, at approximately 3:20 p.m., the Director of Nursing confirmed that the facility failed to provide a clean and homelike environment on one of four nursing units. 28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify a resident representative of a resident to resident abuse incident for one of four residents (Resident R1).Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the facility policy, Abuse, Neglect, and Exploitation dated 2/14/25, indicated that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident. 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 8/12/25, 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). Review of Section C: Cognitive Patterns revealed a BIMS score of 07. Review of Resident R1's clinical record indicated that her child was her emergency contact and responsible party. Review of Resident R1's plan of care initiated 5/9/25, indicated Resident has an impaired mood status related to anxiety, dementia, admission to a skilled nursing facility, and a recent CVA (cardiovascular accident stroke). Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia. Review of Section C: Cognitive Patterns revealed a BIMS score of 04. Review of Resident R2's clinical record indicated that her child was her emergency contact and responsible party. Review of Resident R2's plan of care initiated 10/14/25, indicated Resident R2 has behaviors of combativeness, resisting care, anxiety, and wandering. Review of a progress note dated 10/15/25, at 9:10 p.m. indicated, Resident (Resident R2) witnessed standing over roommate (Resident R1) stating I need to change you Roommate witnessed crying saying she's scared. Attempted to redirect pt (patient) when she became irate saying she is trying to work. Review of Resident R1's progress notes failed to reveal any documentation of the incident or notification to Resident R1's representative of the incident. Review of a progress note dated 11/4/25, at 11:13 a.m. indicated, Resident (Resident R2) observed standing over her roommate (Resident R1) who was in her bed yelling at her stating that she stole her belongings. Resident extremely difficult to redirect. Review of Resident R1's progress notes failed to reveal any documentation of the incident or notification to Resident R1's representative of the incident. During an interview on 12/5/25, at approximately 3:20 p.m. the Director of Nursing confirmed the facility failed to notify a resident representative of a resident to resident abuse incident for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and documents, clinical record review and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in the actual harm of a facial laceration that required sutures for one of three residents (Resident R1) This was identified as past noncompliance.Findings include:Review of facility policy, Safe Resident Handling dated 4/2/25, indicated The facility is to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote safe, secure, and comfortable experiences for the resident while keeping the employees safe in accordance with current standards and guidelines.Review of facility policy, Activities of Daily Living (ADLs) dated 4/2/25, indicated The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems.Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], and readmitted [DATE].Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 7/29/25, included diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), hemiplegia of right side (paralysis or weakness on one side of the body), cerebral vascular infarction (CVA-blood flow to the brain is interrupted, leading to brain tissue damage or death), Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract).Review of the MDS dated [DATE], Section GG: Functional Abilities, Section GG0170- Subsection A, indicated Resident R1 to roll left and right, the ability to roll from lying on back to left or right side and return to lying on back on the bed is at substantial/maximal assistance.Review of Resident R1's plan of care for Alteration in function related to hemiplegia status post CVA and paraplegia dated 5/31/25, requires resident to have an assist of two for ADLs.Review of a progress note dated 9/15/25, at 4:32 p.m., indicated during bed change Resident R1 was rolled over on his side and was unable to stop rolling. He fell onto the floor hitting his forehead. When turned to assess it was observed a large (2-3 inch) laceration. Pressure applied to site and remaining assessment completed. Neuros within normal limits (WNL), no voiced pain, no other bruises or lacerations noted. MD notified and order given to transfer out to hospital. Made comfortable in place until EMT's arrived. OTH (out to hospital) via stretcher and EMT's. Two staff were present during this incident.Review of progress note dated 9/16/25, at 2:03 a.m. indicated Resident R1 returned at 2AM to the facility in stable condition. Head CT WNL (within normal limits). Forehead laceration repaired with sutures (6) to be removed in 7-10 days, follow-up with [hospital] Neurological Institute within 2 weeks. On 9/16/25, at 3:32 p.m. doctor called from the hospital stating, Resident R1 needs to return RE; abnormal x-rays, staff member and PA notified, sister notified, VSS, transfer via stretcher by 2 EMT's, paperwork in hand, transferred with cell phone. Note on 9/17/25, at 1:07 a.m. revealed all testing at the hospital negative for injuries related to the fall, the facility was advised to send the resident back due to an incidental finding of another medical issue and the resident was admitted to the hospital from [DATE], through 10/1/25.Review of facility incident report dated 9/15/25, indicated bedside care was being provided to Resident R1 on 9/15/25 at 1630, two Certified Nursing Assistants (CNA's). There was 1 CNA on each side of his bed. Bed mobility order: assist x2. During the bed change, resident was rolled over on his side and was unable to stop rolling. He fell onto the floor hitting his forehead. Resident is alert and oriented with a BIMS score of 14/15. A large (2-3 inch) laceration was observed on his forehead. Pressure applied to site and remaining assessment competed. Neuros WNL, no voiced pain, no other bruises or lacerations noted. MD notified and order given to transfer OTH. He was made comfortable in place until EMT's arrived. OTH via stretcher and EMT's.Review of Resident R1's plan of care for Resident at risk for falls related to immobility, hemiplegia at right side status-post CVA, included interventions initiated on 6/3/25 to educate the resident and family/caregivers about safety reminders and what to do if a fall occurs.Review of the document Caregiver Guide and Instructions for Safe Bed Mobility dated 9/16/25, provided by the Director of Nursing, revealed that forty staff members were educated on bed mobility and how to roll a resident from one side of the bed to the other for care. This education was confirmed with signatures of attendance and interviews.Review of CNA Employee E1's statement written on 9/15/25 indicated CNA Employee E1 and E2 was giving care on Resident R1 while resident was turned CNA Employee E1 turned to grab washcloth resident slipped out of bed.Review of CNA Employee E2's statement written on 9/15/25 indicated CNA Employee E1 and E2 were giving incontinence care on Resident R1 while he was turned toward CNA Employee E2, so my colleague could grab washcloths he slipped out of bed-feet first and could not stop the fall because of his weight. Second statement on 9/15/25, at 7:00 p.m. revealed resident fell out of bed due to loss of balance while ADL was being performed. Loose BM requiring extensive care by aides.During an interview on 10/7/25, at 12:15 p.m. Director of Therapy Employee E3 confirmed that Resident R1 has had an order for an assist of two since admission.During an interview with Resident R1 he stated, that during the incident he thought that only one CNA was assisting but doesn't really remember.During an interview on 10/7/25, at 12:00 p.m., CNA Employee E1 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During an interview on 10/7/25, at 12:05 p.m. CNA Employee E2 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During an interview on 10/7/25, at 11:50 a.m. LPN Employee E4 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During an interview on 10/7/25, at 11:51 a.m. CNA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During an interview on 10/7/25, at 11:53 a.m. LPN Employee E6 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs. and facility education provided on 9/16/25.During an interview on 10/7/25, at 11:55 a.m. CNA Employee E7 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs. and facility education provided on 9/16/25.During an interview on 10/7/25, at 12:03 p.m. CNA Employee E8 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During an interview on 10/7/25, at 12:07 p.m. CNA Employee E9 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 9/16/25.During interviews on 10/7/25, eight employees (Employee E1, E2, E4, E5, E6, E7, E8, and E9), confirmed they received point of care training on 9/16/25, for bed mobility.During review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1). This was identified as past non-compliance.During an interview on 10/7/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a facial laceration that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)( e)(1) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (c )(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse for one of 104 residents reviewed (Resident R1), which provided the opportunity of an additional eight days for abuse to possibly continue. This failure created an Immediate Jeopardy situation for one of 104 residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse Reporting and Investigation dated 10/2/23, indicated identification, correction and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet residents' needs and have the knowledge of the individual resident care needs and behavioral symptoms. Reporting of all alleged violations is immediate. Review of abuse education provided to facility staff defined abuse as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. the education further stated that an alleged violation whether observed or reported but not yet investigated if verified, can be indication of noncompliance with Federal requirements. Review of the Resident Assessment Instrument 3.0 User's Manual 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 Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, macular degeneration(difficulty with vision), difficulty walking, dementia without behavioral disturbance, psychotic disturbance,mood disturbance and anxiety, adjustment disorder, and cognitive communication deficit. A Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/8/24, indicated the diagnoses remained current. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 4. Review of Resident R1's physician orders active in April 2024, included: -Lexapro 5 mg for depression -Haldol 2.5 mg every 6 hours as needed for agitation, started on date of incident and was given. -Psych consult, last seen 3/29/24. Review of a physician order originally dated 4/3/24, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related behaviors of hitting, pinching, scratching and attempt to use: one on one, activity, adjust room temperature, back rub, change positions, give fluids, give food, redirect, refer to progress notes, remove from environment, return to room, and/or toilet every shift. Review of documentation did not include any behaviors as indicated in the physician orders. Review of Resident R1's plan of care included plan of care for Alzheimer's and behaviors of exit seeking, use of wanderguard, behaviors of physical aggression towards other residents/ staff, and to notify the Physician if any occurs. Plan of care also addressed Resident R1's having potential for urinary tract infections and to monitor for changes in behaviors, pain, etc. Plan of care also addressed Resident R1's impaired cognition. Review of a progress noted dated 3/22/24, indicated Resident R1 was awake at 3:40 a.m., wandering the halls and getting out of bed and staff redirecting him. Review of a progress note dated 3/23/24, at 11:23 p.m., indicated, waking up after sleeping most of the 3-11 shift wandering the halls, attempting to remove items from the medication cart, when being told to leave the items on the cart, he swung at the nurse and staff had to redirect him. Review of a progress note dated 3/24/24, at 3:30 p.m., indicated Resident R1 was standing over the medication cart, removing items, and when the nurse bent over to get trash bag, Resident R1 swung at her and it took three staff to redirect him. The documentation indicated Resident R1's behaviors had escalated and that Administration had been made aware. Review of a progress note dated 3/29/24, from the Psychiatric Nurse Practitioner indicated an assessment of Resident R1 and continued monitoring of his behaviors due to staff indicating that Resident R1 is only aggressive if he is treated rudely and that if behaviors persisted, Seroquel may be used. Review of a progress note dated 4/21/24, 10:45 a.m., indicated that resident R1 had an altered level of cognition, slurred speech, complaints of back of neck pain, a bruise on his left shoulder, left elbow and a large bruise of his left hip and buttocks, and bruising of bilateral knees. He was unable to get out of bed. On call doctor called. The Assistant Director of Nursing (ADON) came into facility and called the Nurse Practitioner who ordered Resident R1 to go to the hospital for evaluation and treatment. Review of a facility provided document dated 4/21/24, indicated that Resident R1 had been assessed for the change in condition, indicated the bruising of Resident R1's scrotal and sphincter areas and that a female resident reported an altercation with Resident R1 and Licensed Practical Nurse (LPN) Employee E1 who had struck Resident R1 in his genital area. Resident R1 was sent to the hospital for evaluation. The document indicated the LPN was immediately removed from the facility and the investigation was being completed. Review of the statement obtained from Resident R2 dated 4/22/24, who observed the altercation, indicated that Resident R1 'was not bothering anyone', he leaned on [LPN Employee E1's] medication cart, LPN Employee E1 told him to get off of her cart and pushed his arm off of her cart, Resident R1 pushed her but she did not move then she began hitting him all over his body except his face, [NAME] she grabbed him and kneed him in his privates, she then kept punching him all over and she knocked him over and she fell on top of him continuing to it him she got up and left him on the floor. Resident R1 a got up and walked to is room and you could tell he was in pain. Review of an undated/untimed statement provided via telephone from LPN Employee E1, the alleged perpetrator, indicated that Resident R1 was hitting her and when he went to hit her he fell and staff helped him up and that LPN Employee E2 was going upstairs to tell them about him (meaning Administration). Review of LPN Employee E2's statement undated who was identified as being present at the time of the altercation indicated that Resident R1 was not violent. Review of a follow-up statement dated 4/25/24, from LPN Employee E2 indicated hat she was not present during the altercation, although identified by Resident R2 as having been present. Review of an undated statement obtained from LPN Employee E3, indicated that she overheard Resident R2 speaking about the incident identifying LPN Employee E1 as the alleged perpetrator who had punched Resident R1 and it was so bad he had to crawl to get up. During the conversation Resident R2 indicated that LPN Employee E2 and Nurse Aide(NA) Employee E4 were at the nurses station and did not intervene. The next morning NA Employee E4 was talking at the desk about the incident, LPN Employee E2 then began to speak about it and stated she could not be responsible for his safety. Further review of the statement indicated that Friday, four days after the incident, LPN Employee E3 indicated Nurse Aide Employee E5 was talking about finding bruising on Resident R1 scrotum and spoke of LPN Employee E1 being the alleged perpetrator. The following day LPN Employee E3 found Resident R1's scrotum excoriated, red on front and back and it was dark purple towards his rectal area and she then contacted the Human Resources (HR) Director Employee E6 about the incident who then contacted Registered Nurse (RN) Unit Manager Employee E7. During a phone interview on 5/7/24, at 8:20 a.m., LPN Employee E3 stated that the staff on Thursday night or Friday morning, I can't remember which day, in the kitchen doing their cold talk and NA Employee E5 was told by LPN Employee E1 to stop talking. and the she had counted medication carts wit LPN Employee E1 and asked her what happened and she said I am not saying anything. LPN Employee E3 stated that once she put two and two together, she then contacted the HR Director Employee E6, that was on Sunday. During the interview, LPN Employee E3 stated that she was aware of the situation that she is required to report but failed to do so before Sunday. The failure to report this instance at the time of occurrence caused the abuse to possibly continue from the date of occurrence of 4/16/24 through the initial report of 4/21/24 or eight days. During an interview on 5/6/24, at 12:20 p.m., the HR Director Employee E6 stated that she was not aware of the incident until Sunday 4/21/24, when LPN Employee E6 text her at 6:50 a.m., and then she called RN Employee E7 and told him what had occurred. She went on to ask LPN Employee E6 if the incident was it on the 24 hour report and did not get an answer. The 24 hour report cannot be found. Further review of the facility documentation did not include any further investigation into the incident. On 5/6/24, at 2:54 p.m., the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 104 residents for failure to report the suspicion and/or observation of staff to resident physical abuse and the Immediate Jeopardy template was provided to facility administration. On 5/6/24, at 4:49 p.m., acceptable Corrective Action Plan was received which included the following interventions: - LPN Employee E1's employment was suspended on 4/21/24, and terminated 4/24/24, due to abuse. -LPN Employee E2's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting the abuse. -Resident R1 is no longer in the facility since 4/21/2. - Nurse Aide Employee E4's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting abuse. - Abuse training will be completed with all staff by 5/2/24, and then had been completed again with specific reviews of intervening and stopping abuse, how to identify abuse and reporting the abuse immediately with no retaliation and non intimidation and use of the 24 hour abuse hotline. which had been complete by 5/7/24, at 10:00 a.m. This specific education will be included for all new hires including agency. - Current employees who are not presently at work will be educated prior to the start of their next shift. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Social Worker will audit all grievances for the past 6 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. - Resident interviews related to abuse were completed and if a non interviewable resident, a skin sweep was completed by 5/7/24. Skin sweeps will be completed weekly by the Director of Nursing or designee weekly for 4 weeks, then monthly for 3 months to ensure abuse prevention policy is followed. -The Social Worker will interview 25% of the residents moving forward to determine if any incidents or concerns for abuse are occuring weekly for 4 weeks, then monthly for three months. -Ongoing results will be submitted o the QA committee. During staff interviews conducted on 5/7/24, between 10:20 - 11:30 a.m., 34 staff members including the 3:00 - 11:00 p.m. and two 11:00 p.m.- 7:00 a.m., staff confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 5/7/24, at 2:06 p.m., when the action plan implementation was verified. During an interview on 5/7/24, at 2:10 p.m. the Nursing Home Administrator confirmed that facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident physical abuse for one of 104 residents, which provided and opportunity of an additional eight days for abuse to possibly continue, and that this failure created an Immediate Jeopardy situation for one of 104 residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)1) Management.

Based on review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to protect residents from staff-initiated physicial abuse. This failure resulted in a staff member physically assaulting a resident and which resulted in serious injuries and transfer to hospital which created an Immediate Jeopardy situation for one of 104 residents (Resident R1). Findings include: Review of the facility's policy Abuse and Neglect - Clinical Protocol reviewed 10/2/23, indicated the facility will provide protection for the health, welfare and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse is defined by willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the Resident Assessment Instrument 3.0 User's Manual 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 Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, macular degeneration (difficulty with vision), difficulty walking, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, adjustment disorder, and cognitive communication deficit. Review of a Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/8/24, indicated the diagnoses remained current. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 4. Review of Resident R1's physician orders active in April 2024, included: -Lexapro 5mg for depression -Haldol 2.5 mg every 6 hours as needed for agitation, started on date of incident and was given. -Psychiatry consult, last seen 3/29/24. Review of a physician order originally dated 4/3/24, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related behaviors of hitting, pinching, scratching and attempt to use: one on one, activity, adjust room temperature, back rub, change positions, give fluids, give food, redirect, refer to progress notes, remove from environment, return to room, and/or toilet every shift. Review of documentation did not include any behaviors as indicated in the physician orders. Review of Resident R1's plan of care included: Alzheimer's and behaviors of exit seeking, use of wanderguard, behaviors of physical aggression towards other residents/staff, and to notify the Physician if any occurs. Plan of care also addressed Resident R1's having potential for urinary tract infections and to monitor for changes in behaviors, pain, etc. Plan of care also addressed Resident R1's impaired cognition. Review of a progress note dated 3/22/24, indicated Resident R1 was awake at 3:40 a.m., wandering the halls and getting out of bed and staff redirecting him. Review of a progress note dated 3/23/24, at 11:23 p.m., as waking up after sleeping most of the 3-11 shift wandering the halls, attempting to remove items from the medication cart, when being told to leave the items on the cart, he swung at the nurse and staff had to redirect him. Review of a progress note dated 3/24/24, at 3:30 p.m., indicated Resident R1 was standing over the medication cart, removing items, and when the nurse bent over to get trash bag, Resident R1 swung at her and it took three staff to redirect him. The documentation indicated Resident R1's behaviors had escalated and that Administration had been made aware. Review of a progress note dated 3/29/24, the Psychiatric Nurse Practitioner indicated an assessment of Resident R1 and continued monitoring of his behaviors due to staff indicating that Resident R1 is only aggressive if he is treated rudely and that if behaviors persisted, Seroquel may be used. Review of a progress note dated 4/21/24, 10:45 a.m., indicated that resident R1 had an altered level of cognition, slurred speech, complaints of back of neck pain, a bruise on his left shoulder, left elbow and a large bruise of his left hip and buttocks, and bruising of bilateral knees. He was unable to get out of bed. On call doctor called. The Assistant Director of Nursing (ADON) came into facility and called the Nurse Practitioner who ordered Resident R1 to go to the hospital for evaluation and treatment. Review of a facility provided document dated 4/21/24, indicated that Resident R1 had been assessed for the change in condition, indicated the bruising of Resident R1's scrotal and sphincter areas and that a female resident reported an altercation with Resident R1 and Licensed Practical Nurse (LPN) Employee E1 had struck Resident R1 in his genital area. Resident R1 was sent to the hospital for evaluation. The document indicated LPN Employee E1 was immediately removed from the facility after notfication of the incident and the investigation was being completed. Review of the statement obtained from Resident R2 dated 4/22/24, who observed the altercation, indicated that Resident R1 'was not bothering anyone', he leaned on [LPN Employee E1's] medication cart, LPN Employee E1 told him to get off of her cart and pushed his arm off of her cart, Resident R1 pushed her but she did not move then she began hitting him all over his body except his face, then she grabbed him and kneed him in his privates, she then kept punching him all over and she knocked him over and she fell on top of him continuing to it him she got up and left him on the floor. Resident R1 got up and walked to is room and you could tell he was in pain. Review of an undated/untimed statement provided via telephone from LPN Employee E1, the alleged perpetrator, indicated that Resident R1 was hitting her and when he went to hit her he fell , and staff helped him up and that LPN Employee E2 was going upstairs to tell them about him (meaning Administration). Review of an udated statement from LPN Employee E2, who was identified as being present at the time of the altercation, indicated that Resident R1 was not violent. Review of a follow up statement dated 4/25/24, from LPN Employee E2 indicated hat she was not present during the altercation, although was identified by Resident R2 as having been present. Review of an undated statement obtained from LPN Employee E3, indicated that she overheard Resident R2 speaking about the incident identifying LPN Employee E1 as the alleged perpetrator who had punched Resident R1 and it was so bad he had to crawl to get up. Resident R2 then indicated that LPN Employee E2 and Nurse Aide(NA) Employee E4 were at the nurses station and did not intervene. The statement then stated, The next morning NA Employee E4 was talking at the desk about the incident, LPN Employee E2 then began to speak about it and stated she could not be responsible for his safety. Further review of the statement indicated that Friday, four days after the incident, LPN Employee E3 indicated she spoke with Nurse Aide Employee E5 who said she found bruising on Resident R1 scrotum and that LPN Employee E1 was the alleged perpetrator. The following day LPN Employee E3 found Resident R1's scrotum excoriated, red on front and back and it was dark purple towards his rectal area and it was only then that she contacted the Human Resources (HR) Director Employee E6 about the incident who then contacted Registered Nurse (RN) Unit Manager Employee E7. During a phone interview on 5/7/24, at 8:20 a.m., LPN Employee E3 stated that the staff on Thursday night or Friday morning, I can't remember which day, were in the kitchen doing their cold talk and NA Employee E5 was told by LPN Employee E1 to stop talking. and the she had counted medication carts with LPN Employee E1 and asked her what happened and she said I am not saying anything. LPN Employee E3 stated that once she put two and two together, she then contacted the HR Director Employee E6, that was on Sunday. During an interview on 5/6/24, at 12:20 p.m., the HR Director Employee E6 stated that she was not aware of the incident until Sunday when LPN Employee E6 texted her at 6:50 a.m., and then she called RN Employee E7 and told him what had occurred. She went on to ask LPN Employee E6 if the incident was it on the 24 hour report and did not get an answer. The 24 hour report has not been located. Further review of the facility documentation did not include any further investigation into the incident. On 5/6/24, at 2:54 p.m., the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 104 residents for staff initiated physical abuse and the Immediate Jeopardy template was provided to facility administration. On 5/6/24, at 4:49 p.m., an acceptable Corrective Action Plan was received which included the following interventions: - LPN Employee E1's employment was suspended on 4/21/24, and terminated 4/24/24, due to abuse. -LPN Employee E2's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting the abuse. -Resident R1 is no longer in the facility since 4/21/24. - Nurse Aide Employee E4's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting abuse. - Abuse training will be completed with all staff by 5/2/24, and then had been completed again with specific reviews of intervening and stopping abuse, how to identify abuse and reporting the abuse immediately with no retaliation and non intimidation and use of the 24 hour abuse hotline. which had been complete by 5/7/24, at 10:00 a.m. This specific education will be included for all new hires including agency. - Current employees who are not presently at work will be educated prior to the start of their next shift. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Social Worker will audit all grievances for the past 6 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. - Resident interviews related to abuse were completed and if a non interviewable resident, a skin sweep was completed by 5/7/24. Skin sweeps will be completed weekly by the Director of Nursing or designee weekly for 4 weeks, then monthly for 3 months to ensure abuse prevention policy is followed. -The Social Worker will interview 25% of the residents moving forward to determine if any incidents or concerns for abuse are occuring weekly for 4 weeks, then monthly for three months. -Ongoing results will be submitted o the QA committee. During staff interviews conducted on 5/7/24, between 10:20 a.m. and 11:30 a.m., 34 staff members including the 3:00-11:00 p.m. and two 11:00 p.m.-7:00 a.m., staff confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 5/7/24, at 2:06 p.m., when the action plan implementation was verified. During an interview on 5/7/24, at 2:10 p.m. the Nursing Home Administrator confirmed that facility failed to protect residents from staff-initiated physical abuse. This failure resulted in a staff member physically abusing a resident causing serious injury, and created an Immediate Jeopardy situation for one of 104 residents. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for two of nine residents (Residents R164 and R45) which resulted in actual harm of a skin tear to Resident R164 and a fractured bone spur and ligament injuries for Resident R45. Findings include: Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of Resident R164's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R164's Minimum Data Set (MDS -periodic assessment of care needs) dated 1/13/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic kidney disease (gradual loss of kidney function), and debility. Review of Resident R164's MDS assessments, Section GG - Functional Abilities and Goals, GG0170A, Roll left and right, indicated that Resident R164 was dependent on staff (helper does all 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 1/6/24, indicated Resident R164 required Bed Mobility Assist x2. Review of Resident R164's plan of care for Assistance with activities of daily living related to impaired mobility and weakness initiated 1/7/24, included the intervention that Resident R164 required the assistance of two staff members for bed mobility. Review of Resident R164's Kardex (document that outlines the patient's ADLs, continence levels, and behaviors, as well as physician orders, advanced directives, diet, and allergies) dated as of 1/12/24, indicated that Resident R164 required bed mobility assistance of two staff members. Review of Resident R164's January 2024 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 1/6/24, through 1/12/24, Resident R164 had bed mobility documented eight times, with five of those times documented as having required two persons. Review of a transcribed statement dated 1/18/24, dictated to Therapy Director Employee E26 by Resident R164 indicated, I was laying down and the aide was on the left side changing me, on Saturday. She rolled me over and down I went. I don't know what I hit my arm on. She rolled me to the right side. She went to the door and asked for help. Review of a facility provided incident report dated 1/13/24, indicated Resident fell from bed while being changed, fell on to his knees, a skin tear on his left forearm noted. Review of an employee statement dated 1/17/24, written by Nurse Aide (NA)Employee E30 indicated, To whom it may concern on Saturday 1-13-2024 (Resident R164) had fallen off the bed onto his knees during a roll for a brief change. I reported to Licensed Practical Nurse (LPN) Employee E31. She came in and flushed and wrapped his left forearm. Today I noticed the dressing she applied four days ago had still been there and was very dry and stuck. I reported it to (LPN Employee E32). Review of an employee statement (undated), written by LPN Employee E31, indicated, I was called into the resident room by the aide. I met the resident on his knee, with a skin tear on his left forearm. I flushed it and applied dressing on his arm. The aide told me that he fell on to his knee during a change and hit his arm on the nightstand at his bed. I notified the physician, and his sister about the fall, filled out an incident report. Review of Resident R164's progress notes failed to reveal when the physician and family were notified, or that a medical provider (physician or on-call provider) assessed Resident R164's skin tear. Review of a physician's note dated 1/20/24, at 5:48 p.m. failed to include information related to the skin tear. Review of Resident R164's physician orders failed to include an order for care of the skin tear sustained on 1/13/24, until 1/18/24. Review of facility submitted information dated 1/18/24, revealed that on 1/13/24, NA Employee E30 provided incontinence care to Resident R164 alone (without additional staff members present), and confirmed that Resident R164 is a bed mobility assist of two. During an interview and observation on 2/12/24, at 10:37 a.m. NA Employee E12 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E12 stated she asks physical therapy. When asked what she would do if therapy staff were not present, NA Employee E12 stated she looks at the charting. When asked to demonstrate this, NA Employee E12 was unable to do so. During an interview on 2/12/24, at 10:40 a.m. NA Employee E35 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E35 stated she reviews the paper sheets at the nurses station. During an interview and observation on 2/12/24, at 10:42 a.m. NA Employee E33 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E33 demonstrated entering the electronic point of care charting portal and opening the resident's Kardex to see the assistance level. During an interview on 2/12/24, at 10:45 a.m. NA Employee E34 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E34 stated she reviews the paper sheets at the nurses' station. During an interview on 2/12/24, at 10:50 a.m. NA Employees E36, E37, and E38 were asked how they know what level of staff assistance for bed mobility is appropriate for a resident. They collectively stated that they would use the Kardex function in the electronic point of care charting portal. Review of Resident R45's admission record indicated she was admitted to the facility on [DATE]. Review of Resident 45's MDS dated [DATE], included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and history of a stroke. Review of Resident R45's MDS dated [DATE], indicated a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact, Section GG, Functional Abilities and Goals, indicated Resident R45 utilized a wheelchair. Additionally, transfer status is supervision or touching assistance. Resident R45 is mobile in the wheelchair. Review of Resident R45's care plan did not address mobility throughout the facility or any leaves of absence unsupervised. Review of a progress note dated 7/1/23, at 7:27 a.m. indicated Called to lobby by security. noted that resident was locked in the bathroom. upon opening the door, she was noted to be lying on the floor with her w/c (wheelchair) tipped on her. assessed and noted three lacerations on her face. One above her left eye, one below her left eye and one on her right cheek. vitals stable. no change in loc (level of consciousness) resident sat in w/c until medics arrived. Review of a physician's note dated 7/1/23, at 4:34 p.m. indicated Resident R45 was sent to the hospital for evaluation of head and facial injuries. Review of hospital documentation dated 7/1/23, indicated that Resident R45 was found to have an acute fractured anterior osteophyte C3 (newly broken bone spur in the neck portion of the spine) and ligament injuries in the neck. Review of a progress note dated 7/4/23, at 10:39 p.m. indicated Resident R45 returned from the hospital. Review of an employee statement (undated) by Security Officer Employee E33 stated, I was sitting at the desk, and I heard someone yelling for help. I got up and followed the sound and it was coming from the bathroom and the door was locked. I use my bank card to get in the bathroom and found (Resident R45) on the floor bleeding from the head/face. I paged staff code blue (need for immediate assistance). During an observation on 2/10/24, at 11:30 a.m., of the lobby restroom on the first floor failed to reveal call lights available for resident use in the restroom. During an interview on 2/10/24, at 11:36 a.m., Maintenance Director Employee E27 confirmed that the lobby restrooms are not routinely locked, and there are not call lights present. During an interview on 2/12/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for two of nine residents, which resulted in actual harm of a skin tear to Resident R164 and fractured bone spur and ligament injuries for Resident R45. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm of a skin tear, and neglect of notifying a physician and procuring order for the care of the skin tear, for one of nine residents (Resident R164). Findings include: Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy. Abuse, Neglect, and Exploitations dated 10/2/23, previously reviewed 10/1/22, stated the facility will implement policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Review of Resident R164's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R164's Minimum Data Set (MDS -periodic assessment of care needs) dated 1/13/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic kidney disease (gradual loss of kidney function), and debility. Review of Resident R164's MDS assessments, Section GG - Functional Abilities and Goals, GG0170A, Roll left and right, indicated that Resident R164 was dependent on staff (helper does all 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 1/6/24, indicated Resident R164 required Bed Mobility Assist x2. Review of Resident R164's plan of care for Assistance with activities of daily living related to impaired mobility and weakness initiated 1/7/24, included the intervention that Resident R164 required the assistance of two staff members for bed mobility. Review of Resident R164's Kardex (document that outlines the patient's ADLs, continence levels, and behaviors, as well as physician orders, advanced directives, diet, and allergies) dated as of 1/12/24, indicated that Resident R164 required bed mobility assistance of two staff members. Review of Resident R164's January 2024 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 1/6/24, through 1/12/24, Resident R164 had bed mobility documented eight times, with five of those times documented as having required two persons. Review of a transcribed statement dated 1/18/24, dictated to Therapy Director Employee E26 by Resident R164 indicated, I was laying down and the aide was on the left side changing me, on Saturday. She rolled me over and down I went. I don't know what I hit my arm on. She rolled me to the right side. She went to the door and asked for help. Review of a facility provided incident report dated 1/13/24, indicated Resident fell from bed while being changed, fell on to his knees, a skin tear on his left forearm noted. Review of an employee statement dated 1/17/24, written by Nurse Aide (NA)Employee E30 indicated, To whom it may concern on Saturday 1-13-2024 (Resident R164) had fallen off the bed onto his knees during a roll for a brief change. I reported to Licensed Practical Nurse (LPN) Employee E31. She came in and flushed and wrapped his left forearm. Today I noticed the dressing she applied four days ago had still been there and was very dry and stuck. I reported it to (LPN Employee E32). Review of an employee statement (undated), written by LPN Employee E31, indicated, I was called into the resident room by the aide. I met the resident on his knee, with a skin tear on his left forearm. I flushed it and applied dressing on his arm. The aide told me that he fell on to his knee during a change and hit his arm on the nightstand at his bed. I notified the physician, and his sister about the fall, filled out an incident report. Review of Resident R164's progress notes failed to reveal when the physician and family were notified, or that a medical provider (physician or on-call provider) assessed Resident R164's skin tear. Review of a physician's note dated 1/20/24, at 5:48 p.m. failed to include information related to the skin tear. Review of Resident R164's physician orders failed to include an order for care of the skin tear sustained on 1/13/24, until 1/18/24. Review of facility submitted information dated 1/18/24, revealed that on 1/13/24, NA Employee E30 provided incontinence care to Resident R164 alone (without additional staff members present), and confirmed that Resident R164 is a bed mobility assist of two. During an interview and observation on 2/12/24, at 10:37 a.m. NA Employee E12 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E12 stated she asks physical therapy. When asked what she would do if therapy staff were not present, NA Employee E12 stated she looks at the charting. When asked to demonstrate this, NA Employee E12 was unable to do so. During an interview on 2/12/24, at 10:40 a.m. NA Employee E35 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E35 stated she reviews the paper sheets at the nurse's station. During an interview and observation on 2/12/24, at 10:42 a.m. NA Employee E33 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E33 demonstrated entering the electronic point of care charting portal and opening the resident's Kardex to see the assistance level. During an interview on 2/12/24, at 10:45 a.m. NA Employee E34 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E34 stated she reviews the paper sheets at the nurses' station. During an interview on 2/12/24, at 10:50 a.m. NA Employees E36, E37, and E38 were asked how they know what level of staff assistance for bed mobility is appropriate for a resident. They collectively stated that they would use the Kardex function in the electronic point of care charting portal. During an interview on 2/12/24, at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to make certain that residents were free from neglect that resulted in actual harm of a skin tear, and neglect of notifying a physician and procuring order for the care of the skin tear, for one of nine residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to provide adequate supervision, implement effective fall interventions and utilize a mechanical lift as per order to promote resident safety resulting in a preventable accident and actual harm to one of 10 residents (Resident R1). Findings include: A review of the facility policy Hoyer Lift-Proper Use dated 5/26/21, indicated residents who are unable to transfer themselves independently or with minimum assistance shall be transferred safely with the Hoyer lift (a mechanical lift used to transfer residents) and two nursing staff are needed to transfer a resident using a Hoyer lift. A review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE], with diagnoses that included heart failure, [CONDITION(S)] (a mental disorder that causes hallucinations and delusions), history of a right [CONDITION(S)], and [CONDITION(S)] (a weakening of the bones). A review of Resident R1's quarterly MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 5/24/21, indicated that the diagnoses remained current. A review of Resident R1's care plan dated 5/26/21, indicated that Resident R1 was at risk of falls due to weakness and deconditioning, and impaired safety awareness. Facility staff would provide Resident R1 with appropriate assistive devices for safe transfers. The care plan stated that the resident required a mechanical lift with assist of two for transfers. Review of Resident R1's physician order dated 2/18/21, indicated that Resident R1 was to be transferred with a mechanical lift. A review of incident report dated 7/4/21, indicated at 10:38 a.m. Resident R1 complained of right lower extremity pain after transfer from the bed to the wheelchair. The physician was notified and examined the resident and ordered x-rays to rule out a fracture. A review of NA Employee E1 Witness Statement dated 7/7/21, indicated that the nurse aide pivoted (stand and turned) Resident R1 from bed to chair with NA Employee E2 without using a mechanical lift. A review of NA Employee E2 Witness Statement dated 7/7/21, indicated the nurse aide did not use a lift and had a hard time getting Resident R1 into the chair and when Resident R1 was in the chair she complained that her leg was broken. A review of Resident R1's Orthopedic (medical speciality that focuses on the skeletal system) consult dated 7/6/21, indicated a closed fracture of the distal end of the right femur. A review of NA Employee E1's employee transcript dated 5/18/21, indicated she had received education on proper body mechanics and use of a mechanical lift, and she was educated on abuse. A review of NA Employee E2's employee transcript dated 6/29/21, indicated she received education on proper body mechanics and use of a mechanical lift, and she was educated on abuse. During an interview on 7/16/21, at 11:00 a.m. the NHA confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 and E2, as they did not use a mechanical lift as ordered to transfer Resident R1. During an interview on 7/16/21, at 10:30 a.m. NA Employee E1 stated she transferred Resident R1 without a mechanical lift because someone on the floor told her it was ok. She stated she rarely worked with Resident R1. She stated she should have checked the transfer status for Resident R1 instead of listening to someone on the floor. During an interview on 7/16/21, at 11:05 a.m. NA Employee E2 stated that Resident R1 kept saying she was a transfer with a mechanical lift, and she could not stand, but NA Employee E1 said they could transfer with a 2 person assist and it would be ok. During an interview on 7/16/21, at 10:20 a.m. Medical Director Employee E3 confirmed Resident R1 could not stand and walk prior to the incident thus, was ordered a mechanical lift for all transfers. During an interview on 7/16/21, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to implement effective fall interventions and utilize a mechanical lift as per physician order resulting in a preventable accident and Resident R1 suffering actual harm from a fractured right femur. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (right femur fracture) for one of 10 residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse and Neglect Prevention dated 5/26/21, indicated the facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the implementation of screening, training, prevention, identification, investigation, protection, and reporting. A review of the facility policy Hoyer Lift-Proper Use dated 5/26/21, indicated residents who are unable to transfer themselves independently or with minimum assistance shall be transferred safely with the Hoyer lift (a mechanical lift used to transfer residents) and two nursing staff are needed to transfer a resident using a Hoyer lift. A review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R1's quarterly MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 5/24/21, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident R1's care plan dated 5/26/21, indicated that Resident R1 was at risk of falls due to weakness and deconditioning, and impaired safety awareness. Facility staff would provide Resident R1 with appropriate assistive devices for safe transfers. The care plan stated that the resident required a mechanical lift with assist of two for transfers. A review of Resident R1's current ADL sheet (Activities of Daily living sheet: document that provides resident level of assistance for nursing staff) undated, indicated that the resident was a transfer assist of two staff with a mechanical lift. A review of Resident R1's physician order dated 2/18/21, indicated that Resident R1 was to be transferred with a Hoyer lift (mechanical lift). A review of incident report dated 7/4/21, indicated at 10:38 a.m. Resident R1 complained of right lower extremity pain after transfer from the bed to the wheelchair. The physician was notified and examined the resident and ordered x-rays to rule out a fracture. A review of NA Employee E1 Witness Statement dated 7/7/21, indicated that the nurse aide pivoted (stand and turned) Resident R1 from bed to chair with NA Employee E2 without using a mechanical lift. A review of NA Employee E2 Witness Statement dated 7/7/21, indicated the nurse aide did not use a lift and had a hard time getting Resident R1 into the chair and when Resident R1 was in the chair she complained that her leg was broken. A review of an Orthopedic Consult dated 7/6/21, indicated a closed fracture of the distal end of the right femur. A review of NA Employee E1's employee transcript dated 5/18/21, indicated she had received education on proper body mechanics, and she was educated on abuse. A review of NA Employee E2's employee transcript dated 6/29/21, indicated she received education on proper body mechanics, and she was educated on abuse. During an interview on 7/16/21, at 11:00 a.m. the NHA confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 and E2, as they did not use a mechanical lift as ordered to transfer Resident R1. During an interview on 7/16/21, at 10:30 a.m. NA Employee E1 stated she transferred Resident R1 without a mechanical lift because someone on the floor told her it was ok. She stated she rarely worked with Resident R1. She stated she should have checked the transfer status for Resident R1 instead of listening to someone on the floor. During an interview on 7/16/21, at 11:05 a.m. NA Employee E2 stated that Resident R1 kept saying she was a transfer with a mechanical lift, and she could not stand, but NA Employee E1 said they could transfer with a 2 person assist. During an interview on 7/16/21, at 10:20 a.m. Medical Director Employee E3 confirmed Resident R1 could not stand or walk prior to the incident, thus was ordered a mechanical lift for all transfers. During an interview on 7/16/21, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that Resident R1 was free from neglect by not providing the necessary services, which resulted in Resident R1 suffering physical harm from a fractured right femur. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited 8/29/19, 11/8/19, 12/9/19, 12/23/19, 7/23/20, 10/1/20, 12/14/20, 12/18/20, 4/28/21. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. Previously cited 4/28/21. 28 Pa Code 211.12(d)(3) Nursing services. Previously cited 12/23/19, 12/18/20, 4/28/21.

Based on review of facility policy and records, observations and staff interviews , it was determined that the facility failed to consistently provide prescribed treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing and prevent worsening of pressure ulcers as required for nine of ten residents reviewed (R32, R59, R33, R28, R34, R35, R60, R61, and R38). This failure placed the facility in an Immediate Jeopardy situation for seven of eight residents with pressure ulcers (R33, R28, R34, R35, R60, R61 and R38). Findings include: A review of the facility policy, Pressure Ulcer Prevention Program, updated 3/22/21, previously updated 9/2/20, indicated the facility shall have a system in place that assures assessments are timely and appropriate and that the facility shall provide care, treatment, and services to promote the prevention of pressure ulcer development and promote the healing of pressure ulcers that are present. The policy further stated the facility's pressure ulcer prevention and treatment program shall include: -Identifying residents at risk for developing pressure ulcers. -Identifying the presence of pressure ulcers at the time of admission. -Identifying and evaluating the risk factors and change in the resident's condition. -Identifying and evaluating risk factors that can be removed or modified. -Implementing individualized, comprehensive plan of care (interventions) to attempt to stabilize, reduce or remove underlying risk factors. -Maintaining and improving tissue tolerance to pressure in order to prevent injury. -Meeting the nutritional needs of the resident. -Monitoring the effectiveness of interventions. -Modifying interventions as appropriate. -Education programs for staff, residents, and their families. A review of the facility policy, Physician Order Review - RN Verification dated 3/22/21, indicated that verification of orders entered into the computer or written on the Kardex shall be completed throughout the shift. Registered Nurse (RN)'s shall be responsible for verifying orders entered by the Unit Secretary. 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 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R32's clinical face sheet indicated he was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], indicated that Resident R32 required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R32 was at risk for development but had no unhealed pressure ulcers or injuries. Review of the facility, Admission Screen, (a cumulative assessment completed on admission/readmission that includes review of the following areas: demographics, medical history, muscle and skeleton, skin integrity, oral and nutrition, nervous system, respiratory system, heart and blood vessels, stomach and intestines, urine and reproductive system, sleep pattern, need for intravenous therapy, pain, risk for falls and safety needs, and sensory deficits). The skin integrity section assessment completed on 2/8/21, at 5:30 p.m. indicated that Resident R32 is at, high risk of pressure ulcer development. Review of the Resident R32's potential for skin integrity plan of care dated 2/12/21, included only facility-wide batch orders for pressure ulcer care. Facility-wide batch orders included the following: -Administer treatments as ordered and monitor for effectiveness. -Follow facility policies/procedures for prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -If resident refuses treatment, confer with the resident interdisciplinary team to determine why and try alternative methods to gain compliance. -Inform the resident/family/caregivers of any new areas of skin breakdown. -Monitor weights as ordered. -Monitor/document/report to medical doctor as needed changes in skin status. -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as directed. -The resident has a pressure reducing device on bed/chair. The resident needs assistance to turn/reposition every two hours, more often as needed or requested. Review of a nursing progress note dated 2/8/21, at 5:32 p.m. indicated that Resident R32 had, skin intact all over his body. During an interview and observation on 3/29/21, at 8:42 a.m. Resident R32 stated that his knee was in pain. The bony prominence on the outside of Resident R32's right knee had an open area. During a staff interview on 3/30/21, at 12:20 p.m. the Wound Nurse, Licensed Practical Nurse (LPN) Employee E1 stated that weekly skin checks, LN (Licensed Nurse) Weekly Skin Observation, a head to toe skin observation completed by floor nurses to identify any new skin areas) were completed by floor nursing staff in conjunction with the resident's shower days. The surveyor observations of 3/29/21, were communicated to LPN Employee E1 and she stated that she would assess Resident R32 that day. Record review on 3/29/21, at 11:00 a.m. indicated the most recent, LN Weekly Skin Observation, was completed on 3/4/21. Record review on 3/31/21, at 9:15 a.m. indicated that Resident R32 was assessed by LPN Employee E1 on 3/30/21, at 5:23 p.m. The note indicated three new wound areas: -Right lateral leg Stage II pressure injury that measured 2.0cm x 2.0cm x 0.1cm, 100% eschar (dry, dark scab or falling away of dead skin), and edges scabbed, peri wound (tissue surrounding a wound) scarred. -Left medial leg 4.5cm x 2.5cm x 0.2cm, an abrasion with pink scab. -Left inner ankle 1.0cm x 1.0cm x 0.3cm, 100% dry discolored black tissue. During an interview on 3/31/21, at 3:00 p.m. Wound Nurse LPN Employee E1 confirmed that the facility failed to complete weekly skin checks, and that Resident R32 had three new areas with an unknown start date, one of which was a pressure area. Review of Resident R32's plan of care did not reveal an update to include interventions for his developed pressure ulcer. Review of the physician's order dated 3/31/21, indicated to apply skin prep to Resident R32's right lateral leg, left inner ankle, and left medial leg. every day shift. Review of the treatment administration record (TAR) from 4/1/21, through 4/10/21, indicated that R32 did not have skin prep applied on: April: 1, 2, 3, 6, 7, 8, 9, and 10, 2021 During an interview on 4/23/21, at 9:25 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to prevent and timely identify Resident R32's wounds and failed to provide ordered interventions for Resident R32. Review of Resident R59's clinical face sheet indicated he was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], indicated that Resident R59 required supervision and assistance of one person for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R59 was at risk for development and had one Stage I pressure ulcer [intact skin with a localized area of non-blanchable (no color change with application of pressure) [CONDITION(S)] (redness)]. Review of the Braden assessment (determination of risk factors for development of pressure ulcers) completed 2/4/21, indicated that Resident R59 was at low risk of pressure ulcer development. Review of the facility, Admission Screen, skin integrity section dated 2/4/21, indicated that Resident R59 did not have any open areas on his skin. Review of the medical record indicated that no, LN Weekly Skin Observations, were completed for Resident R59. Review of the, Weekly Wound Assessment, (a detailed assessment of a known wound) dated 3/3/21, indicated Resident R59 had a newly developed unstageable pressure wound area on the coccyx (the tailbone), with wound dimensions (in centimeters) of L 3.5 x W 2.5 x D UTD. The wound was documented to be painful, have 100% pale yellow slough (dead tissue that needs to be removed for wound to heal), dry edges macerated, peri wound scarred. Review of the Resident R59's skin integrity plan of care dated 2/12/21, included only facility-wide batch interventions. Review of the physician's order dated 3/3/21, indicated that R59 was ordered to have his coccyx pressure wound cleaned and dressed daily. Review of the TAR from 3/3/21, through 4/18/21, indicated that R59 was not documented as having received his dressing changed: March: 3, 4, 5, 7, 11, 13, 16, 17, 19, 20 ,21, 28, 29, 30, 31, 2021 April: 1, 2, 4, 10, 11, 15, and 17, 2021 Review of facility census information indicated that Resident R59 was not hospitalized or on any leave of absence on these dates. Review of the, Weekly Wound Assessment, completed on 4/12/21, indicated an increase in wound dimensions (in centimeters) of L 4.5 x W 3.5 x D UTD. The wound was documented to be painful, 100% dry yellow slough, edges intact, peri wound is warm and red, no drainage. During an interview on 4/23/21, at 9:25 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to prevent deterioration of a wound and failed to implement ordered interventions for Resident R59. Review of the clinical face sheet indicated Resident R33 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], indicated that Resident R33 required supervision and assistance of one person for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R33 was at risk for development and had one unstageable pressure ulcer (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 or eschar). Section C: Cognitive Patterns indicated that Resident R33 had a BIMS Summary Score of 15, cognitively intact. Review of the Braden assessment completed 1/26/21, indicated that Resident R33 was at very low risk of pressure ulcer development. Review of the Admission Screening dated 1/26/21, indicated that Resident R33 had a pressure wound located on his coccyx. Review of the physician's order dated 1/27/21, indicated that R33 was ordered to have his coccyx pressure wound cleaned with normal saline solution, patted dry, Santyl (medication that removes dead skin from wounds), patted dry, calcium alginate (absorbent dressing containing calcium fibers) dressing applied, and covered with a dry dressing. Review of the Weekly Wound Assessment completed on 1/29/21, by Wound Nurse LPN Employee E1 indicated the presence of an unstageable coccyx pressure wound with wound dimensions (in centimeters) of L 2.0 x W 5.0 x D UTD, 100% moist yellow slough, edges macerated, peri wound intact, and pain present. Review of the Resident R33's skin integrity plan of care dated 2/3/21, included only facility-wide batch interventions. Review of the TAR from 1/27/21, through 4/14/21, indicated that R33 was not documented as having received his dressing changed: January: 30, 2021 February: 11, 15, 18, ,23, and 28, 2021 March: 5, 11, 13, 27, 28, 29, and 30, 2021 April: 4, and 10, 2021 Review of the, Weekly Wound Report completed on 3/10/21, indicated an increase in wound dimensions (in centimeters) of L 4.0 x W 4.8 x D 0.5, 100% visible granulation, edges callused with moist yellow slough. Review of the medical record indicated, Weekly Wound Reports, were completed by Wound Nurse LPN Employee E1 on 3/30/21, 4/5/21, and 4/12/21. The report completed on 4/12/21, indicated that Resident R33's coccyx pressure wound had resolved. During an interview on 4/22/21, at 10:54 a.m. Resident R33 stated his wound has not resolved. He further stated the facility staff are overwhelmed and unable to complete his dressing changes. Resident R33 then stated that he completed his own dressing changes on his coccyx wound. During a wound observation requested by the surveyor on 4/22/21, at 11:02 a.m. LPN Employee E101 indicated that Resident R33's wound was not healed and had a small open area. Resident R33 then took a large zippered plastic bag from his drawer with [MEDICATION(S)] and island dressings inside, stating that he used those items when he completed his own dressing changes. Review of the, LN Weekly Skin Observation, completed on 4/23/21, by Wound Nurse LPN Employee E1 indicated, Reopened scabbed area from previously resolved pressure injury, 0.7cm x 0.2cm x 0.4cm undermining 11 o'clock to 2 o'clock deepest at 12 o'clock by 2.2cm, Unable to visualize wound bed, 100% epithelial tissue of what is visible. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to implement ordered interventions to prevent deterioration of a pressure ulcer for Resident R33. Review of the clinical face sheet indicated Resident R28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], indicated that Resident R28 required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R28 was at risk for development and had one Stage III pressure ulcer (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 the Braden assessment completed 9/11/20, indicated that Resident R28 was at high risk of pressure ulcer development. Review of the skin integrity plan of care updated 12/7/20, 2/19/21, and 3/13/21 , included facility-wide batch interventions, and additional interventions for the use of a palm guard, to monitor placement of PRAFO boots (Pressure Relief Ankle Foot Orthosis - boots designed to remove pressure from the back of the heel to help heal and prevent pressure ulcers and muscle tightness), and the presence of a pressure relieving device on the bed. Review of the, Weekly Wound Report, completed by Wound Nurse LPN Employee E1 dated 11/12/20, indicated a newly developed Stage III wound area on the left outer ankle, with wound dimensions (in centimeters) of L 1.0 x W 1.0 x D 0.1. The wound was documented to have 100% granulation tissue and edges macerated (occurs when too much moisture is trapped between the wound and its bandage). Review of Resident R28's physician's order dated 11/13/20, indicated to cleanse left outer ankle with NSS, pat dry. Apply DermaCol Ag (wound care dressing that transforms into a soft gel sheet when in contact with wound drainage) to wound bed and cover with a bordered dressing. Change daily. The order was changed on 1/29/21, to cleanse left outer ankle with normal saline, pat dry. Apply skin prep to peri wound. Apply Santyl to wound bed followed by calcium alginate and cover with a bordered dressing. Change daily and prn. The order was changed on 2/26/21, to cleanse left outer ankle with normal saline, pat dry. Apply skin prep to peri wound. Apply AG/alginate and cover with a bordered dressing. Change daily and prn. Review of the, Weekly Wound Report, completed by Wound Nurse LPN Employee E1 dated 4/23/21, indicated left ankle Stage III pressure wound dimensions (in centimeters) of L 1.4 x W 1.5 x D 0.9. The wound was documented to 99% exposed hardware, 1% granulation tissue, edges macerated, peri wound scarred. Moderated amount of serous drainage. These changes constituted an increase in wound size and depth, less healing tissue, and the presence of scarring. Review of the TAR from 11/14/20, through 4/25/21, indicated that Resident R28 did not have her dressing changed on: November: 15, 16, 18, 19, 20, 23, 25, 28 ,29, 30, 2021 December: 1, 2, 3, 7, 9, 11, 12, 13, 14, 16, 17 21 ,25 ,27, 28, 30, 2021 January: 3, 4, 5, 8, 9, 10, 11, 13, 14, 15, 16, 17, 21, 22, 23, 25, 26, 27, 29, 2021 February: 1, 2, 3, 4, 5, 6, 8, 9, 12, 16, 17, 18, 19, 20, 22, 2, 24, 25, 26, 27, 2021 March: 1, 2, 3, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 25, 27, and 29, 2021 April: 4, 7, 8, 11, 12, 15, 17, 19, 21, 22, 25, 2021 Review of facility census information indicated that Resident R28 was not hospitalized or on any leave of absence on these dates. During an interview on 4/21/21, at 1:10 p.m. Wound Nurse LPN Employee E1 stated that residents unable to reposition on their own are turned and repositioned by staff every two hours. Observations completed on 4/22/21, at 8:30 a.m., 10:38 a.m., 12:45 p.m. and 2:20 p.m. revealed Resident R28 to be laying on her back each time. During an interview on 4/22/21, at 2:24 p.m. LPN Employee E106 confirmed that Resident R28 had not been moved throughout the day. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to identify a wound timely, failed to prevent wound deterioration by providing ordered interventions and turning and repositioning Resident R28. Review of clinical face sheet indicated that Resident R34 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], indicated that Resident R34 was totally dependent and required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R28 was at risk for development and had three Stage IV pressure ulcers (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) which were not present on admission. Review of the Braden assessment completed 7/31/20, indicated that Resident R34 was at very high risk of pressure ulcer development . Review of Resident R34's skin integrity plan of care dated 5/19/20, recently updated 3/22/21, included facility-wide batch interventions and additional interventions of floating heels on pillows while in bed, nutritional supplement as ordered, needs moisturizer applied to skin daily, and to use Dove soap for all baths and showers. Review of the, Weekly Wound Report, completed by Wound Nurse LPN Employee E1 dated 1/14/21, indicated a new unstageable pressure wound on the left buttock, with wound dimensions (in centimeters) of L 6.5 x W 6.2 x D UTD. During an interview on 4/23/21, at 8:30 a.m. Wound Nurse LPN Employee E1 stated that when she completes the, Weekly Wound Assessments, it is for recognized wounds that the wound care team is following. She stated the, LN Weekly Skin Observations, should continue to be done by licensed floor nursing staff even if the resident is being followed by the wound care team, as that is a whole-body check to discover new areas. Review of the medical record indicated that prior to the identification of Resident R34's left buttock pressure wound; the most recent, LN Weekly Skin Observation, was completed on 9/19/21. Review of the physician's order dated 1/19/21, indicated that Resident R34 was ordered to have her buttocks pressure wound cleansed with Dakin's 0.125% solution. Pat day. Apply compound cream and cover with silicone foam daily and as needed for soiling and displacement. A physician's order dated 2/18/21, updated 3/10/21, increased her dressing changes to twice daily. Review of the, Weekly Wound Report, dated 4/20/21, indicated wound dimensions (in centimeters) of L 4.0 x W 6.0 x D 1.5. Review Resident R34's TAR from 1/19/21 through 4/25/21, indicated that Resident R34 did not have her dressing changed on: January: 22, 23, 25, 26, 27, 29, 30, 31, 2021 February (day): 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 15, 18, 19, 21, 22, 25, and 27, 2021 February (evening): 21, 22, 25, and 26, 2021 March (day): 1, 3, 4, 5, 6, 8, 11, 12, 13, 14, 15, 20, 22, 24, 25, 26, 27, 29, and 30, 2021 March (evening): 1, 3, 4, 8, 10, 12, 15, 16, 17, 18, 19, 20, 21, 24, 25, 26, 27, 29, 30, 2021 April (day): 1, 2, 3, 5, 6 ,7, 8, 9, 10, 12, 15, 17 19, 22, 2021 April (evening): 2 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15, 18, 19, 20, 22, 23, 25, 26, 2021 Review of facility census information indicated that Resident R34 was not hospitalized or on any leave of absence on these dates. Observations completed on 4/22/21, at 8:30 a.m., 11:00 a.m., 12:53 p.m. and 2:32 p.m. revealed Resident R34 to be laying on her back each time. During an interview on 4/22/21, at 2:32 p.m. LPN Employee E35 stated she had thought the hospice staff were turning Resident R34. Review of medical record on 4/23/21, at 3:30 p.m. indicated a current order dated 10/10/20, of Cleanse left popliteal (hollow in the back of the knee) wound with Dakin's 0.125% solution, pat dry. Apply skin prep to wound edges and peri wound, allow to dry. Cover wound bed with calcium alginate (cut to fit wound bed), cover with foam dressing. Change daily and prn (as needed) for excessive drainage. Review of wound consultation notes dated 3/10/21, indicated the order to be changed to 0.25% [MEDICATION(S)] cleanse, pat dry, apply Ag alginate to the wound base, and cover with a dry dressing every day and prn. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to identify timely and failed to prevent deterioration by providing ordered interventions including turning and positioning for Resident R34. During an interview on 4/24/21, at 1:30 p.m. the DON confirmed that the physician's orders were not updated with the new order of 3/10/21, and that Resident R34 received the previous outdated orders from 3/10/21, through 4/24/21. Review of the clinical face sheet indicated that Resident R35 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], indicated that Resident R35 required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R35 was at risk for development and had one Stage IV pressure ulcer. Review of the facility, Admission Screen, completed on 3/9/21, at 6:48 p.m. indicated the presence of a coccyx wound, Review of the Braden assessment completed on 3/10/21, indicated that Resident R35 was at very high risk of pressure ulcer development. Review of Resident R35's skin integrity plan of care dated 3/22/21, included facility-wide batch interventions and additional interventions of providing supplements, and moisturizer applied to skin daily. Review of the physician's order dated 3/10/21, indicated that Resident R35 was ordered to have his coccyx/sacral pressure wound bed cleansed with 1/4 strength Dakin's solution. Apply 4x4 gauze soaked in 1/4 strength Dakin's solution, cover with [MEDICATION(S)] dressing (absorptive dressing with waterproof outer layer). Change BID and as needed for soiling/drainage. Review of the, Weekly Wound Report, dated 3/10/21, indicated coccyx wound dimensions (in centimeters) of L 7.5 x W 5.0 x D 1.5 with Undermining 12 o'clock to 12 o'clock deepest at 9 o'clock by 2.0cm, 75% moist yellow slough, 25% granulation tissue, mild odor. Review of Resident R35's TAR from 3/10/21 through 4/25/21, indicated did not receive his dressing changed on: March (day): 11, 12, 14, 15, 16, 17, 20, and 29, 2021 March: (evening): ,12, 13, 17, 18, 19, 20, 21, 23, 27, 28, 29, and 31, 2021 April (day):1, 2, 3, 4, 11, 15, and 18, 2021 April (evening): 1, 4, 8, and 25, 2021 Review of the, Weekly Wound Report, dated 3/30/21, indicated coccyx wound dimensions (in centimeters) of L 7.5 x W 6.0 x D 4.5. The wound was documented to have undermining 9 o'clock 5 o'clock deepest at 1 o'clock by 3cm, 80% moist yellow slough, 20% moist granulation tissue. Odor present, moderate amount of serosanguinous drainage. These changed constitute an increase in depth of the wound, size of undermining, an increase in dead tissue, less healing tissue, and a strong wound order. Observations completed on 4/22/21, at 8:30 a.m., 11:04 a.m., 12:53 p.m. and 2:35 p.m. revealed Resident R35 to be laying on his back each time. Review of medical records on 4/23/21, at 3:30 p.m. indicated the above order dated 3/10/21, of coccyx/sacral pressure wound bed cleansed with 1/4 strength Dakin's solution. Apply 4x4 gauze soaked in 1/4 strength Dakin's solution, cover with [MEDICATION(S)] dressing (absorptive dressing with waterproof outer layer). Change BID and as needed for soiling/drainage to be the order that was currently being administered by staff. Review of wound consultation notes dated 3/19/21, indicated the order to be changed to 0.125% Dakin's irrigation and cleanse, pat dry, apply Santyl to the necrotic areas of the wound bases every morning, then fill the cavity and undermined area with 0.125% Dakin's moistened roll gauze and cover with a dry dressing twice per day and as needed. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to provide ordered interventions and failed to turn and reposition Resident R35. During an interview on 4/24/21, at 1:30 p.m. the DON confirmed that the physician's orders were not updated with the new order of 3/19/21, and that Resident R35 received the previous outdated orders from 3/10/21, through 4/24/21. Review of the clinical face sheet indicated that Resident R60 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS dated [DATE], indicated that Resident R60 was totally dependent and required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R35 was at risk for development and had one Stage II and one Stage III pressure ulcer. Review of the Braden assessment completed 2/3/21, indicated that Resident R60 was at very high risk of pressure ulcer development. Review of the Resident R60's skin integrity plan of care dated 2/18/21, included facility-wide batch interventions and additional interventions for moisturizer applied to skin daily, and to provide nutritional supplements as ordered. Review of the facility, Admission Screen, completed on 2/4/21, at 12:18 a.m. indicated the presence of a sacrum (bone in the lower back situated between the hipbones) pressure wound. Review of the physician's order dated 2/4/21, indicated to cleanse sacrum wound with normal saline solution, pat dry, apply skin prep to peri wound, apply AG/alginate to wound bed, cover with a dry dressing. The order updated 2/18/21, indicated to cleanse sacrum wound with normal saline solution, pat dry, apply skin prep to peri wound, apply [MEDICATION(S)] to wound bed, cover with a dry dressing. Review of the, Weekly Wound Report, dated 2/4/21, indicated a Stage III sacrum wound dimensions (in centimeters) of L 5.5 x W 5.8 x D 0.3 with 100% granulation tissue. Review of Resident R60's TAR from 2/4/21through 4/25/21, indicated did not have her dressing changed on: February: 7, 8, 9, 10, 11, 12, 13, 14, 15, 23, 24, 26, and 28, 2021 March: 5, 7, 13, 16, 18, 19, 29, 30, and 31, 2021 April: 1, 2, 4, 5, 6, 8, 15, 18, and 21, 2021 Review of the, Weekly Wound Report, dated 4/23/21, indicated a Stage III sacrum wound dimensions (in centimeters) of L 3.9 x W 4.1 x D 0.1. The wound was documented as 100% moist red granulation tissue, edges macerated, peri wound has open moisture associated skin damage dimensions (in centimeters) of L 1.7 x W 0.6 x D 0.0. Observations completed on 4/22/21, at 8:50 a.m., 11:03 a.m., 12:45 p.m. and 2:34 p.m. revealed Resident R60 to be laying on his back each time. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to provide ordered interventions and failed to turn and reposition Resident R60. Review of the clinical face sheet indicated that Resident R61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE], indicated that R61 was totally dependent and required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R61 was at risk for development and had one Stage IV pressure ulcers. Review of the Braden assessment completed 2/20/20, indicated that Resident R61 was at moderate risk of pressure ulcer development. Review of Resident R61's skin integrity plan of care dated 3/9/20, most recently updated 1/28/21, included facility-wide batch interventions and additional interventions of using a wedge on the right side and to float heels on pillows while in bed. Observations completed on 4/22/21, at 8:30 a.m., 10:39 a.m., 12:53 p.m. and 2:18 p.m. revealed Resident R61 to be laying on his back each time. Review of medical record on 4/23/21, at 3:30 p.m. indicated a current order dated 3/1/21, of, Cleanse left heel with Normal saline solution. Pat dry. Apply Skin prep to wound edges. Apply Collagen powder to wound bed. Cover with ABD pad and wrap with kerlix every Monday, Wednesday, and Friday. Review of wound consultation notes dated 4/19/21, indicated to discontinue the treatment regimen, begin normal saline solution cleanse, pat dry, apply calcium alginate to the wound area, and cover with a foam dressing every Monday, Wednesday, and Friday for protection. During an interview on 4/23/21, at 9:25 a.m. the NHA and the DON confirmed that the facility failed to turn and reposition Resident R61. Review of the clinical face sheet indicated that Resident R38 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], indicated that R38 required extensive assistance of two persons for bed mobility and Section G: Determination of pressure ulcer risk indicated that Resident R61 was at risk for development and had no pressure ulcers. Review of the Braden assessment completed 9/6/20, indicated that Resident R38 was at moderate risk of pressure ulcer development. Review of the skin integrity plan of care dated 9/8/20, most recently updated 3/16/21, included facility-wide batch interventions and additional interventions of applying protective ointment to bony prominences, floating heels on pillows while in bed, apply moisturizer to skin daily, and to provide supplemental vitamins/minerals. Review of the, Weekly Wound Report, dated 4/16/21, indicated a newly developed Stage III right buttock wound dimensions (in centimeters) of L 4.5 x W 4.5 x D 0.5. The wound was documented as moist granulated tissue, edges macerated, peri wound scarred. Review of the physician's order dated 4/20/21, indicated to apply [MEDICATION(S)] solution 0.25 % to buttock topically every shift for buttock wound. Cleanse buttoc

Based on observations, review of clinical records, facility policies, and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to investigate, document surveillance of and implement preventative measures timely, to address an outbreak of gastrointestinal (GI, relating to the stomach and the intestines) illness resulting in actual harm to 29 of 95 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21,R22, R23, R24, R25, R26, R27, R28 and R29) and failed to provide education to staff members on GI illness and additional handwashing requirements for 89 of 115 employees. Findings include: The Center for Disease Control and Prevention (CDC), Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated [DATE], indicated that healthcare settings that experience an outbreak of gastroenteritis/norovirus should implement the following: Cohorting (residents with symptoms of illness are moved into the same room) and Isolation Precautions -Avoid exposure to vomitus or diarrhea. -Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. -If norovirus gastroenteritis infection is suspected, adherence to personal protective equipment -PPE (gloves, gowns, masks and/or face shields worn to protect the care giver from infection) use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material. -During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. -Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks. -Consider suspending group activities (e.g., dining events) for the duration of a norovirus gastroenteritis outbreak. -Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis. -During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. -Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within ,d+[DATE] days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. The facility policy entitled, Policy for Outbreak Investigation, dated [DATE], previously updated [DATE], indicated that the Infection Preventionist (IP) will conduct the outbreak investigation. Outbreak monitoring and reporting will continue until resolution. Narrative and/or verbal reports will be completed and forwarded to appropriate state and local agencies as required. An outbreak should be suspected if there is a commonality of symptoms among resident and staff. Staff should be educated on communication of information for line lists (surveillance tool for identification of individuals with symptoms for infection control purposes) of ill residents and staff, the need for specimen collection, more frequent vital signs, and intake and output and scrupulous and frequent handwashing. The IP should implement infection control and prevention measures, provide timely and effective monitoring of ill residents, develop a line listing, and update daily, notify state and local health officials, review data for evidence of resolution and communicate findings to employees, medical and administrative staff. Review of the Pennsylvania Department of Health, GI Illness Outbreak Recommendations Checklist, (for GI illness outbreaks in Pennsylvania ' s long-term care facilities) dated [DATE], indicated that for the duration of the outbreak, the facility should increase the frequency of hand hygiene audits and provide written and verbal feedback to staff. The facility policy entitled, Procedure for Isolation - Initiation of Isolation Precautions, dated [DATE], previously updated [DATE], indicated that staff should use the CDC, Guidelines for Isolation Precautions to determine infective materials, precautions needed, duration of precautions, etc. Contact transmission-based precautions are necessary when illness is transmitted by direct contact. Recommendations include gloves, gown, private room or cohorting, designate dedicated items such as blood pressure cuffs, stethoscope, thermometer, for use only on that resident. Signs alerting staff and visitors to see the nurse before entering should be placed on the door, all soiled/contaminated trash and linen should be separately bagged before leaving the room. All PPE should be applied when entering and removed prior to leaving the room, handwashing performed before and after care. The facility policy entitled, Norovirus Outbreak - Cleaning and Disinfection, dated [DATE], previously updated [DATE], indicated that standard precautions for handling soiled resident-service items or linens, include the use of appropriate PPE. On [DATE], at 9:45 a.m. the facility was provided confirmation from the county health department that the GI illness was caused by norovirus. Review of documentation submitted by the facility dated [DATE], indicated that residents began displaying symptoms of nausea, vomiting and diarrhea on [DATE], and 22 residents were presently affected. The documentation also indicated that isolation precautions adhering to the Center for Disease Control and Prevention (CDC) guidelines were immediately implemented and further stated, since identifying the spread of the organism to multiple residents and staff, all of the following had been put into place and maintained. Extensive education has been provided to all staff in the building related to contact isolation and precautions. Line listing maintained of all residents affected. All staff caring for affected residents must wear gloves and gowns and keep soiled linen double bagged and safe. Meetings are now being conducted daily to include a multidisciplinary team making sure that all safeguards are in place to protect both staff and residents. In addition, the situation is being reviewed by the Director of Nursing (DON) and the Nursing Home Administrator (NHA) in morning meeting to address any new issues. The County Health Department will be consulted, and the facility will continue to follow CDC guidelines. Observations on [DATE], beginning at 8:05 a.m. revealed that the following interventions for GI illness stated to be completed in the documentation provided by the facility of [DATE], were not put into place: -Isolation precautions were not instituted for symptomatic residents -Education was not provided to all staff members -Line listing was not created -Staff were not wearing gowns -Soiled linen was not double bagged -County Health Department was not contacted During an interview on [DATE], at 10:45 a.m. the NHA indicated that the local health department had not been contacted about the outbreak. During observations on [DATE], at 11:15 a.m. the Seventh Floor Nursing Unit found no infection control precaution signs on resident doors or personal protective equipment or biohazard bags or bins for discarding contaminated trash and linens stocked in or around the resident rooms. During an interview on [DATE], at 11:20 a.m. Licensed Practical Nurse (LPN) Employee E3, confirmed that there were no infection control precautions put in place for the Seventh Floor Nursing Unit residents in response to the outbreak of GI illness. LPN Employee E3 stated that the residents were told to stay in, isolation meaning they should not leave their rooms and confirmed that there were no supplies of PPE or biohazard bags or bins in the resident rooms. LPN Employee E3 also stated that she was not provided in-service education regarding the outbreak of GI illness. Review of facility census information indicated that Residents R1, R2, R5, R6, R7, R23, R24, and R28 resided in the Seventh Floor Nursing Unit. Review of the line list on [DATE], indicated that these residents had active GI illness symptoms. During an interview on [DATE], at 11:25 a.m. the Infection Preventionist (IP) Employee E1 stated that she had not yet developed a surveillance line listing for the outbreak, she stated that the Certified Registered Nurse Practitioner (CRNP) Employee E2 had given her a list of 22 resident's names that had GI symptoms develop since [DATE]. During an interview on [DATE], at 11:25 a.m. the Infection Preventionist (IP) Employee E1 stated that she had not yet put in place a method to track residents with signs and symptoms of possible GI illness. When asked about the infection control precautions that had been implemented in response to the outbreak of GI illness, IP Employee E1 stated that she had, isolated people by telling them to remain in their rooms but did not prohibit residents without symptoms from utilizing the same bathrooms as residents with symptoms. The IP Employee E1 confirmed that there was not PPE supplies and biohazard containers or bins. Also, receptacles for contaminated linen had not been put in or near the rooms of affected residents. During an interview on [DATE], at 11:30 a.m. LPN Employee E3 confirmed that there were no isolation precautions, PPE, or linen/trash bags for the above listed rooms. During an interview on [DATE], at 11:30 a.m. LPN Employee E3 confirmed that she had not been given any education regarding the infection precautions and control for the outbreak of GI illness. During an interview on [DATE], at 11:40 a.m. Housekeeping Employee E7 confirmed that she had not been given any education regarding the infection precautions and control for the outbreak of GI illness. During an interview on [DATE], at 12:05 p.m. CRNP Employee E2 stated that she became aware of the first resident (Resident R1) suffering symptoms of GI illness on [DATE], and had contacted the Medical Director when more cases arose. She relayed concern to the Medical Director after Resident R12 had expired on [DATE], and the facility had failed to implement any infection control and prevention measures in response to the outbreak, despite being advised to do so by herself and the Medical Director. The CRNP Employee E2 also indicated that she had experienced GI illness symptoms the day after performing CPR on Resident R20. During an interview on [DATE], at 12:40 p.m. the Medical Director stated that she had become aware of the outbreak of GI illness with symptoms [MEDICATION(S)] 24 to 48 hours, after the initial case appeared [DATE], and had advised the Administrator, Infection Preventionist and nursing staff to implement infection control precautions for GI illness, including isolation and cohorting symptomatic residents, use of PPE, performing stool testing as ordered, and increasing hand washing and sanitizing/cleaning of all areas including the kitchen. The Medical Director indicated that on [DATE], she called a meeting of the Nursing Home Administrator, the CRNP, the Infection Preventionist and the Registered Nurse Supervisor Employee E4 out of great concern over the spread of the infection to 29 residents including the death of two residents with symptoms of the GI illness. She informed the RN Supervisor Employee E4 that the facility should implement CDC guidelines for infection prevention precautions and control for GI illness and monitor all residents for development of symptoms and changes of condition. The Medical Director confirmed that infection control prevention, has been a problem since day one, and that the staff failed to implement the infection control and prevention precautions and monitoring as she directed. An observation on [DATE], at 3:45 p.m. revealed an individual carrying food delivery containers in plastic bags entering the facility. During an interview on [DATE], at 8:15 a.m. RN Supervisor Employee E4 confirmed the she had submitted documentation to the Pennsylvania Department of Health on the GI outbreak on [DATE]. RN Supervisor Employee E4 stated she had been advised of the outbreak by the CRNP Employee E2 on [DATE]. RN Employee E4 confirmed that the IP Employee E1 called her on [DATE], and had asked her, what she needed to do. RN Employee E4 told her to put PPE caddies on the doors of rooms with symptomatic residents, educate all staff on infection control precautions, stop outside food from being brought in, sanitize kitchen and all refrigerators and equipment, and possibly test the water. RN Employee E4 stated that after a meeting was held by the Medical Director on [DATE], she told IP Employee E1 to start a surveillance line listing and update with new cases, implement infection control precautions and isolate residents following CDC guidelines for GI illness, educate and increase handwashing for all staff, implement extra sanitizing and cleaning by housekeeping, and bed side commodes should be used to avoid infection spread to roommates. RN Employee E4 confirmed that she didn't know what was actually implemented in response to her advice. Observations of the Fifth Floor Nursing Unit on [DATE], at 11:25 a.m. revealed that Resident R9's room had a, See the Nurse infection precautions sign and PPE in a door hanger but that no other rooms had door hangers containing PPE, no biohazard bags or barrels for disposal of contaminated trash and linen. Housekeeping Employee E7 was observed to be cleaning Resident R9's room without donning a gown and gloves. During an interview on [DATE], at 11:40 a.m. Housekeeping Employee E7 confirmed that the only resident room that had PPE and signage was Resident R16's room. Housekeeping Employee E7 confirmed that she had not been given any education regarding the infection precautions and control for the outbreak of GI illness. On [DATE], the facility provided as list of residents with GI illness and their symptom start dates. Review of the facility census documentation indicated the following non-symptomatic residents became symptomatic for GI illness after remaining cohorted in the same room, with shared restroom facilities as symptomatic residents. Review of progress notes indicated on [DATE], Resident R12 experienced nausea, vomiting, and diarrhea and remained cohorted with Resident R6 who then experienced nausea, vomiting, and diarrhea on [DATE], 2 days later. Review of progress notes indicated on [DATE], Resident R20 experienced nausea, vomiting, and diarrhea and remained cohorted with Resident R11 who began experienced nausea, vomiting, and diarrhea on [DATE], 2 days later. Review of progress notes indicated on [DATE], Resident R26 experienced nausea, vomiting, and diarrhea and remained cohorted with Resident R18 who began experienced nausea, vomiting, and diarrhea on [DATE], 2 days later. Review of progress notes indicated on [DATE], Resident R13 experienced nausea, vomiting, and diarrhea and remained cohorted with Resident R17 who began experienced nausea, vomiting, and diarrhea on [DATE], 1 day later. Record review on [DATE], revealed the following residents remain cohorted with asymptomatic roommates: Review of progress notes and bowel records indicated that Resident R1 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R44 who was asymptomatic. Review of progress notes indicated Resident R2 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R43 who was asymptomatic. Review of progress notes indicated Resident R3 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R45 who was asymptomatic. Review of bowel records indicated Resident R23 began having diarrhea on [DATE], and nausea and vomiting on [DATE]. Resident R23 remained cohorted with Resident R46 who was asymptomatic. Review of progress notes indicated Resident R25 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R47 who was asymptomatic. Review of progress notes indicated Resident R27 experienced nausea and vomiting on [DATE], and remained cohorted with Resident R48 who was asymptomatic. Review of progress notes indicated Resident R4 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R49 who was asymptomatic. Review of progress notes and bowel records indicated Resident R21 experienced nausea and vomiting on [DATE], and remained cohorted with Resident R50 who was asymptomatic. Review of progress notes indicated Resident R5 experienced nausea and vomiting on [DATE], and diarrhea on [DATE]. Resident R5 remained cohorted with Resident R51 who was asymptomatic. Review of progress notes indicated Resident R7 experienced nausea and vomiting on [DATE], and remained cohorted with Resident R52 who was asymptomatic. Review of progress notes and bowel records indicated Resident R8 experienced nausea, vomiting, and diarrhea on [DATE], and remained cohorted with Resident R53 who was asymptomatic. Review of progress notes indicated Resident R10 experienced nausea and diarrhea on [DATE], and vomiting on [DATE]. Resident R10 remained cohorted with Resident R55 who was asymptomatic. Review of progress notes and bowel records indicated Resident R22 experienced nausea and diarrhea on [DATE], and remained cohorted with Resident R56 who was asymptomatic. An observation of the Fifth Floor on [DATE], at 10:25 a.m. revealed Resident R33 had PPE on a door carrier however no other resident rooms were noted to have PPE available, there were two boxes of gloves located on the hand rails in the hallway. During an interview on [DATE], at 10:30 a.m. the observations listed above were confirmed by Environmental Services Employee E6. During an interview on [DATE], at 9:30 a.m. the NHA provided a list of staff who had been provided education on handwashing and GI illness care based on the current GI illness outbreak the facility was experiencing. During an interview on [DATE], at 12:31 p.m. the NHA confirmed that the infection control PPE stock set-up units were just now being put in the rooms for the residents with GI illness. The NHA stated that she, did not know what to do, in response to the outbreak. During a review of the signed education rosters for the, Handwashing and, GI Virus education the following was revealed: Administrative Employees E12, E13, and E14, did not receive handwashing or GI illness education. Clerical Employees E15, E16, E17, E18, E19, E20, and E21, did not receive handwashing or GI illness education. Dietary Department Employees E22, E23, E24, E25, E26, E27, E28, E29, E30, E31, E32, E33, and E34, did not receive handwashing or GI illness education. Environmental Services Department Employees E36, E37, E38, E39, E40 and E41, did not receive handwashing or GI illness education. Laundry Department Employees E42 and E43, did not receive handwashing or GI illness education. Licensed Practical Nurse Employees E44, E45, E46, E47, E48, E49, E50, E51, and E52, did not receive handwashing or GI illness education. Maintenance Employee E53, did not receive handwashing or GI illness education. Nurse Aide Employees E54, E55, E56, E57, E58, E59, E60, E61, E62, E63, E64, E65, E66, E67, E68, E69, E70, E71, E72, E73, E74, E75, E76, and E77, did not receive handwashing or GI illness education. Registered Nurse Employees E78, E79, E80, E81, E82, E83, E84, E85, E86, E87, E88, E89, E90, E91 and E92, did not receive handwashing or GI illness education. Therapy Department Employees E94, E95, E96, E97, E98, E99, and E100, did not receive handwashing or GI illness education. The NHA and the Medical Director were made aware that an Immediate Jeopardy situation existed for residents on [DATE], at 12:30 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On [DATE], at 4:45 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Full house sweep of all residents in the building and those with symptoms need to be moved. -Infection control nurse will be creating a schematic regarding which residents will need to be moved and to where. Moving and cohorting will be done by end of the day today by all available staff. [DATE]. -Residents will be moved to cohort all residents in a newly formed GI isolation area who all have symptoms together on the 4th floor. Residents will remain in isolation for at least 48 hours after symptoms resolve. We will also be placing roommates of infected residents into a temporary isolation for 48 hours to make sure they do not develop symptoms. -Housekeeping will be deep cleaning hallways and infected residents' rooms by end of day today [DATE]. -Family letter was sent to notify responsible parties of infection [DATE]. -Education begins immediately by RN supervisor and Human Resources with everyone and oncoming staff will be done for the staff with the following subjects: By Thursday [DATE] at 5 PM. -Staff will not work until educated --Signs and Symptoms of GI Virus --Handwashing with soap and water --Infection control of a GI Virus --Food Products-not allowed to bring food in from outside --Appropriate donning and doffing of PPE -Stool specimens from two patients with active symptoms were collected and sent to both the county and to [NAME] lab for testing on [DATE]. Results will be reported to MD for further action. This was overseen by the DON. -PPE signage and equipment will be made available for all treatment areas and specifically gowns and gloves for contact precautions and will be checked by all shift supervisors in all shifts. Nursing supervisor has created appropriate signage and placed on [DATE], and PPE stocking will be overseen by Central Supply by [DATE]. -The Audit tool recommended by the CDC guidelines that will be utilized will contain the following items: This will be reviewed at the QAPI Committee and Infection Control meetings. -Patients with suspected norovirus GI illness will be on contact precautions until symptom free at least 24 hours. -Hand hygiene -Equipment Cleaning -Cohort residents -Restricted Activities -Serve Meals in Resident Rooms -Avoid new admissions until symptom free for 48 hours. -Soap and Hand sanitizer out in all places -PPE and signage abundance on floors -Stool specimens -Transferring ill patients-continuing precautions -Utilize commercial disinfectant -Perform cleaning disinfecting on all surfaces in cohorting areas. -Cleaning 3 times a day in all areas of the building -Staff cannot come to work until 48 hours symptom free -Cohort staff on the wards -Limit visitation of all residents. This specific audit tool will be utilized in the following frequency: -Daily for the first week. -2 times a week for the second week -1 time a week for the third week -If at 100% then we will discontinue use of audit tool. The following was implemented by the NHA on or before [DATE]: Returning patients will be placed into standard COVID isolation precautions. MD is ordering isolation precautions for all returning residents. -New admissions are on hold pending MD clearing the facility which will be 48 hours after the last symptomatic patient resolves and after the last staff member reports symptoms. -Restricting all visitors until further notice. -Personal food items are restricted in the following ways: no cooked food from family homes, pre-packaged snacks and drinks will be accepted for residents. Staff is permitted to bring their lunches and order outside food due to no available food provided by the facility. No items are to be consumed or eaten on the units or shared with residents. -PT on hold for all residents with symptoms who are ordered PT until symptoms subside. -Staff should report any symptoms to their supervisors and should not return to work for 48 hours after symptoms subside. -We are limiting large group activities and serving all meals in resident rooms. Symptomatic residents will remain in their rooms. -Housekeeping has been consistently keeping the building sanitized daily. Housekeeping supervisor has been notified and his staff will sanitize heavily used areas like handrails three times a day and other areas two times a day using approved commercial disinfectants. During staff interviews conducted on [DATE], between 12:41 p.m. and 3:27 p.m., 22 of 22 staff members confirmed that they received education on signs and symptoms of GI virus, handwashing with soap and water, infection control of a GI virus infection, appropriate donning and doffing of PPE, and food products not being allowed to be brought in to the facility. A review of the documentation received from the facility on [DATE], at 4:00 p.m. revealed that all elements of the Corrective Action Plan were substantially completed. The Immediate Jeopardy was lifted on [DATE], at 4:15 p.m. when the Corrective Action Plan implementation was verified. During an interview on [DATE], at 4:15 p.m. the NHA confirmed the facility failed to maintain an infection prevention and control program by failing to investigate, document surveillance of, and implement preventative measures timely, to address an outbreak of GI illness resulting in actual harm to 29 of 95 residents who developed GI illness and failed to provide education to staff members on GI illness and additional handwashing requirements to 89 of 115 employees. 28 Pa. Code:201.14(a) Responsibility of licensee. Previously cited: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code:201.18(e)(6) Management. Previously cited: [DATE], [DATE], [DATE] 28 Pa. Code:211.12(a) Nursing services. 28 Pa. Code:211.12(c) Nursing services. Previously cited: [DATE] 28 Pa. Code:211.12(d)(1) Nursing services. Previously cited: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code:211.12(d)(2) Nursing services. Previously cited: [DATE] 28 Pa. Code:211.12(d)(3) Nursing services. Previously cited: [DATE], [DATE], [DATE] 28 Pa. Code:211.12(d)(4) Nursing services. 28 Pa. Code:201.20(a) Staff development.

Based on review of facility policies, manufacturer guidelines, observations, staff and resident interviews, it was determined that the facility failed to maintain a sanitary environment for food preparation, storage and transport, failed to label, date food products, failed to monitor the proper function of the dish machine and three bowl sink, two walk-in coolers, one freezer and one reach in cooler, failed to perform temperature monitoring during food production and prior to service on the tray line and properly perform hand washing, in one of one kitchen, which created the potential for cross-contamination and food borne illness and placed 124 of 129 residents in Immediate Jeopardy. Finding include: Review of facility policy Sanitary Conditions, dated 7/29/19, indicated the Dietary Department will practice sanitary techniques in storing, preparing, serving, and distributing food to prevent food borne illness. Dry Storage storerooms are maintained in a sanitary condition and are dry without water or contamination and adequate protection from rodents and insects. Shelving is located away from sewage pipes, water pipes and floor drains where it cannot be subject to sewage backflow or overflow. Review of the facility policy Sanitation of Food Service Department, dated 7/29/19, indicated that food service staff shall maintain the sanitation of the food service department through compliance with a written, comprehensive cleaning schedule. Review of the facility policy, Cleaning Instructions Cleaning Cabinets and Drawers, dated 7/29/19, indicated that cabinets and drawers will be free of food particles and dirt. Review of the facility policy, Cleaning Instructions Cleaning Counter Spaces, dated 7/29/19, indicated that counter spaces will be wiped down and sanitized prior to and following preparation and meal services, and as needed. Review of the facility policy, Cleaning Instructions Cleaning Food Preparation Appliances, dated 7/29/19, indicated that appliances and food appliances will be cleaned and sanitized after each use. Review of the facility policy, Cleaning Instructions Cleaning floors, tables, chairs, dated 7/29/19, indicated that kitchen floors will be swept and cleaned after each meal. Review of the facility policy, Handling Clean Equipment and Utensils, dated 7/29/19, indicated that clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust. Review of the facility policy, Cleaning Instructions Cleaning Freezers, dated 7/29/19, indicated that walk-in freezers are to be mopped and wash walls and ceilings. Review of the facility policy, Care of Storeroom, dated 7/29/19, indicated that the floors, walls, shelves and equipment in the storeroom are to be kept clean. Refrigerated and frozen foods are dated upon delivery. The storeroom is cleaned on a regular basis and refer to the cleaning schedule. During an observation on 12/17/19, from 8:57 a.m. through 10:20 a.m. of the Main Kitchen with the Certified Dietary Manager (CDM) Employee E19 revealed the following: Kitchen contained numerous flying insects. The insects were on clean utensils, pots, pans and strainers. A hanging rack with two pots and strainer were above an open trash can, flying insects were in the trash can and the pots and strainer contained numerous insects on them. Shelving and counter spaces that contained spices, clean pots, pans, large tins and baking sheets had a layer of grease and food substance on the shelves and on the clean items on those shelves. Equipment in the kitchen, including the mixer, meat slicer, prep tables, oven, steam table, grill and warmer box were greasy and tacky with dried food substances and dried sauces on the surfaces. Walls in the kitchen were greasy with dried food substances and dried sauces on the surfaces. Floors through the kitchen had dried food debris, standing water, paper products and the edges of the floor where meets the wall contained a buildup of a dark dirt-like substance. An observation of a plastic bin that contained a variety of utensils, a brown unknown liquid in the bottom of container with small particles floating in the liquid. An observation of the water filter system connected to the food steamer contained a green substance in the clear canister. An observation of the walk-in freezer revealed: -the freezer floor contained ice buildup with food substances, liquids and papers frozen to the floor. An observation of the walk-in cooler revealed: -the cooler floor contained food substances, liquids and other unknown dark substances on the floor. An observation of the walk-in milk cooler revealed: -smell of sour smell in cooler. -milk spilled on floor, food substances and other unknown dark substances on the floor. An observation of the Dry storage revealed: -a drain pipe from the floor and a smaller pipe draining water from the walk-in freezer. On the floor near the pipe was a puddle of water. There was no air gap for this drain pipe. -flying insects visible through out stock room. -spider webs from the ceiling. -floor dirty with food debris, milk carton, soda can, oatmeal cookie box and loose crackers. During an interview on 12/17/19, at 9:15 a.m. CDM Employee E19 confirmed that the kitchen, coolers, freezer and dry storage were not maintained in sanitary condition which created the potential for cross-contamination and food borne illness. Review of facility policy Hand Washing dated 7/29/19, indicated that hand washing facilities should be readily accessible and equipped with paper towels and soap. Hand washing should occur during food preparation and when changing task. Review of facility policy Cleaning Food Carts dated 7/29/19, indicated that food carts will be cleaned and sanitized immediately after each use. Review of facility policy Dietary Infection Control dated 7/29/19, indicated that all staff are to wash hands when they use their hands in an unsanitary way such as handling dirty dishes. Review of the American Dish Service Conveyor Dishwashers Service Manual dated 2/97, indicated for chemical sanitizing: Final rinse minimum temperature: 120 degrees Fahrenheit (F), Rinse Tank minimum temperature 120 degrees F. and Wash tank minimum temperature 140 degrees. Review of facility policy Dish Machine Temperature Log dated 7/29/19, indicated that dishwashing staff will monitor and record machine temperatures to assure proper sanitizing of dishes. During an observation of the dish washing procedures on 12/17/19, from 9:20 a.m. through 10:08 a.m. in the Main kitchen the following was revealed: Food Service Aide (FSA) Employee E25 with gloved hands removed clean items as they exited the dish machine and then moved the food cart from the dirty side of the dish room, where they returned from breakfast meal. FSA Employee E25 then set up the food carts for the next meal by placing trays inside the carts along with resident meal tickets, utensils and napkins without removing gloves, performing glove changes or performing handwashing. Observation of the five food carts revealed food particles on the inside and the outside, dried sauces, and other unknown substances inside and out. The wheels of the carts were covered in a black substance. During an interview on 12/17/19, at 9:45 a.m. FSA Employee E25 confirmed that proper infection control procedures were not followed by wearing gloves while removing clean items from the dish machine and then setting up the food carts and returning to remove clean items without removing gloves and performing handwashing. CDM Employee E19 and FSA Employee E25 confirmed that the food carts were not cleaned and sanitized after breakfast service which created the potential for cross-contamination and food borne illness. Observation of the dish machine three gauges on the machine never moved during several cycle of dishes being sent through the machine. A fourth gauge off to the back of the machine was filled with water and leaking water around the gauge. The gauge labeled Wash Tank Temp was at 108 degrees Fahrenheit (F), Rinse Tank Temp was at 122 degrees F, and the Final Rinse gauge was at 94 degrees F. Observation of the dish machine revealed no log to monitor and record the dish machine is reaching the proper temperatures and the chemicals are at the proper levels to sanitize. During interviews on 12/17/19, at 9:55 a.m. and at 10:00 a.m. FSA Employee E26 was asked about proper temperature range of the dish machine and the monitoring of the chemicals. FSA Employee E26 identified the gauges but was unaware of the proper temperature and how the monitoring of the chemicals was performed. During an interview CDM Employee E19 could not identify the proper temperature range and the chemical levels of the dish machine and could not tell if the dish machine was functioning at the properly. CDM Employee E19 was asked for temperature and chemical logs for the dish machine and the manufactures guidelines. CDM Employee E19 stated that the facility is not monitoring the temperatures and the chemicals of the dish machine for proper function. CDM Employee E19 confirmed that the facility would not know if the dish machine is working properly and without this monitoring the facility is placing the residents at risk for the potential for cross-contamination and food borne illness. During an interview on 12/17/19, at 1:44 p.m. CDM Employee E19 confirmed that the facility does not have a manufactures guideline for the dish machine. CDM Employee E19 stated that the facility placed the dish machine out of service and has a service company responding. During an interview on 12/17/19, at 2:30 p.m. the Contracted Repair Person confirmed that the dish machine was not reaching the proper temperature to sanitize properly the machine is only reaching the temperature of 110 degrees or less due to the heating element not working. Review of facility policy, Dietary Infection Control dated 7/29/19, indicated that refrigerated foods are to be stored at or below 40 degrees F. Foods that are frozen are stored at or below 0 degrees F. Foods are to be protected from dust, flies, rodents, and other vermin. The foods that are stored in the stockroom are placed on clean racks at least six inches off the floor. The room is clean, dry and cool. All leftovers are labeled, covered and dated when stored. They are used within 48 hours. Review of facility policy, Sanitary Conditions dated 7/29/19, indicated the Dietary Department will practice sanitary techniques in storing, preparing, serving, and distributing food to prevent food borne illness. Bulk foods are to be stored in a container with a lid. Temperatures are taken on all refrigerators and freezers units in the morning and at the end of the day and recorded on the refrigerator and freezer temperature logs. Review of the facility policy, Care of Storeroom, dated 7/29/19, indicated that refrigerated and frozen foods are dated upon delivery. Review of the facility policy, Dry Storage Area, dated 7/29/19, indicated that the store room should have good ventilation and the temperature should be 50 to 70 degrees F. Containers with tight-fitting covers should be used for storing cereal, grain products, dried vegetables and broken lots of bulk foods. Observations of food storage revealed the following: Reach in cooler revealed: No temperature log. -opened ketchup, chocolate syrup and thickened milk undated. Cooler has a leak and a pan is placed underneath to catch water. Walk-in freezer revealed: No temperature log. -the freezer motor and fans contained ice buildup the shelving and boxes below that contained ice and there were large chunks of ice on the floor. -on the floor was a metal cover that belonged to a control box on the freezer wall that had wires exposed. Freezer contained the following: No temperature log. -pan of beans unlabeled, undated and uncovered. -open single serve ice cream opened and partially eaten. -tray of sweet potato pie unlabeled and undated. -box of chopped spinach open to the air and undated. -box of green beans open to the air and undated. -box of French toast open to the air and undated. -box of beef patties open to the air and undated. -box of skinned beef livers open to the air and undated. -sausage undated and unlabeled. -banana bread dated 7/13/19. Walk-in-cooler contained the following: No temperature log. -no thermometer in the cooler. -opened sliced meat unlabeled and undated. -one lemon on shelf, soft, black colored and grey fuzzy substance. -whipped cream open with no lid. -hard boiled eggs opened to air and undated. -box of bacon opened to air and undated. -pan of soup unlabeled and undated. -pan of rice unlabeled and undated. -cheese sandwiches uncovered, unlabeled and undated. -pan of gravy, unlabeled and undated. -pan of potatoes, unlabeled and undated. Walk-in milk cooler revealed: No temperature log. -door will not close due to broken door latch and door not sealing. -two opened [MEDICATION NAME] milk with no open date. Dry storage revealed: No temperature log. -10# Cans not dated. -bottle of molasses opened and undated. -bag of sugar opened to air and undated. -bag of bread crumbs opened to air and undated. -bottle of sweet and sour sauce opened undated. -bag of rigatoni (pasta) opened to air and undated. -bottle of vinegar undated. During an interview on 12/17/19, at 9:35 a.m. CDM Employee E19 was requested to provide temperature logs for all the coolers/freezers in the kitchen. CDM Employee E19 stated that the facility has not been monitoring the temperatures. CDM Employee E19 confirmed that by failing to monitor the temperatures of the food storage in the coolers, freezer and storage room and by failing to properly store, label, date and maintain the equipment the facility created the potential for food borne illness and cross-contamination. During the interview CDM Employee E19 was asked about the freezer ice build-up and accuracy of the freezer temperature on the outside gauge. CDM Employee E19 was going to have maintenance look into the concern. Review of facility policy, Sanitary Conditions- Handling of Ice dated 7/29/19, indicated that employees are not permitted to put their hands, cup, ect. into the machine to scoop ice. During an observation on 12/17/19, at 12:42 p.m. FSA Employee E26 with cup in hand, place cup in the ice machine to fill cup instead of using the scoop. During an interview on 12/17/19, at 12:46 p.m. CDM Employee E19 confirmed that the facility failed to maintain a sanitary environment within the ice machine. Review of facility policy, Employee Sanitary Practices, indicated that all employees shall wear hair restraints. Avoid touching mouth or face while preparing food. Review of facility policy, Hand Washing dated 7/29/19, indicated that hand washing facilities should be readily accessible and equipped with paper towels and soap. Hand washing should occur during food preparation and when changing task. During observations on 12/17/19, of the tray line area the following was observed: At 9:42 a.m. a cellular phone was on the meat cutter, cutting surface plugged in charging. At 9:45 a.m. Prep Cook Employee E31 was not wearing hair restraint on their beard and was observed preparing food in the grill area, removed gloves, opened walk-in freezer, returned with box, opened box and then reapplied gloves without performing hand washing. At 10:10 a.m. the handwashing sink in main kitchen was not stocked with paper towels and there was no place to dispose of used paper towel. At 10:15 a.m. a review of the facilities Tray Line Temperature Log revealed that the last documented temperatures were 7/3/19. During an interview on 12/17/19, at 10:10 a.m. Prep Cooks Employee E23 stated that food temperatures are not being performed during food production and prior to service on the tray line. During an interview on 12/17/19, at 10:16 a.m. CDM Employee E19 confirmed that the facility failed to maintain a sanitary environment while preparing food on the tray line and failed to provide adequate supplies to perform hand washing and proper place to disposal of supplies. CDM Employee E19 confirmed that the facility is not performing tray line temperatures which creates the potential for food borne illness. During an interview and observation on 12/17/19, at 3:20 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing in the main kitchen the confirmed the conditions of the kitchen. During observations on 12/18/19, from 8:05 a.m. through 9:20 a.m. of the kitchen the following was observed: During observations on 12/18/19, from 8:05 a.m. through 9:20 a.m. of the kitchen the following was observed: At 8:05 a.m. a cellular phone was plugged in and charging on the meat slicer cutting surface. At 8:07 a.m. of the tray line revealed that the food temperatures were not monitored on the tray line prior to serves. At 8:12 a.m. the walk-in freezer that the inside thermometer was at 10 degrees F and the outside thermometer was at -4 degrees F. At 8:16 a.m. the walk-in cooler was not closing due to a broken latch. At 8:20 a.m. the water filter system connected to the food steamer still contained a green substance in the clear canister. At 8:30 a.m. a blank temperature/chemical logs hanging on the dish machine and on the wall next to the three bowl sinks. During an interview on 12/18/19, at 8:40 a.m. the CDM Employee E19 confirmed that the facility failed to maintain a sanitary environment for food preparation, monitor tray line temperatures, monitor food storage temperatures for the coolers and the freezer, failed to address the food steamer water filter and failed to monitor the proper function of the dish machine and the three bowl sink which creates the potential for cross-contamination and food borne illness. CDM Employee E19 was asked about the freezer and ice build-up that was a concern on 12/17/19, nothing was addressed and now the difference between the inside and outside thermometer. CDM Employee E19 confirmed that staff have not been educated on the processes of addressing these concerns that create the potential for cross-contamination and food borne illness. During an interview on 12/18/19, at 3:40 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain a sanitary environment for preparation, storage and transport of food, failed to label, date food products, failed to monitor the proper function of the dish machine and 3 bowl sink, two walk-in coolers, one freezer and one reach in cooler, failed to perform temperature monitoring during food production and prior to service on the tray line and properly perform hand washing, in the kitchen The facility was notified of the Immediate Jeopardy on 12/18/19, at 3:40 p.m. and an immediate corrective action plan was requested. An immediate corrective action plan received on 12/18/19, at 6:46 p.m. and accepted. The plan included, after the issues were identified, the dish machine was shut down and residents were served on paper products. A service call was placed to an outside contractor to evaluate functionality of the dishwasher. State Chemical repaired the dish machine and was approved to be placed back in service. The facility implemented temperature logs for the dish machine immediately, implemented tracking of sanitization of the dish machine using test strips and indicating results, the temperature and sanitation log must be completed four times per day (6a,10a, 2p, 6p) completed ongoing as an essential duty. Dietary Staff will be educated on the proper temperature ranges of the dish machine as well as the proper sanitization levels and if a variance occurs, the dish machine will be immediately shut down and out of service until further instruction is given. Prior to the dish machine being put back into service all dietary staff will be educated. The Administrator, or designee, will audit daily for compliance and follow up will occur for any issues in compliance identified. It was identified that the facility was not monitoring and recording temperatures of the kitchen coolers or freezers. The facility will implement temperature logs for the coolers and freezers to be recorded twice per day (10a, 6p). Dietary Staff will be educated on proper temperature guidelines of both freezers and coolers, taking temperatures twice per day educated on reporting variance in temperature to the Dietary Supervisor, or designee. Dietary Supervisor, or designee will be responsible to monitor compliance of taking and recording of these temperatures daily. The Administrator, or designee, will monitor compliance in recording and obtaining temperatures follow up and follow through of non-compliance identified. It was identified that the three-bowl sink was not being monitored for proper sanitization levels facility will implement a sanitization log for the three-bowl sink to ensure sanitization is at the proper level and will monitor sanitization level of the three-bowl sink four times per day. Dietary Staff will be educated on the proper sanitization level of the three-bowl sink. Signage will be hung as a visual indicator for each bowl use. The Administrator, or designee, will monitor compliance in recording and obtaining temperatures follow up and follow through of noncompliance identified. It was identified that the Steamer Filter was not being maintained. The steamer was be placed out of service until service for safe function can be completed by a contracted provider. It was identified that dietary staff were not obtaining temperatures of food prior to serving to residents. The facility will implement a Food Temperature Log with guidelines of food temperatures for safe serving. Dietary Staff will be educated on temping food when taken out of the oven and initiating tray line, three times per day. Dietary Staff will be educated on recording food temperatures on the Food Temperature Log and will be educated to not serve food if it does not temp within range, Hot foods 135-140 degrees and cold foods 30-40 degrees. It was identified that dietary staff were not changing gloves, were not washing hands and there were no paper towels present in the kitchen for staff to use after handwashing. Staff will be educated immediately on proper use of gloves, handwashing, and cross contamination by the Director of Nursing. Housekeeping Supervisor will ensure that the kitchen is stocked daily with paper towels. The Dietary Supervisor, or designee will do rounds daily in the kitchen at a minimum of three times per day to check for proper infection control procedures. Any issues identified will be addressed with the staff member. The Administrator will monitor the tracking tool daily. It was identified that the kitchen overall presented dirty, cluttered and unsanitary. Cleaning schedules for daily assignments, weekly assignments, and rotating assignments will be comprised to ensure cleanliness of the kitchen. Daily cleaning will be verified by the Dietary Supervisor, or designee, using and audit named Daily Cleanliness Audit tool. Immediate education was completed with Dietary staff on 12/18/2019 at 6am, 10am, and 3pm on monitoring and logging Dishwasher temperatures, sanitation levels, monitoring and recording freezer and cooler temperatures. Dietary staff will be educated prior to the start of their shifts. All shifts will be completed with staff by the end of the day 12/19/19. All logs will be in place and completion will have occurred beginning immediately and ongoing. Cleaning schedules will be devised and in placed by end of day 12/19/19. Dietary staff will be educated prior to the start of their shifts. All shifts will be completed with dietary staff by the end of the day 12/19/19. Preventative maintenance schedule will be devised by end of day 12/19/19. All residents will be assessed for any signs or symptoms of foodborne illness. This will be completed by nursing staff by end of day 12/19/19, initially and ongoing. Continued monitoring of the facility conducted by the state agency revealed the following: On 12/19/19, at 8:30 a.m. of the walk-in freezer revealed a tray of pies open to air, undated and omelets open to air and undated. The dry storage area had a puddle of water on the floor and the drain pipe for the freezer had no air gap. A cart with an ice chest with water inside and a water jug from the nursing units was being stored in room without being cleaned from use on the nursing unit. A bag of bread crumbs open to air and undated, box of navy beans open to air and undated, two bags of spaghetti open to air and undated, bag of flour opened to air and undated, an open bottle of vinegar undated, a box of bowls on the floor and numerous flying insects in the room. On 12/19/19, at 8:40 a.m. Bank Manager/Concierge Employee E30 who was covering supervisor in the kitchen was asked about the status of the function of the freezer due to the ice build up brought to CDM Employee E16 on 12/17/19, and the temperature difference that was a concern during an observation with CDM Employee E19 on 12/18/19, at 8:12 a.m., Bank Manager/Concierge Employee E30 was unaware of the issue. The Bank Manager/Concierge Employee E30 confirmed that the facility failed to store food and maintain equipment in a manner to prevent the potential for cross-contamination and food borne illness. On 12/19/19, at 11:45 a.m. of the tray line Prep Cook Employee E23 was not wearing a hair restraint on their beard. On 12/19/19, at 12:05 p.m. Prep Cook Employee E32 was observed with gloved hands walking through out the kitchen touch multiple surfaces and objects with changing gloves or performing handwashing. On 12/19/19, at 8:40 a.m. Bank Manager/Concierge Employee E30 confirmed that Prep Cooks Employee E23 and E32 created the potential for cross-contamination and food borne illness by not wearing hair restraint and not changing gloves and performing handwashing. An observation on 12/19/19, at 12:05 p.m. Contracted Repair company confirmed to be working on the walk-in freezer. Documentation provided by the facility on 12/19/19, the NHA confirmed that the company fixed the walk-in freezer ' s thermometer and left fan running wrong direction. During an observation on 12/19/19, at 4:35 p.m. through 5:30 p.m. of the tray line and dish room the following was observed: -Prep Cook Employee E36 used Styrofoam plate and plastic ware to scratch face, with gloved hands adjusted shirt, opened cabinet, retrieved a cutting board, then went back to serving food, then opened a plastic bag of Styrofoam bowls against chest and left tray line for buns brought back to the tray line and opened with the removed buns with the same gloved hands and continued to serve food on the tray line. -Numerous flying insects were throughout the kitchen during tray line. -Prep Cook Employee E36 failed to perform tray line temperatures prior to the start of tray line. Dish room- -Dietary Aide Employee E37 was observed with gloved hands load dirty dishware, then removed gloves, rinse hands in dirty side of rinse sink for approximately three seconds, then removed the clean dishware, stacked and carried plates against chest to the tray line, then Dietary Aide Employee E37 cleaned the inside of the tray carts without performing handwashing. During an interview on 12/19/19, at 7:20 p.m. the Nursing Home Administrator confirmed that proper infection control techniques were not maintained during tray line and dish washing which created the potential of cross contamination and food borne illness. During interviews on 12/20/19, at 12:30 p.m. Prep Cooks Employees E23 and E31, FSA Employee E25 and E26 and Registered Dietitian Employee E22 confirmed being educated on the facilities policies on maintaining a sanitary environment in the kitchen and maintain a sanitary environment for food preparation, storage and transport, were educated on the facilities policy how to label, date food products and how to monitor the proper function of the dish machine and three bowl sink. They were educated on the facilities policy on proper storage in the two walk-in coolers, freezer and reach in cooler and the monitoring of proper food storage temperatures and to perform temperature monitoring during food production and prior to service on the tray line and properly perform hand washing. The Immediate Jeopardy was called on 12/18/19, at 3:40 p.m., the Immediate Jeopardy was lifted 12/20/19, at 2:45 p.m., and scope and severity was lowered to an F, when the updated immediate corrective action plan was received and implementation was verified which included: the Nursing Home Administrator made certain the dish machine was functioning properly, implement temperature logs for the dish machine including monitoring of the temperatures and the chemical levels and educated all dietary staff on the proper levels. Education, monitoring and logs were created for the three-bowl sink for proper sanitization levels. The implemented a Food Temperature Log with guidelines of food temperatures for safe serving. Temperature logs for the coolers and freezer were created to monitor the proper storage temperatures of foods. The steamer will be placed out of service until service from a contracted provider. A preventative maintenance schedule was be devised for all kitchen equipment. All residents were assessed for any signs or symptoms of foodborne illness. The facility failed to maintain a sanitary environment, monitor the proper function of the dish machine and three bowl sink, which created the potential for cross-contamination and food borne illness and placed 124 of 129 residents in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code: 207.2 (a) Administrator's Responsibility. 28 Pa. Code 207.4 Ice containers and storage. 28 Pa. Code 211.6(c)(d)(f) Dietary services.