Every finding on record at St Francis Center for Rehabilitation & Healthcare

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to obtain a physician order for tracheostomy size for one of one resident reviewed with tracheostomy (Resident R2).Findings:Review of facility policy Tracheostomy Care revealed tracheostomy tubes should be changed as needed or as ordered. Preparation and assessment include checking the physician order. Review of Resident R2's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 1, 2026, revealed the resident was severely cognitively impaired and had a diagnosis of respiratory failure (not enough oxygen passes from your lungs to your blood). Review of Resident R2's MDS revealed the resident received tracheostomy care (a surgically created hole in your trachea that allows for breathing).Review of Resident R2's care plan revised June 11, 2025, revealed the resident had altered respiratory status related, but not limited to, tracheostomy and pulmonary edema.Observations on June 3, 2026, at 12:30 p.m. revealed Resident R2 had a tracheostomy.Review of Resident R2's clinical record revealed a physician order dated December 12, 2025, to change the tracheostomy disposable inner cannula every day shift.Review of Resident R2's clinical record revealed no physician order for size of tracheostomy to be used.Interview on June 4, 2026, at 1:20 p.m. with Resident R2's assigned Licensed Nurse, Employee E10, revealed the employee was unable to find a physician order for tracheostomy size and was further unaware what tracheostomy size Resident R2 required.Interview on June 4, 2026, at 1:25 p.m. with the 4th floor Unit Manager Licensed Nurse, Employee E7, confirmed there was no physician order for Resident R2's tracheostomy size.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, observation, review of clinical record, and interview with staff it was determined that the facility failed to ensure that residents/resident's next of kin/legal guardian/power of attorney are notified of changes in resident's care related to ankle monitoring bracelet for one of 37 residents reviewed (Resident R175). Review of facility policy on notification and change of condition, revised May 2025, revealed that the facility shall utilize a notification process when there is change in the resident's medical condition and or status. Unless otherwise instructed by the resident, a nurse will notify the residents' representative Review of Resident R175's clinical record revealed that Resident R175 has a diagnosis of anxiety disorder (intense, excessive, persistent worry or fear) and unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Observation conducted on June 2, 2026, at 11:24 a.m. revealed Resident R175 was in his/her room and was wearing a monitoring device on his/her ankle. Review of Resident R175's physician orders revealed orders dated April 3, 2026, to check function and placement of [NAME] Chip Function (monitoring device) to the right ankle, daily to prevent elopement.Further review of Resident R175's clinical record revealed no documented evidence that the family was notified of the wander guard use.Interview June 4, 2026, with Director of Nursing (DON), Employee E2, confirmed that the unit manager did not call the family to inform them of the wander guard applied to Resident R175's ankle. 28 Pa Code 211.10 (c) Resident care policies28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide written notice of a room change for one of 37 residents reviewed (Resident R105). Findings Include:Review of Resident R105's clinical record revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview with Resident R105 on June 2, 2026, revealed on May 28, 2026, his/her room was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident R105 further reported being unhappy with the room move and was not informed why he/she needed to move.Review of Resident R105's entire clinical record revealed no documented evidence that the resident or resident representative were notified of the room change and subsequent response from the resident or resident representative.Interview with the Director of Nursing, Employee E2, on June 2, 2026, confirmed there was no documented evidence of the room move process/notification to the resident/representative and stated Social Services would be responsible for such documentation.Interview on June 4, 2026, with the Social Worker, Employee E5, confirmed no documented evidence was available to show that Resident R105 was given written notice, including the reason for the room change, prior to Resident R105's room change on May 28, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide proper notification to the physician in a timely manner for one of 37 residents reviewed (Resident R26).Findings Include:Review of Resident R26's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2026, revealed the resident has a BIMS (Brief Interview for Mental Status - cognitive assessment) Score of 7 (severe cognitive impairment) and diagnoses of anemia (lack of healthy red blood tissues), osteoarthritis (degenerative joint disease) , and malnutrition (lack of sufficient nutrients in the body). Resident R26 was admitted to the facility on [DATE]. Continued review of Resident R26's comprehensive MDS dated [DATE], revealed the resident required partial/moderate assistance from staff for rolling left/right and sitting to lying.Review of Resident R26's comprehensive care plan revealed the resident is on anticoagulant therapy and is at risk of bleeding and bruising. During an interview on June 3, 2026, at 10:00 a.m. Resident R26 reported a bump to the top of his/her head because nurses were careless during care.Review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 7:45 a.m. that indicated Resident R26 complained of head pain. Per the nursing note, an assessment revealed a quarter size hematoma on the top of Resident R26's head. Resident R26 alleged he/she was dropped at home being carried up the steps by family.Further review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 11:30 a.m. that Resident R26's representative was seeking information about the hematoma and further alleged Resident R26 was manhandled.Review of facility documentation revealed a facility incident report for Resident R26 Bruise dated May 31, 2026, that indicated while Resident R26 was being repositioned in bed, staff unintentionally hit his/her head on the headboard. The incident report indicated that the incident happened on May 31, 2026.Review of Employee Statement Via Telephone dated May 31, 2026, by Nurse Aide, Employee E11, revealed with assistance from Registered Nurse, Employee E12, Resident R26 was repositioned in bed. When moving Resident R26, he/she hit the headboard by accident. The statement was not signed by the employee.Review of Employee Statement Via Telephone dated May 31, 2026, by Registered Nurse, Employee E12, revealed when assisting Nurse Aide, Employee E11, to reposition Resident R26 in bed and pulling him/her up, the staff unintentionally hit Resident R26's head on the headboard. The statement was not signed by the employee.Review of facility staffing punch reports revealed Registered Nurse, Employee E12, did not work on the date the alleged incident occurred (May 31, 2026).Interview on June 5, 2026, at 10:30 a.m. with Director of Nursing, Employee E2, and Regional Staff, Employee E13, and E14, revealed based on a follow-up interview with Nurse Aide, Employee E11, and Registered Nurse, Employee E12, the incident happened on May 30, 2026, during the 3:00 p.m. to 11:00 p.m. shift.Interview on June 5, 2026, at 10:30 a.m. with Director of Nursing, Employee E2, and Regional Staff, Employee E13, and E14, confirmed Nurse, Aide, Employee E11, and Registered Nurse, Employee E12, did not promptly notify the physician or document accidentally hitting Resident R26's head on the headboard. It was not until they were questioned after a hematoma was found in the morning of May 31, 2026, that staff reported hitting Resident R26's head on the headboard. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete, accurate, and thorough investigation of alleged abuse and neglect for two of 37 residents reviewed (Resident R37 and R26). Findings Include: Review of facility policy Abuse Prevention/Reporting revised February 25, 2025, revealed the facility will investigate of all suspected cases of abuse. Further review of the facility policy revealed the facility will collect written documentation such as signed witness statements, statements of accused personnel, medical records, incident reports and other pertinent information. Review of Resident R37's quarterly MDS (an assessment of resident needs) dated May 3, 2026, revealed the resident was severely cognitively impaired and diagnosed with obstructive uropathy (blockage in the urinary system). Review of the MDS revealed Resident R37 used a supra pubic catheter for urinating (a tube inserted through a small incision in the lower abdomen to drain urine directly from the bladder) and was incontinent of bowel needing staff assistance with toileting. Review of Resident R37's care plan revealed a history of falls with interventions that included keeping the resident's bed in the lowest position (lowering the bed closer to the floor shortens the distance a person would fall, which lessens the severity of potential injuries). Review of Resident R37's nursing progress note dated May 12, 2026, at approximately 4:00 a.m. revealed the resident was found on the floor next to his/her bed bleeding on the side of the head. The physician gave new orders to transfer Resident R37 to the hospital for further evaluation. Review of facility documentation related to the incident, revealed a witness statement from Resident R37's nurse aide, Employee E15, revealed, The patient was last taken care of at 2:30 a.m., (does not state what type of care was provided) and was last seen at 3am. Continued review of facility documentation revealed no documented evidence that the facility determined what was the positioning of the bed when Resident R37 was found on the floor an hour after care was provided. Interview with the second-floor unit manager, Employee E6, on June 4, 2026, at 10:48 a.m. revealed Resident R37 sustained a 4-centimeter (cm) laceration to the head. Interview with the Director of Nursing, Employee E2, on June 5, 2026, at 12:00 p.m. confirmed the facility failed to determine the position of Resident R37's bed after the fall. Review of Resident R26's comprehensive Minimum Data Set (MDS – federally mandated resident assessment and care screening) dated May 14, 2026, revealed the resident has a BIMS (Brief Interview for Mental Status – cognitive assessment) Score of 7 (severe cognitive impairment) and diagnoses of anemia (lack of healthy red blood tissues), osteoarthritis (degenerative joint disease) , and malnutrition (lack of sufficient nutrients in the body). Resident R26 was admitted to the facility on [DATE]. Continued review of Resident R26's comprehensive MDS dated [DATE], revealed the resident required partial/moderate assistance from staff for rolling left/right and sitting to lying. Review of Resident R26's comprehensive care plan revealed the resident is on anticoagulant therapy and is at risk of bleeding and bruising. During an interview on June 3, 2026, at 10:00 a.m. Resident R26 reported a bump to the top of his/her head because nurses were careless during care. Review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 7:45 a.m. that indicated Resident R26 complained of head pain. Per the nursing note, an assessment revealed a quarter size hematoma on the top of Resident R26's head. Resident R26 alleged he/she was dropped at home being carried up the steps by family. Further review of Resident R26's clinical record revealed a nursing note dated May 31, 2026, at 11:30 a.m. that Resident R26's representative was seeking information about the hematoma and further alleged Resident R26 was manhandled. Review of facility documentation revealed a facility incident report for Resident R26 Bruise dated May 31, 2026, that indicated while Resident R26 was being repositioned in bed, staff unintentionally hit his/her head on the headboard. The incident report indicated that the incident happened on May 31, 2026. Continued review of facility documentation revealed employee statements were obtained by alleged perpetrators Nurse Aide, Employee E11, and Registered Nurse, Employee E12. Employee statements were electronically typed and noted to be via telephone with interviews conducted by the Director of Nursing, Employee E2. Review of Employee Statement Via Telephone dated May 31, 2026, by Nurse Aide, Employee E11, revealed with assistance from Registered Nurse, Employee E12, Resident R26 was repositioned in bed. When moving Resident R26, he/she hit the headboard by accident. The statement was not signed by the employee. Review of Employee Statement Via Telephone dated May 31, 2026, by Registered Nurse, Employee E12, revealed when assisting Nurse Aide, Employee E11, to reposition Resident R26 in bed and pulling him/her up, the staff unintentionally hit Resident R26's head on the headboard. The statement was not signed by the employee. Review of facility staffing punch reports revealed Registered Nurse, Employee E12, did not work on the date the alleged incident occurred (May 31, 2026). Further review of facility documentation revealed no witness statements were obtained from Resident R26, or other staff and residents. Interview on June 5, 2026, at 10:00 a.m. with the Director of Nursing, Employee E2, confirmed the timeline of alleged incident was unclear and further confirmed no statement from Resident R26, or other staff and residents was obtained. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, observation, interviews with resident and staff it was determined that the facility failed to provide quality of care in accordance with physician orders for two of 37 residents reviewed (Resident R287 and R78). Findings Include: Review of Resident R287's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle). Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use Infuvite Adult Intravenous (IV) Solution (multiple vitamin) at 80 milliliter/hour (ml/hr) intravenously one time per day. Further review of Resident R287's clinical record revealed a physician order dated June 2, 2026, for Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride - used to maintain fluid and electrolyte balance) administered at 75 ml/hr intravenously every shift for four days. Observations on June 2, 2026, at 11:45 a.m. revealed Resident R287 was in bed with the IV Sodium Chloride Solution running at 75 ml/hr. Observations revealed the contents of the Sodium Chloride Solution were discolored bright yellow. Interview on June 2, 2026, at approximately 12:00 p.m. with Licensed Nurse, Employee E8, confirmed Resident R287's Sodium Chloride Solution bag was not properly labeled and was mixed together with the Infuvite Adult Intravenous (IV) Solution. Further interview on June 2, 2026, at approximately 12:00 p.m. Licensed Nurse, Employee E8, confirmed that the physician order for infuvite did not indicate to mix it with the sodium chloride solution, but that that it was a recommendation by the pharmacy instructions to add infuvite to sodium chloride. Review of Resident R78's clinical records revealed the resident was alert and oriented, admitted to the facility on [DATE], and has a diagnosis of Prurigo nodularis (is a chronic skin condition characterized by extremely itchy, firm nodules that often result from persistent scratching). During an interview with Resident R78 on June 2, 2026, at 10:00 a.m. the resident stated, I have been itchy, I told them (the nursing staff) weeks ago. It is getting worse it hurts sitting in my wheelchair. The resident continued to say when he/she has an incontinent episode in the adult brief, the urine burns his/her rash. Observations of Resident R78's torso appeared to have linear red marks from the resident scratching. Review of Resident R78's clinical record revealed a physician progress note dated, May 1, 2026, that noted a rash around the resident's diaper areas and ordered zinc oxide ointment to be applied topically to the resident's area. The ointment was applied two times a day from May 1, 2026, until May 11, 2026. During this time (May 1, 2026, through May 11, 2026) there was no documented evidence of an ongoing assessment of the resident's response to the treatment. Review of the resident's weekly skin checks did not note any new or current skin changes. Continued review of Resident R78's clinical record revealed there were no new treatment changes after the zinc order was completed, until 7 days later when the physician saw the resident again on May 18, 2026. Review of Resident R78's clinical record revealed a physician note dated May 18, 2026, which revealed Earlier this month, he/she developed a diaper area rash and was started on zinc oxide BID (twice per day). Today, Resident R78 states the rash feels like it is getting worse instead of better. I spoke with patient and sister at bedside and discussed starting clotrimazole TID (three times a day) and they agreed. Clotrimazole 1% ointment to groin and inner thighs TID x 14 days. Review of Resident R78's medication administration record revealed the resident's Clotrimazole cream was ordered for seven days and not 14 days, as initially prescribed. Further review of Resident R78's clinical record revealed a physician note dated May 27, 2026, that revealed Resident R78 was seen due to worsening pain and irritation in the diaper area rash. Resident R78 reported increased discomfort and states the rash is not improving with zinc oxide and clotrimazole. Based on worsening symptoms, the physician transitioned treatment to nystatin cream QID (four times a day) and for wound care nurse to evaluate. Further review of Resident R78's wound notes revealed the resident was not assessed for the skin rash until June 4, 2026. Interview with the Director of Nursing, Employee E2, on June 5, 2026, at 11:00 a.m. confirmed the above. 28 Pa. Code 211.12 (d)(5)

Based on review of clinical records, observations, and staff interviews it was determined that the facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards for 1 of 37 residents observed (Resident R287).Findings Include:Review of Resident R287's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of malignant neoplasm of the tongue (tongue cancer) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to loss of fat and muscle).Continued review of Resident R287's clinical record revealed a physician order dated May 24, 2026, to use Infuvite Adult Intravenous (IV) Solution (multiple vitamin) at 80 milliliter/hour (ml/hr) intravenously one time per day.Further review of Reisdent R287's clinical record revealed a physician order dated June 2, 2026, for Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride) administered at 75 ml/hr intravenously every shift for four days.Observations on June 2, 2026, at 11:45 a.m. revealed Resident R287 was in bed with the IV Sodium Chloride Solution running at 75 ml/hr. Observations revealed the contents of the Sodium Chloride Solution was discolored bright yellow.Further observations on June 2, 2026, at 11:45 a.m. revealed a label Intravenous Solution Additives affixed to Resident 287's IV Sodium Chloride Solution bag, but did not indicate the additive.Interview on June 2, 2026, at approximately 12:00 p.m. with Licensed Nurse, Employee E8, confirmed Resident R287's Sodium Chloride Solution bag was not properly labeled with the additive. Licensed Nurse, Employee E8, reported that the Sodium Chloride Solution had been mixed together with the Infuvite Adult Intravenous (IV) Solution for administration.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to implement an effective infection control program related personal protective equipment for one of 37 residents observed (Resident R2).Findings Include: Review of facility policy on personal protective equipment revealed that personal protective equipment appropriate to specific task requirements is available at all times. Further review of facility policy revealed employees required to perform tasks that may involve exposure to blood/body fluids will be provided appropriate protective clothing and equipment. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Anoxic Brain Damage (when the brain is deprived of oxygen) and Chronic Respiratory Failure with Hypoxia (the lungs cannot supply enough oxygen to the blood). Observation conducted on June 5, 2026, at 9:52 a.m. revealed that an enhanced barrier precaution sign (infection control measures that expand the use of gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms) was posted outside Resident R2's bedroom door with available personal protective equipment, including re-washable cloth gowns Observation on June 5, 2025, at 9:53 a.m. revealed Resident R2 was in bed and had a tracheostomy (a surgically created hole in your trachea that allows for breathing).Observation on June 5, 2026, at 9:58 a.m. revealed that yellow re-washable cloth gowns, and a plastic bag containing yellow cloth gowns were on top of the chair inside Resident R2's room.Interview on June 5, 2026, at 9:58 a.m. with Licensed Nurse, Employee E9, confirmed that that yellow re-usable cloth gowns and a plastic bag containing yellow cloth gowns were on top of the chair inside Resident R2's room. Further, Licensed Nurse, Employee E9, confirmed the gowns should be used only once and then properly disposed of for laundering. Licensed Nurse, Employee E9, subsequently placed the gowns in plastic bag, and took them out of the room to dispose of properly. 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility documentation and staff interview it was determined that the facility failed to include active input from residents, their representative(s), family members, and representatives of direct care staff in the facility assessment process.Findings Include: Review of facility documentation titled, Facility Assessment dated April 22, 2026, states the people involved in the process are the Administrator, Director of Nursing, Governing Body Rep, and the Medical Director. Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment on April 22, 2026, revealed no documented evidence that the facility included input from residents/resident representatives, or active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA), input from resident.Interview on June 5, 2026, at 1:00 p.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Facility failed residents with food preferences.Based on interviews with residents, observations of the food service and a test tray evaluation, interviews with dietary staff, reviews of policies and procedures and reviews of resident council and food committee meeting minutes, it was determined that each resident was not receiving foods and drinks to accommodate their individualized preferences. Appealing food and drink options of similar nutritive value were not being planned and provided on facility menus. (Residents R58, R47, R164, R145, R 207, R208, R220, R77, R117, R196, R64, R194, R144, R219, R86, R50, R234 and R115). Findings include: A review of the facility policy titled resident food committee dated March 2020 revealed that the facility staff were responsible for supporting the food committee established by the residents. The purpose of the residents meeting was to review the menus planned by the Food and Nutrition Department, review special food activities and give the residents a chance to voice concerns about facility food. The policy also said the food service director was responsible for documenting the minutes of the food committee concerns, needs and actions taken to reasonably resolve the food and nutrition issues. The policy indicated that the quality assurance and performance improvement committee would be responsible for overseeing the food committee concerns and accomplishments as part of quality review. A review of the policy titled menu standards dated March 2020 revealed that menus are developed according to standards of menu planning, production and service. The policy indicated that the menu was planned to ensure nutritional adequacy, regulatory compliance, operational efficiencies and to enhance residents' quality of life. The policy indicated that menus are planned to meet national guidelines, to reflect religious, cultural and ethnic needs of the residents based on the advice of the resident council and food committee. A group meeting held with residents at 11:00 a.m., on July 16, 2025 and individual interviews held throughout the days of the survey July 14 to July 18, 2025 revealed that Residents were dissatisfied with the menu planning, foods and fluids being served from the food and nutrition services department. Residents reported that they were not getting foods that they preferred. Residents reported that the menu items planned were not consistently served. The residents reported that the foods lacked variety. There was no variety in the foods provided for a lactose intolerant resident. Residents that were lactose intolerant were asking for a variety of lactose free desserts. The residents were upset that hot dogs and Italian sausage items were taken off the menu. The residents did not like the preparation method and type of meat used for the cheese steak hoagie. The residents reported that the preparation method of the vegetable soup was poor too oily and from a can. The residents were requesting that gravy be served with the chopped steak. The residents were asking that turkey bacon be added to the menu. The residents were reporting that chicken fingers and French fries were being served too often. Residents said that they never get a fried egg and that they were interested. The residents wanted regular coffee. The residents reported that decaffeinated coffee was only offered. Review of the resident council and food committee meeting minutes for the months of April, May and June 2025 revealed that the residents had been complaining about the preparation methods of foods, accuracy of foods and fluids delivered for point of service, entrees selected for the menus not satisfactory and that their individual food preferences were not being honored.Interview with the director of dietary services, Employee E10 at 10:30 a.m., on July 17, 2025, confirmed the on-going (April, May and June, 2025) food and beverage concerns from the residents. The director of dietary also confirmed during this interview that there was a lack of documentation related to the minutes kept for the food committee concerns, needs and actions taken to reasonably resolve the food and nutrition issues.A review of the likes and dislikes listed by the dietitians for Residents R47, R50, R145, R77, R207, R208 were not revised to reflect their food preferences. Resident R47 was allergic to eggs however there was no documentation to indicated that food preferences were updated related to egg substitutes or cottage cheese or cream cheese or yogurt for breakfast instead of eggs. Resident R47 wanted regular coffee. There was no documentation to indicate that this resident preferred decaffeinated coffee. Resident R50 was requesting bacon cheeseburgers be added to her diet routinely. There was no documentation to indicate that this resident's food preferences were updated to reflect her needs. Resident R145 was requesting more variety for the menus the resident asked for hot dogs as a menu item. There was no documentation to indicated that this resident's food preferences were updated to reflect her request. Resident R145 also wanted regular coffee. There was no documentation to indicate that Resident R145 preferred a decaffeinated beverage. Resident R77 wanted fresh fruit not canned fruit for her meals. There was no documentation to indicate that the fresh fruit preference was revised as a like for this resident. Resident R207 was ordered a lactose free diet by the physician. This resident was requesting to have a variety of lactose free desserts added to his diet. There was no documentation to indicate that this resident's food preferences were being updated and honored. Resident R208 was requesting that more fresh fruit be added to her diet. There was no documentation to indicate that the resident's food choice was honored. Canned fruit was listed on the menu as being preferred by this resident. Observations during the noon meal service on July 14, 2025 on the fourth floor nursing unit revealed that nursing and dietary staff were not providing all food items listed on the menu for the residents. Residents' meal trays were observed without eight ounces milk; although the preplanned menus indicated that the milk was supposed to be served with lunch. Interview with the director of dietary services, Employee E10 at 12:30 p.m., on July 14, 2025, revealed that the resident who did not get milk do not like it. The director of dietary said that this dislike was recorded in the nutritional care plan. A review of the nutritional care for the residents on the fourth floor nursing unit, revealed that there was no documentation to indicated that all of the residents on the fourth floor preferred not to have milk served at their noon meal services. The lack of updating the nutritional care plans related to beverage choices (eight ounces of milk) for the fourth floor residents that were eating their noon meals on July 14, 2025 was confirmed during interview with the dietitian, Employee E15, at 11:00 a.m., on July 18, 2025. PA 28 Code 201.14(a) Responsibility of licenseePA 28 Code 201.18(b)(1)(3)(e)(1) ManagementPA 28 Code 211.10(a)(b)(c)(d) Resident care policiesPA 28 Code 211.12(d)(3)(5) Nursing services

Based on observation, staff interview and review of facility policy, it was determined that the facility failed to ensure that medications were stored in a safe manner during medication administration. Findings include: Review of facility policy on Medication Storage date March 2020, section Policy Statement revealed that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under section Policy Interpretation and Implementation #1. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. #2. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. #3. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals unless permitted by the physician. #7. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. #9. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. Observation conducted on July 15, 2025, at 8:50AM during medication administration reveled that a zip-lock bag containing Spiriva (oral inhalation spray) and Fluticasone Propionate (nasal spray) was on top of the medication cart. Further observation revealed that Spiriva and the Fluticasone were labelled with Resident R65's name. Further observation revealed that licensed nurse Employee E17 went into room [ROOM NUMBER] to administer medications to a resident in room [ROOM NUMBER] and left the Spiriva and fluticasone medications unattended on top of the medication cart. Upon Employee E17's return to the medication cart, she proceeded to put away the Spiriva and Fluticasone. Interview with Employee E17 conducted at the time of the observation confirmed that she left the Spiriva and Fluticasone unattended on top of the medication cart. Further medication administration observation conducted on July 15, 2025, at 9:38AM revealed that a bottle of MiraLAX was on top of the medication cart. Further observation revealed that Employee E17 went to room [ROOM NUMBER] to administer medication to a resident room [ROOM NUMBER] leaving the MiraLAX lax unattended on top of the medication cart. Interview with Employee E17 conducted at the time of the observation confirmed that she left the MiraLAX unattended on top of the medication cart while she went to room [ROOM NUMBER] to administer medication to a resident. 28 Pa. Code 201.18(b)(l) Management28 Pa. Code 211.12(d) Nursing Services28 Pa. Code 211.9 (i) Pharmacy Services

Based on interviews with staff, and review of clinical records it was determined the facility failed to obtain laboratory services to meet the needs of one of 38 resident records reviewed (Resident R105). Findings include:Review of Resident R105 clinical records revealed the resident was diagnosed with hypothyroidism (underactive thyroid). Physician orders dated May 14, 2025, instructed a Thyroid stimulating thyroid test (measures the amount of TSH levels in the blood) in five weeks.On July 16, 2025, during an interview with the Unit Manager, Licensed Practical Nurse, Employee E18 stated the doctor has in the progress notes continue to monitor but failed to show the May 2025 order for TSH levels was completed.PA 28 Code 211.12(d)(3)(5) Nursing services.

Based on the observations and staff interviews, it was determined that the facility failed to ensure that the residents were treated with dignity and respect for one of four nursing units reviewed (Fourth Floor Main). Findings include: Observation of fourth floor main dining room on September 25, 2024, from 12:00 p.m. to 12:40 p.m. revealed that there were 14 residents in the dining room. It was revealed that there were two residents on table eating the lunch, five other residents on the same table were not served their meals. Two residents who received lunch tray early were finished by 12:30 p.m. while all other residents on the same table were not served. Further observation revealed that cart with trays for other residents arrived at the unit at 12:32 p.m., and were served by 12:35 p.m.11 trays arrived for the rest of 12 residents in the dining room. One resident did not receive the tray until 12:40 p.m. Interview with Nurse Aide, Employee E8, on September 25,2024, from 12:30 p.m stated two of five residents sitting at the center table received the lunch tray around 11:30 a.m., remaining residents lunch tray arrived an hour later at 12:30 p.m. Interview with Employee E9 Unit Manager, on September 25, 2024, from 12:40 p.m., confirmed that the residents who were eating in fourth floor main nursing were not served at the same time for residents in the same table. 28 Pa. Code: 201.29(j) Resident rights.

Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission relating to oxygen administration for one of thirty-five residents reviewed. (Resident R99) Findings Include: Review of the facility policy titled, Resident Plan of Care with a revision date of June 2024 states, Policy Statement- Our facility's Care Planning/Interdisciplinary Team is responsible for the development of a plan of care for each resident. Policy Interpretation and Implementation states, The care plan is based on the resident's assessment and is developed by a Care Planning/Interdisciplinary Team. The Interdisciplinary Team, resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. Review of Resident R99's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease, Congestive Heart Failure, and Hypertension. Observation of Resident R99 on September 24, 2024 at 11:01 a.m. revealed the resident was in bed resting with his oxygen administered. Review of resident R99's physician orders revealed an order for oxygen 2 liters via nasal canula continuously dated August 20, 2024. Review of Resident R99's baseline care plan dated August 20, 2024 revealed there was no focus area for oxygen therapy. Interview held on September 25, 2024 at 10:21 a.m. with licensed nurse, Employee E3 who confirmed that there was no current care plan in place for oxygen for Resident R99 although he has been on oxygen since being admitted to the facility. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(2) Nursing services

Review of facility policies, observations, review of clinical records, and interviews with residents and staffed revealed that the facility failed to ensure resident care plan were revised related to bed rails, beds against the wall, oxygen therapy, and diet for five of thirty-five residents reviwed. (Residents R106, R42, R96, R125, and R574). Findings Include: Review of Resident R106's clinical record revealed the diagnoses of paraplegia (paralysis of the legs and lower body), need for assistance with personal care, pressure ulcer of sacral region- stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), and osteomyelitis (infection in the bone) of vertebra. Interview with Resident R106 on Monday, September 23, 2024, at 11:46 a.m., revealed that she has been requesting bed side rails since she was transferred on second floor unit - 2 Main on September 12, 2024. Per R106's statement - she is paraplegic and bed side rails are helpful for her to be able to pull herself up in bed. Further review of clinical record revealed admission 'Bed Rail Evaluation,' completed on August 16, 2024, at 2:58 p.m. which indicated that Resident R106 expressed a desire to have bed side rails raised while in bed for safety and comfort, that resident is currently using the bedrail for positioning or support, and bedrails are indicated at this time. Review of R106's care plan revealed no evidence of goals or interventions related to bedrail use. Review of Resident R42's clinical record revealed Resident R42 was admitted to the facility on [DATE] with a diagnosis of orthopedic aftercare following surgical amputation, acute kidney failure, and muscle weakness. Resident R125 was admitted on to hospice services on September 17, 2024 with a diagnosis of atherosclerotic heart disease (damage in the hearts major blood vessels). Observation of Resident R42 on September 23, 2024 at 10:05 a.m. revealed Resident R42 was receiving oxygen 2 liters via nasal cannula. Review of Resident R42's care plan revealed no care plan related to oxygen therapy. Interview with Employee E2, Director of Nursing, on September 25th, 2024 at 1:50 p.m. confirmed Resident R42 did not have a care plan for oxygen therapy. Review of Resident R96's physician order dated May 29, 2024, revealed a diet order for regular diet. Observation of Resident R96's meal ticket on September 25, 2024, at 12:35 p.m. revealed that the resident was receiving regular diet with regular consistency. Review of an active care plan for Resident R96 dated July 20, 2023, revealed that the resident was on renal (a diet that helps people with chronic kidney disease or who are on dialysis maintain balanced levels of minerals, electrolytes, and fluids in their bodies) /no added salt/chopped diet with thin liquids. Interview with Registered Dietician on September 26, 2024 at 11:50 a.m. confirmed that the diet order for Resident R96 did not match the care and the care plan was not revised to reflect the changes. Review of Resident R125's clinical record revealed Resident R42 was admitted to the facility on [DATE] with a diagnosese of acute and chronic respiratory failure, cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and muscle weakness. Observation of Resident R125 on September 23, 2024 at 10:35 a.m. revealed Resident R125 had the right side of her bed pushed against the wall. Interview on September 23, 2024 at 10:40 a.m. with Employee E5, Registered Nurse, confirmed Resident R125's right side of bed was against the wall. Clinical record review revealed Resident R125 did not have a care plan in place for Resident R125's bed against the wall. Observation of Resident R574 on September 25, 2024 at 11:54 a.m. revealed the resident had her bed positioned with the left side fully against the wall. Interview with licenssed nurse Employee E3 on September 25, 2024 at 11:57 a.m. confirmed Resident R574's right side of the bed was against the wall. Review of Resident R574's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Muscle Weakness, Difficulty in Walking, Heart Failure, and Unspecified Fall Subsequent Encounter. Clinical record review revealed Resident R574 did not have a care plan in place for Resident R574's bed against the wall. Interview with the Director of Nursing Employee E2 on September 27, 2024 at 12:25 p.m. revealed the resident's bed was moved against the wall after a fall Resident R574 had on September 21, 2024 based on her request. The Director of Nursing Employee E2 confirmed that this preference was not added to the resident's care plan. 28 Pa Code 211.12(d)(5) Nursing Services

Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities of daily living was maintained and did not diminish for one of 35 resident records reviewed (Resident R141). Finding include: Review of the facility policy titled, Restorative Therapy effective March 2020, states Restorative Nursing Programs (RNP) will be provided and considered for residents admitted to the facility with restorative needs and who will benefit from a restorative program in conjunction with formalized rehabilitation therapy. The rehabilitation staff will assist with the identification of residents who will benefit from Restorative nursing; work with nursing to identify and design appropriate programs; and provide restorative program training to the Certified Nurse Assistant (aka Nursing Assistant). When a restorative nursing program is established by a therapist, the residents' individualized restorative program goals and plans will be written by the rehab staff. Restorative Program documentation will provide a summary of the resident's overall monthly achievements. The Staff Development Coordinator and the Rehab staff will work as a team to provide education to facility staff as required. Review of Resident R141's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of chronic pain syndrome, muscle wasting and atrophy, not elsewhere classified, in his bilateral upper arms, muscle weakness, osteoarthritis, contracture of muscle, multiple sites, and was morbidly obese. During an interview with Resident R141 on September 24, 2024, at 12:30 p.m. indicated he no longer received restorative therapy. The resident stated, There are ten of us that should be getting restorative therapy, five days a week and I walk with them. When the facility is short staffed, the restorative nurses are taken off their assignments and put on as aides. I don't get the therapy like I was, and I see a difference. I was able to walk and now I can't. Review of Resident R141's physician orders instructed to evaluate and treat the resident to address TherAct, (therapeutic activities), TherEx,(therapeutic exercises) NMR, (neuromuscular re-education) WC Mgmt Training (wheelchair management training), gait training, patient and caregiver education and safe discharge planning that started on January 9, 2024, and ended on February 8, 2024. Review of Resident R141's clinical record revealed a care plan was developed for the resident's Impaired ability to walk related to fall risk that may benefit from a restorative nursing program (RNP), date initiated on February 12, 2024. The goal dated February 12, 2024, revised on July 5, 2024, target date of October 15, 2024, Will maintain or improve distance walked through the next review. The RNP care plan included intervention dated February 12, 2024, for ambulation, to Maintain or increase self-performance in walking and to oversee restorative interventions provided and document progress at least monthly. Review of the resident's clinical record revealed a nursing progress note from the Director of Nursing dated March 31, 2024, stating, Decreased range of motion and flexibility related to muscle weakness that may benefit from a restorative nursing program, the note continued to say that the resident participated in RNP for March 2024 and ambulated a total of 150 feet with FWW (front wheeled walker) and WC (wheelchair) to follow. Program will continue as a maintenance program as it's beneficial to him. Review of Resident R141's Restorative Nursing Task dated February 12, 2024, indicated The resident will walk to the nursing station from their room, 200 feet with a rolling walker to increase independence. Further review of the RNP revealed in the past 30 days from August 28 to September 26, 2024 the resident was documented receiving only six days of restorative therapy on September 7,9,12,18,20, 25, 2024. Interview with the Director of Nursing on September 26, 2024, at 9:00 a.m. confirmed when the facility is understaffed the restorative aides will be reassigned as nursing aides. 28 Pa. Code 211.109d) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursign services

Based on the review of clinical record, interview with resident and staff, it was determined that the facility failed to administer the medication in a timely manner as ordered by the physician and according to the professional standards of practice for two of 35 residents reviewed. (Resident R179 and Resident R147) Findings Include: Review of facility policy Administering Medication dated June 2024, revealed Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered one hour before and after the prescribed times. Standard prescribed times will include but not limited to a. Morning Medication b. Afternoon meds c. Early evening meds d. Late evening meds e. Night meds f. Specific prescribed medication times Interview with Resident R147 on September 23, 2024, at 10:24 a.m. stated he received the medication often late; he stated sometimes the medications that needed to be taken with meals and medications that needed to be taken before meals were not given timely. He stated sometimes his morning medication which he usually takes before 9 a.m. are not given until noon. Review of physician order for Resident R147 for the month of September 2024, revealed, orders for: Apixaban Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for chronic atrial fibrillation in the morning and evening. Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to homelessness. Farxiga Oral Tablet 10 MG, give 1 tablet by mouth one time a day related to type 2 diabetes mellitus. Furosemide Oral Tablet 40 MG, give 1 tablet by mouth one time a day related to congestive heart failure. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day related to hypertension. Mometasone Furoate Inhalation Aerosol 100 MCG/ACT 2 puff inhale orally two times a day related to chronic obstructive pulmonary disease. Sacubitril-Valsartan Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day related to hypertension. Review of Medication Administration Audit Report for Resident R147 dated September 22, 2024 revealed the following: On September 22, 2024: Apixaban scheduled for morning and evening, given at 12:08 p.m., and 5:31 p.m. which is only 5.30 hours apart. Cymbalta scheduled for morning, given at 12:07 p.m., Farxiga scheduled for morning, given at 12:07 p.m., Furosemide scheduled for morning, given at 12:08 p.m., Metoprolol Succinate scheduled for morning, given at 12:08 p.m., Mometasone Furoate Inhalation scheduled for morning and evening, given at 12:08 p.m., and 5:31 p.m. Sacubitril-Valsartan scheduled for morning and evening, given at 12:07 p.m., and 5:32 p.m. which is only 5.30 hours apart. Review of physician order for Resident R179 for the month of September 2024, revealed, orders for: Baclofen Oral Tablet 5 MG Give 1 tablet by mouth three times a day muscle spasm. Gabapentin Oral Capsule 400 MG, give 1 capsule by mouth three times a day related to neuralgia and neuritis morning dose scheduled at 9:00 a.m. Review of Medication Administration Audit Report for Resident R179 dated September 22 and September 23, 2024, revealed that Resident R22 received all the above medications as follows: Baclofen scheduled for 9:00 a.m., 2 p.m. given at 11:27 a.m., and 2:19 p.m. less than 3 hours apart. Gabapentin scheduled for 9:00 a.m., 2 p.m. given at 11:27 a.m., and 2:19 p.m. less than 3 hours apart. Drug information report for Sacubitril-Valsartan revealed that take it at the same time each day-for example, when you first wake up and again before you go to bed. Drug information report for Mometasone Furoate Inhalation revealed that take Mometasone Furoate Inhalation every day, with 2 puffs in the morning and 2 puffs in the evening. If you miss a dose of Mometasone Furoate Inhalation, skip your missed dose and take your next dose at your regular time. Do not take Mometasone Furoate Inhalation more often or use more puffs than you have been prescribed. Drug information report revealed that Gabapentin capsules, tablets, and oral solution are usually taken with a full glass of water (8 ounces [240 milliliters]), with or without food, three times a day. These medications should be taken at evenly spaced times throughout the day and night; no more than 12 hours should pass between doses. Interview with the Pharmacist on September 26, 2024, at 2.10 p.m. stated Eliquis should be taken 2 times a day, it had to be separated by at least 8 hours, 5 hours apart was not appropriate. Interview with the Director of Nursing on September 26, 2024, at 2.30 p.m. stated twice daily medication such as Apixaban, blood pressure medication should have scheduled and administered at 9:00 a.m. and 9:00 p.m. and morning medications should not be given at lunch time. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure physician orders were followed in relation to oxygen administration for one of thirty-five residents reviewed. (Resident R98) Findings Include: Review of facility policy titled, Oxygen Administration- Resident with a revision date on December 2022 states, Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the procedure state, . 4. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate ordered. 5. Place appropriate oxygen device on the resident. 6. Adjust the oxygen delivery device so that it is comfortable for the resident. 7. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. 8. Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened. 9. Observe the resident upon setup and periodically thereafter to be sure oxygen is tolerated. Review of Resident R98's record revealed the resident was admitted to the facility with the diagnosis of chronic obstructive pulmonary disease (lung condition cause by damage and inflammation to the lungs). Observation of Resident R98 in her room on September 24, 2024 at 10:01 a.m. revealed the resident was in bed resting wearing oxygen. The oxygen level was checked and was running at 3 liters. Review of resident R98's physician orders revealed an order from August 5, 2024 that read, Oxygen 2L via nasal cannula continuously. Review of Resident R98's oxygen level on September 25, 2025 at 11:33 a.m. revealed the resident's oxygen level was running at 3 liters. The level was confirmed by licensed nurse Employee E3 as being incorrect. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(3) Nursing Services 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on clinical record review and facility policy, it was determined that the facility failed to ensure the timely availability of medication for one of 35 residents reviewed (Resident R12). Findings include: Review of the facility policy titled Pharmacy Services effective March 2020 states, The facility shall accurately and safely provide or obtain pharmacy services including the provision of routine and emergency medication and biologicals and the services of a licensed Pharmacist. The same policy states, The facility shall contract with a licensed Pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet the state and federal requirements. Review of Resident R12's physician orders indicated Ativan gel 0.5mg/ml be applied to the resident three times a related to the resident's diagnosis of anxiety disorder. Review of Resident R12's nursing progress notes and the medication administration record revealed the Ativan gel was not administered due to pharmacy services as follows: Nursing note dated January 29, 2024, noted the medication was Awaiting on pharmacy to deliver. Nursing Note dated, January 30, 2024, noted the medication was Awaiting on pharmacy to deliver. Nursing notes on January 31, 2024, at 9:01 a.m. and 2:08 p.m. noted the medication was still pending due to pharmacy delivery. Nursing note on February 16, 2024, noted the medication was Awaiting pharmacy. Nursing note, on March 17 at 10:52 a.m. indicated the medication was, Unavailable. Nursing notes for June 21, 2024, indicated at 2:01 p.m. the medication was Awaiting delivery and at 6:07 p.m. was Pending from the pharmacy. Nursing notes for June 22, 2024 indicated at 2:10 p.m. nursing spoke with the pharmacy and the pharmacy indicated the Ativan gel would be sent out on the next run. At 6:37 p.m. nursing noted the medication was is still on order. Nursing notes for June 23, 2024, indicated at 9:33 a.m. pharmacy would send out the Ativan gel on the next run, at 12:04 p.m., the mediction was noted Awaiting delivery' and at 2:15 p.m stated the Ativan gel was still Awaiting delivery. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.9(d) Pharmacy services

Based on review of clinical records, interview with staff, and review of facility documentation, it was determined that the facility failed to ensure a resident was treated with dignity and respect when staff attempted to provide care for one of 35 residents reviewed (Resident R322). Findings include: Review of a facility reported incident dated August 25, 2024 indicated a 11-7 aide mistakenly thought Resident R322 needed her brief changed and took the covers off the resident without asking. The facility documentation revealed in Resident R322's interview the resident said the aide came over to her bed and pulled the sheets off of her. The resident asked, 'What are you doing.' The resident said the aide stopped and apologized and said I am sorry I just thought you needed to be changed. The resident felt he should have asked first and felt, violated when he took her blankets off without asking. Facility documentation stated the resident said 'He didn't touch me-He thought I wore a brief -He should have asked.' 28 Pa Code 201.18(e)(1)(h) Management 28 Pa Code 201.29 (a)(c)(j)(k) Resident rights

Based on review of facility policies, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that one of 20 residents was free from physical abuse from a nursing staff and that the resident was protected from further physical abuse. (Resident R1) This failure resulted in an immediate jeopardy situation for Resident R1 who was slapped across the face by a nursing staff. The facility failed to suspend the perpetrator from employment at the time of the incident and remained in the facility for the duration of the shift placing six additional residents (Resident 12, Resident 13, Resident 14, Resident R15, Resident R16, Resident R17) at risk for physical abuse. Findings include: Review of the facility's Policy Abuse Prevention/Reporting with a revision date of August 2020 documented abuse prevention program components which included but are not limited to the following (1) screening of potential hires (2) training of staff in interventions, reporting, detection and prevention (3) prevention through the ongoing monitoring of the staff interacting with residents, and (4) protection for individuals from abuse during investigations and allegations. Continue review of the policy also documented procedures that have been developed and implemented to properly screen, report, protect, investigate, and correct issues related to abuse such as staff members immediately reporting all suspected cases of abuse to Administrator or designee, and staff members reporting all complaints, concerns, or suspicions of abuse to the Administrator or designee. During the investigation, the facility collects, maintains, and safeguards material pertinent to the investigation, in addition to taking measure to protect the accuser from retaliation by the accused. The policy stated that the accused will either be suspended pending the investigation or transferred to another unit at the discretion of the Administrator as dictated by the severity of the accusation. Review of Resident R1's April 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the resident's Annual Minimum Data Set Assessment (MDS- assessment of resident's care needs) dated March 3, 2022, indicated that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The behaviors did not put others at significant risk for physical injury and did not significantly intrude on the privacy or other's activities. The resident was also assessed as exhibiting wandering behaviors. Continue review of the MDS revealed that the resident required limited assistance of staff for transfers, supervision with locomotion on the unit and the mobility devices utilized by the resident were wheelchair and walker. Review of Resident R1's plan of care indicated a plan of care dated March 2021 for resident walking unassisted, having combative behavior towards staff, in addition to being at risk for harming herself. Interventions for this person-centered plan of care include, the administration of the resident's medications as ordered and monitor for effectiveness, avoiding confrontation with the resident during periods of aggressive behavior, and then reapproaching the resident, addition to contacting the resident' daughter to help calm the resident, and utilizing psychiatry and psychological services. Further review of the plan of care also indicated a plan of care for post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) with interventions that included encouragement to participate in activities of interest, Psychological consultation and treatment as needed. Review of information received from the facility revealed that on April 11, 2022, at approximately 12:30 a.m. during the 11:00 p.m. to 7:00 a.m. shift on the 4 Main nursing unit, licensed nurse, Employee E6 reported to the nursing supervisor Employee E7 that she witnessed nurse aide, Employee E5 smack Resident R1 on her face. Review of Licensed nurse, Employee E6's witness statement indicated that Resident R1 was sitting in front of the nursing station in her wheelchair yelling, screaming, and cursing, and calling people names. Licensed nurse, Employee E6 reported that the resident started to ambulate in her wheelchair down the hall screaming when nurse aide, Employee E5 brought the resident to the nursing station to sit next to her. Licensed nurse, Employee E6 indicated in her witness statement that Resident R1 was upset during this time, and that the resident was swinging her hands trying to hit nurse aide, Employee E5. Licensed nurse, Employee E6 reported that she witnessed nurse aide, Employee E5 grab the resident's hands and stated, I like to see you try to do something, and then proceeded to smack the resident in her face. Licensed nurse, Employee E6 reported that she asked nurse aide, Employee E5 what she was doing and who the resident was, but nurse aide, Employee E5 never answered. Licensed nurse, Employee E6 stated that she (Employee E6) got up, and nurse aide, Employee E5 told her that she (Employee E5) was not going to take anything. Review of the witness statement provided by nurse aide, Employee E5 on April 11, 2022, indicated that nurse aide, Employee E5 went to get Resident R1 and brought her to the nursing station when she saw her trying to enter another resident's room. nurse aide, Employee E5 reported that while at the nursing station, the resident was cursing, banging on the desk, talking loudly, and that the resident spitted on her. Nurse aide, Employee E5's statement concluded with the nursing supervisor, Employee E7 asked her what happened and requested a statement from her. Nurse aide, Employee E5 also reported that she was moved off the unit. During an interview with Nursing supervisor, Employee E7 on April 15, 2022, at 7:00 a.m. Nursing supervisor, Employee E7's witness statement that she wrote on April 11, 2022, was read and reported by Employee E7 to be accurate. Nursing supervisor, Employee E7 reported that licensed nurse, Employee E6 came to her at approximately 12:45 a.m. on April 11, 2022, and stated that she watched nurse aide, Employee E5 slap a resident in the face. Nursing supervisor, Employee E7 reported that she asked licensed nurse, Employee E6 where the resident was, and that she should not have left the resident with nurse aide, Employee E5. Licensed nurse, Employee E6 reported that she did not feel comfortable in the building and that she was going to leave. Nursing supervisor, Employee E7 indicated during the interview that after licensed nurse, Employee E6's verbal report she then went to find nurse aide, Employee E5, and asked her to step away from Resident R1, and then proceeded to ask her what happened on the unit. Nursing supervisor, Employee E7 reported that nurse aide, Employee E5 stated that Resident R1 was going in and out of rooms, and that she brought her to the nursing station. Nursing supervisor, Employee E7 reported that she then asked nurse aide, Employee E5 what she did to the resident, and Employee E5 replied that she did not do anything and that she just brought her to the nursing station. Nursing supervisor, Employee E7 reported that she asked nurse aide, Employee E5 if she touched the resident, and she stated that she responded, no. In addition to her written statement, Nursing supervisor, Employee E7 reported during the interview that she transferred nurse aide, Employee E5 to the 4 Pavilion Nursing unit where the aide worked the rest of the shift providing care to residents on that unit. Review of nursing assignment sheets for April 11, 2021, 11-7 shift revealed that nurse aide, Employee E5 was assigned to provide care to 14 residents in the 4 Main unit prior to be transferred to the 4 Pavilion nursing unit. Further review of the nursing assignment sheets revealed that after the alleged physical abuse incident involving Resident R1, Employee E5 was then assigned to provide care to six residents in the 4 Pavilion nursing unit. Nursing supervisor, Employee E7 reported that after she spoke with licensed staff, Employee E6 who reported the incident, she sent a text message to the Director of Nursing (DON), that she needed her to call her now. Nursing supervisor, Employee E7 reported that the DON called her back between 6:00 a.m. and 6:30 a.m. on April 11, 2022. Nursing supervisor, Employee E7 proceeded to tell the DON that Licensed nurse, Employee E6 reported to her that she saw nurse aide, Employee E5 slap Resident R1. Nursing supervisor, Employee E7 stated that the DON told her to get nurse aide, Employee E5 out of the building, and that she should not be there when there was an alleged assault or abuse. During an interview with nurse aide, Employee E8 (a nurse aide on 4 Main nursing unit) on April 15, 2022, at approximately 7:15 a.m. Employee E8's witness statement that she wrote was read and she reported it as being accurate, explaining during the interview that she was on the computer at the nursing station, and could see Resident R1 screaming and cursing. Nurse aide, Employee E8 reported that nurse aide, Employee E5 then brought the resident up to the front in her wheelchair. Nurse aide, Employee E8 confirmed in her interview on April 15, 2022, that she did not know that anything happened between nurse aide, Employee E5 and Resident R1, until Licensed nurse, Employee E7 asked her what was going on. During an interview with nurse aide, Employee E9 (a nurse aide on 4 Main nursing unit) on April 15, 2022 at approximately 7:23 a.m. Employee E9's witness statement was reviewed, and she reported that it was accurate explaining that she was providing care to another resident, did not witness the incident, but did see nurse aide, Employee E5 and Resident R1 sitting at the nursing station. Surveyor attempted to contact Licensed nurse, Employee E6 on April 15, 2022, at approximately 1:25 p.m. via telephone for interview but contact was not successful. During an interview with the Director of Nursing (DON), the Nursing Home Administrator (NHA), the Regional Nurse and the Regional Administrator, on April 14, 2022, at approximately 1:30 p.m. the DON confirmed that she received a text message on her cell phone between 12:00 a.m. and 12:30 a.m. on April 11, 2022, but did not see the text message until she woke up between 6:00 a.m. and 6:30 a.m. The DON reported that she called the facility, spoke with Nursing supervisor, Employee E7, and confirmed that she was still there and told Employee E7 to get nurse aide, Employee E5 out of the building. The DON instructed the Assistant Director of Nursing (ADON) and Nursing supervisor, Employee E7 to speak with nurse aide, Employee E5 and notify her that she was suspended pending the investigation of the incident. The DON reported that both she and the NHA met with nurse aide, Employee E5 later in the day on April 11, 2022, and she denied that she slapped the resident. The DON reported that Employee E5 was not notified during the meeting that there was a video which captured her slapping Resident R1. Interview conducted with the DON on April 15, 2022, at 1:19 p.m. confirmed the nursing assignment for April 11, 2022, 11-7 shift in which the nurse aide, Employee E5 was transferred to the 4 Pavilion Nursing unit and was assigned to provide care to six residents (Resident 12, Resident 13, Resident 14, Resident R15, Resident R16, Resident R17). Review of Resident R12's admission MDS dated [DATE], revealed that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed as cognitively intact requiring extensive assistance with bed mobility, dressing and personal hygiene. Review of Resident R13's admission MDS dated [DATE], revealed that the resident was cognitively intact and required extensive assistance with bed mobility, dressing and personal hygiene. Resident R13 had impairments of upper and lower extremities with no ambulatory capabilities. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R14's admission MDS dated [DATE], revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had impairments of the upper extremities and had no ambulatory capabilities. Resident R14 was incontinent of bowel and bladder. Review of Resident R15's quarterly MDS assessment dated [DATE], revealed that the resident was cognitively intact. The resident required supervision for transfers and setup for dressing. Review of Resident R16's admission MDS assessment dated [DATE] revealed that the resident was cognitively intact and demonstrated wandering behaviors. Resident R16 required two-person physical assist for transfers and dressing. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R17's clinical record revealed that the resident was newly admitted to the facility on [DATE]. Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on April 14, 2022, at 4:24 p.m., for failure to ensure that a resident was free from physical abuse from a nursing staff and that the resident and other residents were protected from further abuse. The Immediate Jeopardy template was provided to the Administrator on April 14, 2022, at 4:24 p.m. and an immediate action plan was requested. On April 14, 2022, at 9:47 p.m. the facility provided the following corrective action plan: 1. Performing body checks on all residents to ensure residents had not experienced abuse or had any physical signs of abuse. 2. Updating the facility abuse policy to include that all personnel are to report all suspected cases of abuse, complaints, concerns, and suspicion of abuse in person or verbal conversation to the Administrator/designee, or to the Director of Nursing, and supervisor in the absence of the Administrator. The policy was also updated to state that accused will be suspended immediately and through the investigation process. 3. Educating all facility staff and agency staff on the updated abuse policy, including a written competency. 4. Completing an audit of residents twice a week for 30 days by the Director of Nursing or designee, to ensure that residents are not experiencing abuse or have any physical signs of abuse. This audit will be reviewed at the QAPI meeting (Quality Assessment Performance Improvement meeting-a meeting/documented plan that guides the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance, and continually improved). The implementation of the action plan was verified on April 15, 2022. Interviews conducted with facility staff on April 15, 2022, reported they had all been in-serviced on the facility resident abuse prohibition policy, recognizing the signs of resident abuse, to whom to immediately report an allegation of resident abuse and actions to be taken related to incidents of resident abuse. The Immediate Jeopardy was lifted on April 15, 2022, at 4:45 p.m. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

APPEAL FILED Based on observation, review of clinical records, facility policy and procedures, facility documentation, hospital records and other documentation and interviews with residents and staff, it was determined that the facility failed to respond in a timely manner to acute changes in the medical condition of one resident (Resident CL2) which resulted in an Immediate Jeopardy situation. Additionally, the facility failed to ensure that residents with wounds were monitored appropriately and failed to follow physician orders and/or notify physicians of changes in resident medical condition in a timely manner for nine of 28 residents reviewed (Residents CL2, R28, CL5, CL8, R25, R166, R228, CL1 and CL3). Findings include: Review of the facility policy, Change in Resident's Condition, dated revised [DATE], revealed the staff were, To alert the Physician and family to a change in resident's condition and to obtain orders for prompt medical treatment and for changes in care, if necessary . and . When a significant change in resident's condition is observed, the Charge Nurse and the Supervisor will be notified immediately. 3. A significant change in condition includes but is not limited to: . Sudden acute changes in mental status or levels of consciousness, critical lab results, . a sudden drop in O2 (oxygen) saturation, other relevant healthcare issues. The Charge Nurse/Supervisor will contact the resident's physician. If the physician or the covering physician is not available, the Medical Director will be contacted. Documentation will be made in the nurse's progress notes. Review of the clinical record for Resident CL2 revealed that the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to, hypertension (high blood pressure),[MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), [MEDICAL CONDITION] (extreme weakness of one side of the body)- affecting the right dominant side, Dysphagia (difficulty swallowing), [MEDICAL CONDITION] ([MEDICAL CONDITION]-poor circulation of the extremities) and [MEDICAL CONDITION] (inability of the kidneys to function properly). An Admission Minimum Data Set (MDS- an assessment of resident needs tool) dated [DATE], noted that the resident had moderately impaired cognition (cognition-mental process of being awake, alert and aware and able to process information independently). The MDS further revealed that Resident CL2 was non-ambulatory (unable to walk), required extensive assistance from staff for transferring (moving from one area to another) eating, drinking, completing personal hygiene and bathing. Additionally, the clinical record indicated that the resident was a Full Code (resident and/or responsible party had expressed the desire to have a full resuscitation or CPR performed in the event of a medical emergency). Further review of Resident CL2's clinical record revealed that on [DATE], nursing staff had documented in the resident's Medication Administration Record [REDACTED]. Nursing progress notes dated [DATE], at 14:52 (2:52 p.m.) indicated that the resident had taken all his scheduled medications and had received his dressing change as ordered. The note further indicated that nursing staff had administered four ounces of the house supplement (liquid nutritional supplement) to the resident at 4:00 p.m. Interview with Employee E2, Director of Nursing, on [DATE] at 12:30 p.m. revealed that facility nurses' chart by exception (system of clinical documentation by which staff only notates the presence of abnormalities.). Continued review of the Resident CL2's clinical record revealed no additional nursing documentation regarding the status of Resident CL2 until at 18:31 (6:31 p.m.) Nsg (Nursing) Supervior (sic) in to assess resident as per sons request who was visiting father at bedside. Resident non-responsive to verbal stimuli. Change in mental status. Call placed to MD. Nursing documentation further indicated that the resident's . Blood Pressure low ,[DATE]. Call placed to MD. gave orders to send resident out to ER (emergency room ) for eval (evaluation). Call placed to ambulance ETA (estimated time of arrival) ,[DATE] mins. (minutes). A telephone interview with Employee E5, medical director, on [DATE], at 1:30 p.m. revealed that the medical director had spoken with Employee E12, on-call physician, related to Resident CL2's transfer to the hospital on [DATE]. Employee E5 confirmed that the on-call physician had been contacted by nursing staff regarding the resident's unresponsiveness. Employee E5 further indicated that nursing staff had reported to the on-call physician that he/she had not noticed much difference in the change of the resident's condition since the start of her/his shift, and for that reason the attending physician had not ordered a [DATE] emergency transport to the hospital. In further interview on [DATE], at 9:30 a.m., Employee E5 stated that he had concerns with communication between the nursing staff and the physician staff. Employee E5 indicated that physician staff get a lot of phone calls late at night related to laboratory results, when the physicians are available to staff during the day. Employee E5 also indicated that he agreed 100% that there was an inconsistency of nursing staff and that there was a high degree of variability with nurses' knowledge and familiarity of the residents. Review of ambulance transport records for Resident CL2 dated [DATE], revealed that the ambulance company had been contacted by the facility to provide Non-Emergent from the facility to the hospital for a patient with a noted change in mental status. Further review of the ambulance record revealed the following documented time frames: dispatched to the facility at 7:00 p.m., arrived at the facility at 7:18 p.m., at resident at 7:22 p.m., left the facility at 8:08 p.m. and arrived at the hospital at 8:12 p.m Additional review of the ambulance transport documentation indicated that the total mileage from the facility to the hospital was 0.3 miles. Continued review of the ambulance transport documentation indicated that ambulance staff had noted that The patient required ALS (Advanced Life Support) because he was unresponsive . with a blood pressure of ,[DATE]. Further review of the ambulance transport record indicated that nursing staff had reported to them that the family was in to visit the patient and found him unresponsive. Nursing staff did not know how long the resident had been like this and . they cannot confirm a definite time that patient was last seen normal. Additionally, the ambulance transport record indicated that following the ambulance staff's initial physical assessment of Resident CL2 they determined that the Initial Patient Acuity for the resident was Emergent. Further documentation in the ambulance transport record indicated that they placed the resident on a cardiac monitor, administered oxygen to the resident, began intravenous fluids (I.V.- method of providing fluids and/or medication through a vein) and checked the resident's glucose level prior to leaving the facility. Review of Resident CL2's emergency room record revealed the following documentation: Time of Greet: Sun. [DATE], at 8:17 p.m. Further review of the emergency room record for Resident CL2 revealed that the resident was unresponsive, with an Acuity level critical. Doctor's notes dated [DATE], at 1:23 a.m., revealed that patient to be admitted for [MEDICAL CONDITION] . and he will be admitted to the ICU (Intensive Care Unit). A physician's History and Physical dated [DATE], indicated that the resident had been admitted to the ICU (intensive care unit) with diagnoses, including but not limited to, Septic Shock (form of shock which develops due to the presence of bacteria in the bloodstream), UTI, (urinary tract infection ), severe dehydration with a Sodium level (Sodium- an electrolyte present in the bloodstream) of 161(normal value ,[DATE] mEq/L (miliequivalents per liter- a volume) and a BUN (Blood Urea Nitrogen- a laboratory test used to assess kidney function and hydration status) of 140 (normal ,[DATE]) mg/dl (miligrams per deciliter- a volume). Interview with Employee E1, administrator, on [DATE], at 9:00 p.m., revealed that the administrator was unaware of the approximate one and one quarter hour delay in the transport of an unresponsive resident to the emergency room . Further interview with the administrator confirmed that the resident had been transported to the hospital via a routine ambulance transport company. The administrator further indicated that the facility had been experiencing problems with their current ambulance transport company. The facility's nursing staff failed to identify an acute change in one resident's medical condition (Resident CL2), and failed to accurately report that acute change in condition to the resident's physician. Due to the failure of nursing staff in accurately identifying and reporting these changes in the resident's condition the resident was subsequently transported to the hospital via a routine ambulance transport, resulting in further delay in the start of necessary medical treatment (intravenous fluids and antibiotics therapy) and resulting in actual harm to the resident. Continued review of the clinical record for Resident CL2 revealed a Nursing Admission Tool dated [DATE], which indicated that upon admission, Resident CL2 was noted with the following skin impairments; reddened area to the sacrum (lower back), wound to the front of the left lower leg and an old wound that healed to the front right lower leg. There were no other wounds noted by nursing staff at the time of the resident's admission into the facility. Review of Resident CL2's Admission MDS (Minimum Data Set -an assessment tool) dated [DATE], revealed that the resident had been identified as at increased risk for skin breakdown. Review of an individualized care plan dated [DATE], related to Resident CL2's wounds directed the staff to assess for signs and symptoms of infection and notify physician: . change in vital signs or resident's status. Further review of Resident CL2's care plan indicated that staff should turn the resident every two hours and call the physician with any concerns. Review of the facility's Wound Round Logs dated [DATE], revealed the presence of new wound (wound #1) to the resident's right heel which measured 4.5 cm (centimeters) long by 3.0 wide by 0.2 cms deep. Review of the wound care consultant's notes, dated [DATE] revealed that in addition to ordering daily treatments to the wound, the consultant recommended to staff that the resident's heel be offloaded (relieved from pressure of mattress) with boots. Review of nursing progress notes dated [DATE], revealed no clinical documentation that nursing staff had noted the presence of a new wound to the resident's right heel or that staff had notified the resident's attending physician of the presence of a new wound. Additionally, there was no documentation that Resident CL2's physician had been notified of the Wound Consultant's recommendation to offload the heels with boots. Further review of Resident CL2's care plan revealed no documentation that nursing staff had ever updated the care plan to include the use of offloading boots as recommended by the wound care consultant. Wound care consultant's FOLLOW UP NOTE, dated [DATE], revealed that the consultant had performed a surgical debridement of the resident's right heel at the bedside. Further review of the consultant's notes indicated that Consent obtained from patient. Further review of Resident CL2's clinical record revealed no documented evidence that an informed consent (formal discussion of risk versus benefit of procedure with patient) had been obtained prior to the start of this procedure. An Admission Minimum Data Set (MDS- an assessment of resident needs tool) dated [DATE], noted that the resident had moderately impaired cognition (cognition-mental process of being awake, alert and aware and able to process information independently). Wound care consultant's FOLLOW UP NOTE dated [DATE], indicated that the consultant had performed an additional surgical debridement (surgical excision of non-healing skin) of the right heel at the resident's bedside. Wound care consultant documentation again revealed that Consent obtained from patient, with no documented evidence that an informed consent for the procedure had been obtained. The consultant's notes further indicated that the incision had been taken . down to and including bone. Continued review of the facility's Wound Round Logs dated [DATE], revealed the presence of a new skin wound noted on the resident's left heel (Wound #2). Further review of the [DATE], Wound Round Log revealed that under the heading Date of origin/Facility(F) or Community (C- a wound acquired outside of the facility) no data had been entered and the space was blank. The wound was described as 2.5 cm (centimeters) long by 1 cm wide. Review of the wound care consultant's FOLLOW UP NOTE dated [DATE], revealed that the resident . continues with large amount of bone exposure. and identifies a . new purple discoloration. In addition, the consultant's notes indicated that the consultant would contact the resident's wife regarding surgical intervention. Continued review of Resident CL2's clinical record revealed no nursing progress notes which indicated that staff had notified the resident's physician of the development of a new wound on the resident's left heel, the large amount of bone exposure, the new presence of purple discoloration to the skin or the wound care consultant's new recommendation for surgical treatment. Further review of wound care consultant's FOLLOW UP NOTE dated [DATE], revealed the presence of a new FTW (Full Thickness Wound-wound involving skin, muscle and exposing bone) on the resident's right dorsal (front) foot (Wound #3). It was measured as 2 cms (centimeters) long by 0.8 cms wide by 0.2 cms deep. Documentation from the wound care consultant dated [DATE], indicated that the consultant had been In contact with both daughters- will plan for debridement (surgical excision of non-healing skin done to promote healing). Nursing progress notes dated [DATE], revealed no documentation that nursing staff had notified the resident's physician of the presence of the new full thickness wound on the resident's dorsal foot or the wound care consultant's recommendation and plan to take the resident to surgery. Review of wound care consultant's FOLOW UP NOTE dated [DATE], indicated that the resident had developed a new wound to the right posterior calf (Wound #4) measuring 4.0 cms long by 2.5 cms wide by 0.1 cms deep and a new wound to the left posterior calf (Wound #5) 2.4 cms long by 1.8 cms wide by 01.cm deep. The [DATE], wound care consultant's FOLLOW UP NOTE revealed no additional recommendations for the treatment of [REDACTED]. The note further indicated that the resident Continues with non-viable (not capable of living or growing) tissue, bone exposure and odor. A review of nursing progress notes dated [DATE], revealed no documentation that the resident's physician was notified of the development of two additional new wounds or that the consultant had detected an odor from the wounds. Review of Resident CL2's Medication Administration Record [REDACTED]. Nursing documentation in the July MAR indicated [REDACTED]. However, continued review of both the wound care consultant's FOLLOW UP NOTE and the facility's Wound Round Log revealed that no wound to the left calf was identified until [DATE], five days after the treatments were documented as administered by nursing staff. Continued review of the weekly Wound care consultant Follow-Up notes dated [DATE], [DATE], [DATE], [DATE], revealed recommendations from the wound care consultant to Monitor for decreased circulation. Continued review of Resident CL2's clinical record revealed no documentation that nursing staff had monitored the circulation to the resident's lower extremities as recommended by the wound care specialist. Review of resident CL2's care plan related to the resident's alteration in skin integrity (wounds) dated initiated [DATE], revealed no additional nursing interventions (i.e. checking for the presence of pulses, assessing the color of the skin and/or checking the temperature of the skin) had been developed to monitor the circulation to the resident's lower extremities as recommended. Further review of Resident CL2's clinical record revealed no documentation in the clinical notes to indicate that the resident's attending physician, Employee E5, had removed the resident's bandages examined and/or assessed the status of the resident's wounds. In addition, there was no documentation in Resident CL2's clinical record that any diagnostic test or studies had been ordered to check the status of the resident's lower circulation to his lower legs and/or the status of the resident's [MEDICAL CONDITION]. Interview with Employee E2, Director of Nursing, on [DATE], revealed that nursing staff chart by exception. In further interview Employee E2 confirmed that nursing staff would be expected to document the presence of any abnormalities in the resident's clinical record. Continued review of Resident CL2's clinical record revealed no nursing documentation that any of the wounds found by the wound care specialist during weekly wound rounds ([DATE], [DATE], [DATE] and two new wounds on [DATE]) had been observed by any of the nursing staff who, would have been turning and repositioning the resident every two hours as per the resident's care plan and performing local wound care daily as per the wound care specialist's recommendations since [DATE]. Employee E2 was unable to explain how these resident's wounds were all identifed by the wound care specialist during weekly rounds when nursing staff were turning the resident every two hours and performing daily skin care. Review of Resident CL2's attending physician and medical director (Employee E5) and/or physician assistant (Employee E9) clinical notes dated [DATE], through [DATE], revealed that the resident has been seen by his providers regularly since his admission into the facility. Further review of the clinical notes revealed that, upon admission into the facility, the resident was noted with [MEDICAL CONDITION] ([MEDICAL CONDITION]- impaired circulation to the lower extremities) and an, open wound to the left lower leg. Continued review of the clinical notes revealed no documentation that the resident's physician had been notified or was aware of the development of five new skin wounds since the time of the resident's admission. Additionally, there was no documentation in the clinical notes to indicate that Employee E5 had removed the resident's bandages examined and/or assessed the status of the resident's wounds. Interview with Employee E5 on [DATE], at 9:30 a.m., confirmed that he was Resident CL2's attending physician and that he was responsible for the overall care of the resident. Further interview with Employee E5 revealed that the physician could not recall the last time he had examined the resident's lower extremity wounds and/or checked for the presence of pulses. In further interview, Employee E5 indicated that the resident was being followed by a Wound Care Consultant (contracted service which provides wound care to residents in the facility) and that the physicians defer to them for the resident's wound care. Additionally, Employee E5 indicated during the interview that he had not ordered any new studies to assess the current status of the resident's circulation as these were, done in the hospital and he does not like to repeat studies. Interview with Employee E9, Wound Care Physician, on [DATE], at 9:15 a.m., revealed that the wound care consulting company had been contacted to provide wound care services to Resident CL2. Further interview with Employee E9 confirmed that he personally had not seen and/or examined Resident CL2's wounds. Employee E9 indicated that the resident had been seen weekly by a CRNP (certified registered nurse practitioner) to assess the condition of the resident's wounds. Employee E9 further confirmed that the condition of the resident's wounds had deteriorated since admission and that the resident had wounds that went down to the bone with exposed tendon. Further interview with Employee E9 confirmed that the resident's [MEDICAL CONDITIONS] has progressed. Additionally, Employee E9 confirmed that the wound care consulting company had made multiple recommendations to the facility to monitor the status of Resident CL2's circulation. Review of the emergency room record for Resident CL2 dated [DATE], at 8:22 p.m. revealed that at the time of the resident's admission into the hospital the resident was noted with the following wounds: Stage II pressure ulcer (ulcer involving the top layers of skin) to the sacrum (lower back) 2 cm long by 2 cm wide, Stage IV pressure ulcer(ulcer involving loss of skin layers, exposing muscle and bone) to the right heel 10 cm long by 8 cm wide and draining green fluid, Stage IV pressure ulcers to bilateral (both) calfs ,[DATE] inches long by 3 inches wide and a Stage III pressure ulcer (ulcer involving full thickness of skin loss, exposing tissues) to the left heel 6 cms wide by 4 cm long. The resident was subsequently admitted to the ICU (Intensive Care Unit) with diagnoses, including but not limited to, Stage II decubitus ulcer, [DIAGNOSES REDACTED] of the ankle and foot and neglected elder. The facility failed to ensure that one resident identified as at increased risk for skin breakdown received thorough monitoring and treatment of [REDACTED]. Further review of the clinical record revealed that the resident's weight on [DATE], was 170.4 pounds, a loss of 12 pounds since the time of the resident's admission, a period of 54 days. A Dietary Weight Change Note dated [DATE], indicated that the dietitian was aware of Resident CL2's weight loss and indicated that the weight loss was significant and that the dietitian would continue to monitor the resident. A review of Resident CL2's subsequent weight on [DATE], was 166.5 pounds, an additional loss of 4.2 pounds. Review of a dietary Weight Change Note dated [DATE], again identified that the resident had a significant weight loss and that the resident had been noted with a decreased appetite and was consuming approximately ,[DATE]% at meals. The noted further indicated that the resident's family had requested that the facility provide the resident with Glucerna (liquid nutrition supplement for people with diabetes). Review of a Physician Weight Change Notification and Dietary Recommendation Form dated [DATE], revealed that the dietitian had recommended that Resident CL2 be weighed weekly times four weeks. Further review of Resident CL2's weights revealed that the resident was weighed the following day on [DATE], and was noted as weighing 178 pounds but no further weights were documented until [DATE], indicating that staff had missed two of the four weekly weights ordered. Further review of Resident CL2's weights revealed that on [DATE], the resident was noted as weighing 164.3 pounds, a 13.7 pound weight loss over 19 days. Further review of Resident CL2's weights revealed no documentation that the resident had been reweighed following the documented 13.7 pound weight loss of [DATE]. A review of Resident CL2's emergency room record revealed that the resident was admitted to the emergency roiagnom on [DATE], at approximately 8:17 p.m. Further emergency room documentation indicated that the resident appeared cachectic (emaciated) and was noted as unresponsive and malnourished. Doctors notes dated [DATE], at 9:58 p.m. revealed patient to be admitted for [MEDICAL CONDITION] (infection of the bloodstream) . and [MEDICAL CONDITION] (low red blood cell count) he will be admitted to the ICU. Further review of Resident CL2's emergency room record revealed .Impression and Plan Problem List: 1) Septic Shock due to urinary tract infection ., 8) Dehydration with [MEDICAL CONDITION] (elevated Sodium level), 9) Malnutrition, and 10) Neglected elder. Continued review of Resident CL2's clinical record revealed that the Hydration Risk Assessment had been completed on [DATE], following the resident's admission into the facility. The admission hydration risk assessment indicated that the resident had a score of three and identified the resident as a hydration risk. The assessment further indicated that the resident had been placed on the hydration program and recommended that the resident receive four ounces of additional fluid three times per day. Continued review of the clinical record revealed that a second Hydration risk assessment had been completed on [DATE], with no further documentation of additional hydration risk assessments noted in the clinical record. Review of Dietary progress notes dated [DATE], through [DATE], revealed the following: on [DATE] Resident's CBW (current body weight) is 170.4# (pounds) . triggers for significant wt (weight) loss x 1 mon (month) of -6.4% (5 (May)/-182.1#) r/t (related to) decreased PO (by mouth) intakes of ,[DATE]% and daily diuretic of [MEDICATION NAME] ([MEDICATION NAME]- drug which pulls excess fluid from the body) 40 mg (milligram).; [DATE] CBW is 166.5#, Triggers for significant wt loss x 3 m of -8.7% (4 (April)/182.4#) r/t decreased po intakes of ,[DATE]% and daily diuretic of [MEDICATION NAME] 40 mg ; [DATE] R/T family concern: CBW is 166.5# sig wt loss x 3 m of -8.7% and [DATE] . CBW is 7(July)/166.5# sig wt loss A review of an individualized care plan developed for Resident CL2 dated [DATE], indicated that the resident had been identified as at increased risk for an alteration in nutrition and/or hydration status. Further review of the care plan directed staff to provide the resident with the diet and supplements as ordered, encourage the resident to consume ,[DATE]% of all meals and to document the residents meal consumption. Further review of the nutrition and hydration care plan revealed no further interventions developed to reduce the risk of dehydration to the resident. Further review of the Resident CL2's care plan revealed that the resident had a foley catheter (tube that is inserted directly into the bladder to drain urine from the bladder). Interventions identified to reduce the risk of complications related to the use of catheters included, Encourage/provide fluid intake and Report any change in color, odor, or decreased urine output to physician. A Nutrition Assessment-Admission/Readmitted d [DATE], revealed that Resident CL2 was unable to drink fluids independently and required assistance from others, had decreased oral intake, the presence of vascular wounds (skin alterations related to poor circulation) and recommended that the resident receive four ounces of fluid q (every) shift (8 hour period) while the resident is awake. In addition, the Nutrition Assessment indicated that the resident should receive ,[DATE] mls of fluid daily to ensure the resident received adequate hydration. Interviews with Employees E3, Dietitian, and E4, regional Dietitian, on [DATE], at 1:00 p.m. revealed that the meal percentage logs are the dietitians primary method they utilize to review how well the residents are eating and drinking. Further interview with Employees E3 and E4 revealed that the meal consumption logs are pre-populated with percentage values that nurse aides must select from to enter the meal consumption data into the system. The employees confirmed that when utilizing this system, staff are unable to document any other values other than what is preloaded into the system which limits the staff's ability to report more specific values. Further interviews with Employees E3 and E4 revealed that as dietitians they are only able to extract an approximation of how well the residents are eating and drinking in the facility. Employees E3 and E4 confirmed that based on the preloaded values entered into the electronic meal consumption system they were unable to determine if Resident CL2 consumed 0% or 25% of his meal and fluids on the dates those values were entered. Nursing progress notes dated [DATE], through [DATE], revealed no clinical documentation that nursing staff had advised Resident CL2's physician of the noted decline in the resident's intake of meals and fluids. Continued review of Resident CL2's emergency room record revealed a Consultation dated [DATE], at 7:38 a.m. which revealed Physical Exam . Skin is notable for tenting over his chest and neck consistent with severe dehydration By history he has not been eating or drinking well at the nursing home for the for the last 2 weeks. The patient presents with extremely high serum sodium and associated with neurological changes with [MEDICAL CONDITION] (acute mental disorder characterized by disorientation and altered consciousness) and these changes were (sic) not happen over many days or a week or more. The resident was subsequently admitted to the ICU (Intensive Care Unit) with diagnoses, including but not limited to, Stage II decubitus ulcer, [DIAGNOSES REDACTED] of the ankle and foot and neglected elder. An Immediate Jeopardy situation was identified to the Nursing Home Administrator(NHA) on [DATE], at 2:00 p.m. related to the findings identified on [DATE] and [DATE], when it was revealed that the facility failed to secure emergency transportation for one resident who was unresponsive with [MEDICAL CONDITION] resulting in a 1 ,[DATE] hour delay in treatment to the resident who was admitted to the ICU in Septic Shock and the facility failed to develop and implement an effective system for the ongoing monitoring of residents' skin conditions for the prevention of skin breakdown. The corrective action plan include the following interventions: 1. R.N. supervisors were inserviced by the staff educator on [DATE], on evaluating residents with a change in medical condition, notifying physicians regarding changes in resident condition and making rounds on every shift to evaluate the effectiveness of physican ordered interventions. Five of eight nursing supervisors inservice training was completed on [DATE]. R.N. Supervisors not on duty will be re-educated prior to the start of their next shift. 2. Licensed nurses on duty will be inserviced immediately by the staff educator on notifying R.N. supervisors of residents with change in condition from baseline and adding residents to the 24 hour report. Licensed nurse training will continue to ensure training is received prior to the start of their shift. 3. All residents in house will receive a skin assessment for wounds. Assessments will begin immediately and all residents will have a skin assessment completed by [DATE]. Licensed Nurses will be in-serviced immediately on completing weekly skin assessments. New areas of skin alteration will be reported to the registered nurse for fur(TRUNCATED)

APPEAL FILED Based on review of clinical records and facility policy and procedure and facility documentation and interviews with staff, it was determined that the facility failed to maintain acceptable parameters of nutrition for two of 28 residents reviewed (Residents CL2 and CL8) resulting in an Immediate Jeopardy situation for one resident (Resident CL2). Findings include: Review of the facility policy, Weighing Resident, dated November 2015, revealed that . 3. All residents will be weighed monthly . and .residents that show a five pound weight loss or gain from the previous month will be reweighed. Additionally, the policy indicated that .7. Residents with orders for weekly weights will be identified each week by the dietitian or Nursing supervisor . Review of the clinical record for Resident CL2 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing admission assessment completed on April 13, 2017, further reflected that the resident had been noted with multiple wounds that were present upon admission into the facility. Review of a nutrition admission assessment for Resident CL2 completed on April 14, 2017, revealed that the resident's current body weight was 182.4 pounds and that the resident been identified at high risk for nutrition and hydration problems. The nutrition assessment further indicated that the resident would be followed by a dietitian. Further review of the clinical record revealed that the resident's weight on June 9, 2017, was 170.4 pounds, a loss of 12 pounds since the time of the resident's admission, which was a period of 54 days. A Dietary Weight Change Note dated June 12, 2017, indicated that the dietitian was aware of Resident CL2's weight loss and indicated that the weight loss was significant and that the dietitian would continue to monitor the resident. A review of Resident CL2's subsequent weight on July 5, 2017, was 166.5 pounds, an additional loss of 4.2 pounds. Review of a Dietary Weight Change Note dated July 6, 2017, again identifed that the resident had a significant weight loss and that the resident had been noted with a decreased appetite and was consuming approximately 25-75% at meals. The note further indicated that the resident's family had requested that the facility provide the resident with Glucerna (liquid nutrition supplement for people with diabetes). Review of a Physician Weight Change Notification and Dietary Recommendation Form, dated by dietary on July 20, 2017, revealed that the dietitian had recommended that Resident CL2 be weighed weekly times four weeks. Further review of Resident CL2's weights revealed that the resident was weighed the following day on July 21, 2017, and was noted as weighing 178 pounds but no further weights were documented until August 10, 2017, indicating that staff had missed two of the four weekly weights ordered. Dietary notes dated July 20, 2017, at 11:54 a.m. revealed that the resident continued with significant weight loss and was noted with variable meal intakes of 0-76% (mostly 50). In addition, it was again noted that the family had approached facility staff with concerns related to the resident's weight and had requested that the facility obtain an appetite stimulant. Further review of Resident CL2's weights revealed that on August 9, 2017, the resident was noted as weighing 164.3 pounds, a 13.7 pound weight loss over 19 days. Further review of Resident CL2's weights revealed no documentation that the resident had been reweighed following the documented 13. 7 pound weight loss of August 9, 2017. A review of an individualized care plan developed for Resident CL2 dated 04/14/17, indicated that the resident had been identified as increased risk for an alteration in nutrition and/or hydration status. Further review of the care plan directed the staff to provide the resident with the diet and supplements as ordered, encourage the resident to consume 75-100% of all meals and to document the resident's meal consumption. Further review of the nutrition and hydration care plan revealed no further interventions developed to reduce the risk of dehydration to the resident. A review of Resident CL2's Meal Percentage logs dated August 1, 2017, through August 13, 2017, revealed that of 39 possible meals, the resident had been noted as having refused to eat three meals, consumed less than 25% of 18 meals and less than 50% of 9 meals in the month of August. The meal percentage data further revealed that the resident had either refused or consumed less than 50% of his meals on 30 of 39 possible meals and had not reached the meal consumption goals established in the resident's nutrition and hydration plan of care. Interviews with Employees E3, Dietitian, and E4, Regional Dietitian, on August 21, 2017, at 1:00 p.m. revealed that the meal percentage logs are the dietitians primary method they utilize to review how well the residents are eating and drinking. Further interview with Employees E3 and E4 revealed that the meal consumption logs are pre-populated with percentage values that the nurse aides must select from to enter the meal consumption data into the system. The employees confirmed that when utilizing this system, the staff are unable to document any other values other than what is preloaded into the system which limits the staff's ability to report more specific values. Further interviews with Employees E3 and E4 revealed that as dietitians they are only able to extract an approximation of how well the residents are eating and drinking in the facility. Employees E3 and E4 confirmed that based on the preloaded values entered into the electronic meal consumption system they were unable to determine if Resident CL2 consumed 0% or 25% of his meal and fluids on the dates those values were entered. A review of Resident CL2's emergency room record revealed that the resident was admitted to the emergency roiagnom on [DATE], at approximately 8:17 p.m. Further emergency room documentation indicated that the resident appeared cachectic (emaciated) and was noted as unresponsive and malnourished. The doctor's notes dated August 13, 2017, at 9:58 p.m. revealed patient to be admitted for [MEDICAL CONDITION] (infection of the bloodstream) . and [MEDICAL CONDITION] (low red blood cell count) he will be admitted to the ICU. Further review of Resident CL2's emergency room record revealed, .Impression and Plan Problem List: 1) Septic Shock due to urinary tract infection ., 8) Dehydration with [MEDICAL CONDITION] (elevated Sodium level), 9) Malnutrition, and 10) Neglected elder. An Immediate Jeopardy situation was identified to the Nursing Home Administrator (NHA) on August 19, 2017, at 2:00 p.m. related to the findings identified on August 18, 2017, and August 19, 2017, when it was revealed that the facility failed to develop and implement an effective, comprehensive system for the ongoing monitoring of residents nutritional status which resulted in one resident being admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. The corrective action plan include the following interventions: 1. R.N. supervisors were inserviced by the staff educator on August 19, 2017, on evaluating residents with a change in medical condition, notifying physicians regarding changes in resident condition and making rounds on every shift to evaluate the effectiveness of physican ordered interventions. Five of eight nursing supervisors inservice training was completed on August 19, 2017. R.N. Supervisors not on duty will be re-educated prior to the start of their next shift. 2. Licensed nurses on duty will be inserviced immediately by the staff educator on notifying R.N. supervisors of residents with change in condition from baseline and adding residents to the 24 hour report. Licensed nurse training will continue to ensure training is received prior to the start of their shift. 3. All residents in house will receive a skin assessment for wounds. Assessments will begin immediately and all residents will have a skin assessment completed by August 21, 2017. Licensed Nurses will be in-serviced immediately on completing weekly skin assessments. New areas of skin alteration will be reported to the registered nurse for further assessment. Registered nurses will assess area, document changes, notify physician and responsible party and implement treatment plan of care as ordered. 4. All current residents with wounds will be assessed, treatments and plan of care reviewed and updated immediately. 5. Residents with weight loss in the last 30 days will be reviewed by the Dietitian starting immediately, reweights obtained, physicians notified, new orders implemented and documented in the medical record immediately. 6. Dietitian will review weights and re-weights needed during morning clinical meeting. Weights will be assigned to the unit managers for follow-up on same day and brought to afternoon meeting to be verified. Verified weight changes will be reviewed by the dietitian for further recommendations. Recommendations will be discussed with physician, responsible representative and implement treatment and plan of care as ordered. 7. Residents transferred to the hospital in the last 30 days will be reviewed immediately for the timeliness of the hospital transfer. If the current transportation services is unable to provide an acceptable ETA 9-1-1 will be called. Facility has contracted with a new transportation service, which will go into effect on September 1, 2017. 8. The Director of Nursing services or designee will complete daily audits of the 24 hour report for identified baseline condition changes, current physician ordered interventions, and response to intervention for 14 days, then 3 times a week for 14 days, then weekly for 30 days. Identifed trends will be brought to the AD H(NAME) (committee set up to deal with a specific issue) QAPI (Quality Assurance Performance Improvement) committee for further recommendations. 9. By the end of the day today, August 19, 2017, we will have 30 licensed nurses and CNAs (nurses aides) educated on the above areas. Education will continue until 100% is achieved. The Immediate Jeopardy was removed on August 21, 2017, at 4:30 p.m. after it was verified that the corrective action plan was implemented. Review of the clinical record for Resident CL8 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Resident CL8's weights revealed an admission weight of 160 lbs. (pounds) and a weight of 157.8 lbs. the next day. There was no documented evidence that the resident had been weighed again. Review of the initial nutritional assessment/admission assessment dated [DATE], revealed that the resident was a diabetic (inability of the body to produce insulin to utilize the blood sugar) and had high blood pressure, and the recommended diet was CCD/NAS (diabetic/no added salt) and monitoring was required, and the resident had a wound. A protein supplement was recommended. Review of the physician's orders dated July 21, 2017, revealed that the resident was diagnosed with [REDACTED]. Further review of physician's orders revealed that on July 31, 2017, the resident was diagnosed with [REDACTED]. The resident had been vomiting on August 5 and 6, 2017, and the nursing progress notes indicated that the resident was vomiting. Review of Resident CL8's laboratory tests reveal that on July 26, 2017, revealed that the resident's BUN (blood urea nitrogen) was 54 mg/dl (milligrams per deciliter - normal range 6-25 mg/dl) and the Creatinine was .9 mg/dl (normal range is .5-1.1 mg/dl. These studies indicate the resident's hydration (fluid) needs.) The resident received IVF (intravenous (through the vein) fluids.) On July 28, 2017, the BUN was 40 mg/dl and the Creatinine was .9 mg/dl and the resident's Total Protein was 5.9 mg/dl, (normal is 6.3-8.2 mg/dl) and [MEDICATION NAME] was 2.8 g/dl (grams per deciliter. The normal is 3.6-5.2 g/dl. The results of this study reveals low protein and poor nutrition.) A progress note dated July 25, 2017, added the [DIAGNOSES REDACTED]. The physician ordered a calorie count for three days on August 2, 2017, which was not completed by staff. The facility did not have a nutritional assessment and monitoring for Resident CL8. This resident had two infections with antibiotic treatments, two worsening wounds, hypovolemia (low fluid volume), was treated with IVF, had diarrhea, nausea and vomiting and had abnormal laboratory results with a new [DIAGNOSES REDACTED]. The facility failed to develop and implement an accurate and comprehensive system for the monitoring of residents' nutritional status and failed to ensure that resident weights were completed in a timely manner. 42 CFR 483.25(g)(1)(3) Maintain Nutrition Status Unless Unavoidable Previously cited 12/21/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/20/17, 01/04/17, 09/17/16, 07/26/16, 01/30/15 28 Pa. Code 201.18(a) Management Previously cited 01/30/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 01/04/17, 01/30/15 28 Pa. Code 201.18(e)(3) Management Previously cited 01/30/15 28 Pa. Code 211.5(f) Clinical records Previously cited 04/20/17, 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 01/04/17, 12/21/15, 01/30/15

APPEAL FILE Based on review of clinical records, facility policy and procedures, facility documents, hospital records, other documents and interviews with staff, it was determined that the facility failed to ensure that residents received the appropriate level of health care services, treatments and care related to nutrition, hydration and wound care services, resulting in neglect to 11 of 28 residents reviewed (Residents CL2, CL8, R228, R25, R166, R28, CL3, CL1, CL5, R250 and R137). Additionally, the facility failed to identify one resident with an acute change in their medical condition and failed to accurately report that change in condition to the resident's physician causing a delay in the start of necessary medical treatment resulting in severe dehydration and septic shock, causing actual harm to the resident (Resident CL2). Findings include: Review of facility policy, 111, Change in Resident's Condition, dated revised [DATE], . 1. When a significant change in the resident's condition is observed, the Charge Nurse and Supervisor will be notified immediately. And . A significant change in condition includes but is not limited to: . Sudden acute changes in mental status or levels of consciousness (i.e. confusion in a normally AAO (awake, alert and oriented) x 3 resident; unresponsiveness. The policy further indicated that .5. The Charge Nurse/Supervisor will contact the resident's physician. A description of the change in condition is made and the orders of the physician will be carried out immediately. Review of facility policy, Resident Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property dated revised [DATE] revealed, The facility's goal is to anticipate and prevent abuse through ongoing in-service of staff . regarding interactions with the residents . providing thorough staff screening and training and sufficient staff to effectively care plan and monitor residents. Additionally, the policy defined Neglect as refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to, nutrition, medication, therapies and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Review of the clinical record for Resident CL2 revealed that the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to, hypertension (high blood pressure),[MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), [MEDICAL CONDITION] (extreme weakness of one side of the body)- affecting the right dominant side, Dysphagia (difficulty swallowing), [MEDICAL CONDITION] ([MEDICAL CONDITION]-poor circulation of the extremities) and [MEDICAL CONDITION] (inability of the kidneys to function properly). An Admission Minimum Data Set (MDS- an assessment of resident needs tool) dated [DATE], noted that the resident had moderately impaired cognition (cognition-mental process of being awake, alert and aware and able to process information independently). The MDS further revealed that Resident CL2 was non-ambulatory (unable to walk), required extensive assistance from staff for transferring (moving from one area to another) eating, drinking, completing personal hygiene and bathing. Additionally, the clinical record indicated that the resident was a Full Code (resident and/or responsible party had expressed the desire to have a full resuscitation or CPR performed in the event of a medical emergency). Further review of Resident CL2's clinical record revealed that on [DATE], nursing staff had documented in the resident's Medication Administration Record [REDACTED]. Nursing progress notes dated [DATE], at 14:52 (2:52 p.m.) indicated that the resident had taken all his scheduled medications and had received his dressing change as ordered. The note further indicated that nursing staff had administered four ounces of the house supplement (liquid nutritional supplement) to the resident at 4:00 p.m. Interview with Employee E2, director of nursing, on [DATE] at 12:30 p.m. revealed that facility nurses' chart by exception (system of clinical documentation by which staff only notates the presence of abnormalities.). Continued review of the Resident CL2's clinical record revealed no additional nursing documentation regarding the status of Resident CL2 until at 18:31 (6:31 p.m.) Nsg (Nursing) Supervior (sic) in to assess resident as per sons request who was visiting father at bedside. Resident non-responsive to verbal stimuli. Change in mental status. Call placed to MD. Nursing documentation further indicated that the resident's . Blood Pressure low ,[DATE]. Call placed to MD. gave orders to send resident out to ER (emergency room ) for eval (evaluation). Call placed to ambulance ETA (estimated time of arrival) ,[DATE] mins. (minutes). A telephone interview with Employee E5, medical director, on [DATE], at 1:30 p.m. revealed that the medical director had spoken with Employee E12, on-call physician, related to Resident CL2's transfer to the hospital on [DATE]. Employee E5 confirmed that the on-call physician had been contacted by nursing staff regarding the resident's unresponsiveness. Employee E5 further indicated that nursing staff had reported to the on-call physician that he/she had not noticed much difference in the change of the resident's condition since the start of her/his shift, and for that reason the attending physician had not ordered a [DATE] emergency transport to the hospital. In further interview on [DATE], at 9:30 a.m., Employee E5 stated that he had concerns with communication between the nursing staff and the physician staff. Employee E5 indicated that physician staff get a lot of phone calls late at night related to laboratory results, when the physicians are available to staff during the day. Employee E5 also indicated that he agreed 100% that there was an inconsistency of nursing staff and that there was a high degree of variability with nurses' knowledge and familiarity of the residents. Review of ambulance transport records for Resident CL2 dated [DATE], revealed that the ambulance company had been contacted by the facility to provide Non-Emergent from the facility to the hospital for a patient with a noted change in mental status. Further review of the ambulance record revealed the following documented time frames: dispatched to the facility at 7:00 p.m., arrived at the facility at 7:18 p.m., at resident at 7:22 p.m., left the facility at 8:08 p.m. and arrived at the hospital at 8:12 p.m Additional review of the ambulance transport documentation indicated that the total mileage from the facility to the hospital was 0.3 miles. Continued review of the ambulance transport documentation indicated that ambulance staff had noted that The patient required ALS (Advanced Life Support) because he was unresponsive . with a blood pressure of ,[DATE]. Further review of the ambulance transport record indicated that nursing staff had reported to them that the family was in to visit the patient and found him unresponsive. Nursing staff did not know how long the resident had been like this and . they cannot confirm a definite time that patient was last seen normal. Additionally, the ambulance transport record indicated that following the ambulance staff's initial physical assessment of Resident CL2 they determined that the Initial Patient Acuity for the resident was Emergent. Further documentation in the ambulance transport record indicated that they placed the resident on a cardiac monitor, administered oxygen to the resident, began intravenous fluids (I.V.- method of providing fluids and/or medication through a vein) and checked the resident's glucose level prior to leaving the facility. Review of Resident CL2's emergency room record revealed the following documentation: Time of Greet: Sun. [DATE], at 8:17 p.m. Further review of the emergency room record for Resident CL2 revealed that the resident was unresponsive, with an Acuity level critical. Doctor's notes dated [DATE], at 1:23 a.m., revealed that patient to be admitted for [MEDICAL CONDITION] . and he will be admitted to the ICU (Intensive Care Unit). A physician's History and Physical dated [DATE], indicated that the resident had been admitted to the ICU (intensive care unit) with diagnoses, including but not limited to, Septic Shock (form of shock which develops due to the presence of bacteria in the bloodstream), UTI, (urinary tract infection ), severe dehydration with a Sodium level (Sodium- an electrolyte present in the bloodstream) of 161(normal value ,[DATE] mEq/L (miliequivalents per liter- a volume) and a BUN (Blood Urea Nitrogen- a laboratory test used to assess kidney function and hydration status) of 140 (normal ,[DATE]) mg/dl (miligrams per deciliter- a volume). Interview with Employee E1, administrator, on [DATE], at 9:00 p.m., revealed that the administrator was unaware of the approximate one and one quarter hour delay in the transport of an unresponsive resident to the emergency room . Further interview with the administrator confirmed that the resident had been transported to the hospital via a routine ambulance transport company. The administrator further indicated that the facility had been experiencing problems with their current ambulance transport company. The facility's nursing staff failed to identify an acute change in one resident's medical condition (Resident CL2), and failed to accurately report that acute change in condition to the resident's physician. Due to the failure of nursing staff in accurately identifying and reporting these changes in the resident's condition the resident was subsequently transported to the hospital via a routine ambulance transport, resulting in further delay in the start of necessary medical treatment (intravenous fluids and antibiotics therapy) and resulting in actual harm to the resident. Continued review of the clinical record for Resident CL2 revealed a Nursing Admission Tool dated [DATE], which indicated that upon admission, Resident CL2 was noted with the following skin impairments; reddened area to the sacrum (lower back), wound to the front of the left lower leg and an old wound that healed to the front right lower leg. There were no other wounds noted by nursing staff at the time of the resident's admission into the facility. Review of Resident CL2's Admission MDS (Minimum Data Set -an assessment tool) dated [DATE], revealed that the resident had been identified as at increased risk for skin breakdown. Review of an individualized care plan dated [DATE], related to Resident CL2's wounds directed the staff to assess for signs and symptoms of infection and notify physician: . change in vital signs or resident's status. Further review of Resident CL2's care plan indicated that staff should turn the resident every two hours and call the physician with any concerns. Review of the facility's Wound Round Logs dated [DATE], revealed the presence of new wound (wound #1) to the resident's right heel which measured 4.5 cm (centimeters) long by 3.0 wide by 0.2 cms deep. Review of the wound care consultant's notes, dated [DATE] revealed that in addition to ordering daily treatments to the wound, the consultant recommended to staff that the resident's heel be offloaded (relieved from pressure of mattress) with boots. Review of nursing progress notes dated [DATE], revealed no clinical documentation that nursing staff had noted the presence of a new wound to the resident's right heel or that staff had notified the resident's attending physician of the presence of a new wound. Additionally, there was no documentation that Resident CL2's physician had been notified of the Wound Consultant's recommendation to offload the heels with boots. Further review of Resident CL2's care plan revealed no documentation that nursing staff had ever updated the care plan to include the use of offloading boots as recommended by the wound care consultant. Wound care consultant's FOLLOW UP NOTE, dated [DATE], revealed that the consultant had performed a surgical debridement of the resident's right heel at the bedside. Further review of the consultant's notes indicated that Consent obtained from patient. Further review of Resident CL2's clinical record revealed no documented evidence that an informed consent (formal discussion of risk versus benefit of procedure with patient) had been obtained prior to the start of this procedure. An Admission Minimum Data Set (MDS- an assessment of resident needs tool) dated [DATE], noted that the resident had moderately impaired cognition (cognition-mental process of being awake, alert and aware and able to process information independently). Wound care consultant's FOLLOW UP NOTE dated [DATE], indicated that the consultant had performed an additional surgical debridement (surgical excision of non-healing skin) of the right heel at the resident's bedside. Wound care consultant documentation again revealed that Consent obtained from patient, with no documented evidence that an informed consent for the procedure had been obtained. The consultant's notes further indicated that the incision had been taken . down to and including bone. Continued review of the facility's Wound Round Logs dated [DATE], revealed the presence of a new skin wound noted on the resident's left heel (Wound #2). Further review of the [DATE], Wound Round Log revealed that under the heading Date of origin/Facility(F) or Community (C- a wound acquired outside of the facility) no data had been entered and the space was blank. The wound was described as 2.5 cm (centimeters) long by 1 cm wide. Review of the wound care consultant's FOLLOW UP NOTE dated [DATE], revealed that the resident . continues with large amount of bone exposure. and identifies a . new purple discoloration. In addition, the consultant's notes indicated that the consultant would contact the resident's wife regarding surgical intervention. Continued review of Resident CL2's clinical record revealed no nursing progress notes which indicated that staff had notified the resident's physician of the development of a new wound on the resident's left heel, the large amount of bone exposure, the new presence of purple discoloration to the skin or the wound care consultant's new recommendation for surgical treatment. Further review of wound care consultant's FOLLOW UP NOTE dated [DATE], revealed the presence of a new FTW (Full Thickness Wound-wound involving skin, muscle and exposing bone) on the resident's right dorsal (front) foot (Wound #3). It was measured as 2 cms (centimeters) long by 0.8 cms wide by 0.2 cms deep. Documentation from the wound care consultant dated [DATE], indicated that the consultant had been In contact with both daughters- will plan for debridement (surgical excision of non-healing skin done to promote healing). Nursing progress notes dated [DATE], revealed no documentation that nursing staff had notified the resident's physician of the presence of the new full thickness wound on the resident's dorsal foot or the wound care consultant's recommendation and plan to take the resident to surgery. Review of wound care consultant's FOLOW UP NOTE dated [DATE], indicated that the resident had developed a new wound to the right posterior calf (Wound #4) measuring 4.0 cms long by 2.5 cms wide by 0.1 cms deep and a new wound to the left posterior calf (Wound #5) 2.4 cms long by 1.8 cms wide by 01.cm deep. The [DATE], wound care consultant's FOLLOW UP NOTE revealed no additional recommendations for the treatment of [REDACTED]. The note further indicated that the resident Continues with non-viable (not capable of living or growing) tissue, bone exposure and odor. A review of nursing progress notes dated [DATE], revealed no documentation that the resident's physician was notified of the development of two additional new wounds or that the consultant had detected an odor from the wounds. Review of Resident CL2's Medication Administration Record [REDACTED]. Nursing documentation in the July MAR indicated [REDACTED]. However, continued review of both the wound care consultant's FOLLOW UP NOTE and the facility's Wound Round Log revealed that no wound to the left calf was identified until [DATE], five days after the treatments were documented as administered by nursing staff. Continued review of the weekly Wound care consultant Follow-Up notes dated [DATE], [DATE], [DATE], [DATE], revealed recommendations from the wound care consultant to Monitor for decreased circulation. Continued review of Resident CL2's clinical record revealed no documentation that nursing staff had monitored the circulation to the resident's lower extremities as recommended by the wound care specialist. Review of resident CL2's care plan related to the resident's alteration in skin integrity (wounds) dated initiated [DATE], revealed no additional nursing interventions (i.e. checking for the presence of pulses, assessing the color of the skin and/or checking the temperature of the skin) had been developed to monitor the circulation to the resident's lower extremities as recommended. Further review of Resident CL2's clinical record revealed no documentation in the clinical notes to indicate that the resident's attending physician, Employee E5, had removed the resident's bandages examined and/or assessed the status of the resident's wounds. In addition, there was no documentation in Resident CL2's clinical record that any diagnostic test or studies had been ordered to check the status of the resident's lower circulation to his lower legs and/or the status of the resident's [MEDICAL CONDITION]. Interview with Employee E2, Director of Nursing, on [DATE], revealed that nursing staff chart by exception. In further interview Employee E2 confirmed that nursing staff would be expected to document the presence of any abnormalities in the resident's clinical record. Continued review of Resident CL2's clinical record revealed no nursing documentation that any of the wounds found by the wound care specialist during weekly wound rounds ([DATE], [DATE], [DATE] and two new wounds on [DATE]) had been observed by any of the nursing staff who, would have been turning and repositioning the resident every two hours as per the resident's care plan and performing local wound care daily as per the wound care specialist's recommendations since [DATE]. Employee E2 was unable to explain how these resident's wounds were all identifed by the wound care specialist during weekly rounds when nursing staff were turning the resident every two hours and performing daily skin care. Review of Resident CL2's attending physician and medical director (Employee E5) and/or physician assistant (Employee E9) clinical notes dated [DATE], through [DATE], revealed that the resident has been seen by his providers regularly since his admission into the facility. Further review of the clinical notes revealed that, upon admission into the facility, the resident was noted with [MEDICAL CONDITION] ([MEDICAL CONDITION]- impaired circulation to the lower extremities) and an, open wound to the left lower leg. Continued review of the clinical notes revealed no documentation that the resident's physician had been notified or was aware of the development of five new skin wounds since the time of the resident's admission. Additionally, there was no documentation in the clinical notes to indicate that Employee E5 had removed the resident's bandages examined and/or assessed the status of the resident's wounds. Interview with Employee E5 on [DATE], at 9:30 a.m., confirmed that he was Resident CL2's attending physician and that he was responsible for the overall care of the resident. Further interview with Employee E5 revealed that the physician could not recall the last time he had examined the resident's lower extremity wounds and/or checked for the presence of pulses. In further interview, Employee E5 indicated that the resident was being followed by a Wound Care Consultant (contracted service which provides wound care to residents in the facility) and that the physicians defer to them for the resident's wound care. Additionally, Employee E5 indicated during the interview that he had not ordered any new studies to assess the current status of the resident's circulation as these were, done in the hospital and he does not like to repeat studies. Interview with Employee E9, Wound Care Physician, on [DATE], at 9:15 a.m., revealed that the wound care consulting company had been contacted to provide wound care services to Resident CL2. Further interview with Employee E9 confirmed that he personally had not seen and/or examined Resident CL2's wounds. Employee E9 indicated that the resident had been seen weekly by a CRNP (certified registered nurse practitioner) to assess the condition of the resident's wounds. Employee E9 further confirmed that the condition of the resident's wounds had deteriorated since admission and that the resident had wounds that went down to the bone with exposed tendon. Further interview with Employee E9 confirmed that the resident's [MEDICAL CONDITIONS] has progressed. Additionally, Employee E9 confirmed that the wound care consulting company had made multiple recommendations to the facility to monitor the status of Resident CL2's circulation. Review of the emergency room record for Resident CL2 dated [DATE], at 8:22 p.m. revealed that at the time of the resident's admission into the hospital the resident was noted with the following wounds: Stage II pressure ulcer (ulcer involving the top layers of skin) to the sacrum (lower back) 2 cm long by 2 cm wide, Stage IV pressure ulcer(ulcer involving loss of skin layers, exposing muscle and bone) to the right heel 10 cm long by 8 cm wide and draining green fluid, Stage IV pressure ulcers to bilateral (both) calfs ,[DATE] inches long by 3 inches wide and a Stage III pressure ulcer (ulcer involving full thickness of skin loss, exposing tissues) to the left heel 6 cms wide by 4 cm long. The resident was subsequently admitted to the ICU (Intensive Care Unit) with diagnoses, including but not limited to, Stage II decubitus ulcer, [DIAGNOSES REDACTED] of the ankle and foot and neglected elder. The facility failed to ensure that one resident identified as at increased risk for skin breakdown received thorough monitoring and treatment of [REDACTED]. Further review of the clinical record revealed that the resident's weight on [DATE], was 170.4 pounds, a loss of 12 pounds since the time of the resident's admission, a period of 54 days. A Dietary Weight Change Note dated [DATE], indicated that the dietitian was aware of Resident CL2's weight loss and indicated that the weight loss was significant and that the dietitian would continue to monitor the resident. A review of Resident CL2's subsequent weight on [DATE], was 166.5 pounds, an additional loss of 4.2 pounds. Review of a dietary Weight Change Note dated [DATE], again identified that the resident had a significant weight loss and that the resident had been noted with a decreased appetite and was consuming approximately ,[DATE]% at meals. The noted further indicated that the resident's family had requested that the facility provide the resident with Glucerna (liquid nutrition supplement for people with diabetes). Review of a Physician Weight Change Notification and Dietary Recommendation Form dated [DATE], revealed that the dietitian had recommended that Resident CL2 be weighed weekly times four weeks. Further review of Resident CL2's weights revealed that the resident was weighed the following day on [DATE], and was noted as weighing 178 pounds but no further weights were documented until [DATE], indicating that staff had missed two of the four weekly weights ordered. Further review of Resident CL2's weights revealed that on [DATE], the resident was noted as weighing 164.3 pounds, a 13.7 pound weight loss over 19 days. Further review of Resident CL2's weights revealed no documentation that the resident had been reweighed following the documented 13.7 pound weight loss of [DATE]. A review of Resident CL2's emergency room record revealed that the resident was admitted to the emergency roiagnom on [DATE], at approximately 8:17 p.m. Further emergency room documentation indicated that the resident appeared cachectic (emaciated) and was noted as unresponsive and malnourished. Doctors notes dated [DATE], at 9:58 p.m. revealed patient to be admitted for [MEDICAL CONDITION] (infection of the bloodstream) . and [MEDICAL CONDITION] (low red blood cell count) he will be admitted to the ICU. Further review of Resident CL2's emergency room record revealed .Impression and Plan Problem List: 1) Septic Shock due to urinary tract infection ., 8) Dehydration with [MEDICAL CONDITION] (elevated Sodium level), 9) Malnutrition, and 10) Neglected elder. Continued review of Resident CL2's clinical record revealed that the Hydration Risk Assessment had been completed on [DATE], following the resident's admission into the facility. The admission hydration risk assessment indicated that the resident had a score of three and identified the resident as a hydration risk. The assessment further indicated that the resident had been placed on the hydration program and recommended that the resident receive four ounces of additional fluid three times per day. Continued review of the clinical record revealed that a second Hydration risk assessment had been completed on [DATE], with no further documentation of additional hydration risk assessments noted in the clinical record. Review of Dietary progress notes dated [DATE], through [DATE], revealed the following: on [DATE] Resident's CBW (current body weight) is 170.4# (pounds) . triggers for significant wt (weight) loss x 1 mon (month) of -6.4% (5 (May)/-182.1#) r/t (related to) decreased PO (by mouth) intakes of ,[DATE]% and daily diuretic of [MEDICATION NAME] ([MEDICATION NAME]- drug which pulls excess fluid from the body) 40 mg (milligram).; [DATE] CBW is 166.5#, Triggers for significant wt loss x 3 m of -8.7% (4 (April)/182.4#) r/t decreased po intakes of ,[DATE]% and daily diuretic of [MEDICATION NAME] 40 mg ; [DATE] R/T family concern: CBW is 166.5# sig wt loss x 3 m of -8.7% and [DATE] . CBW is 7(July)/166.5# sig wt loss A review of an individualized care plan developed for Resident CL2 dated [DATE], indicated that the resident had been identified as at increased risk for an alteration in nutrition and/or hydration status. Further review of the care plan directed staff to provide the resident with the diet and supplements as ordered, encourage the resident to consume ,[DATE]% of all meals and to document the residents meal consumption. Further review of the nutrition and hydration care plan revealed no further interventions developed to reduce the risk of dehydration to the resident. Further review of the Resident CL2's care plan revealed that the resident had a foley catheter (tube that is inserted directly into the bladder to drain urine from the bladder). Interventions identified to reduce the risk of complications related to the use of catheters included, Encourage/provide fluid intake and Report any change in color, odor, or decreased urine output to physician. A Nutrition Assessment-Admission/Readmitted d [DATE], revealed that Resident CL2 was unable to drink fluids independently and required assistance from others, had decreased oral intake, the presence of vascular wounds (skin alterations related to poor circulation) and recommended that the resident receive four ounces of fluid q (every) shift (8 hour period) while the resident is awake. In addition, the Nutrition Assessment indicated that the resident should receive ,[DATE] mls of fluid daily to ensure the resident received adequate hydration. Interviews with Employees E3, Dietitian, and E4, regional Dietitian, on [DATE], at 1:00 p.m. revealed that the meal percentage logs are the dieticians primary method they utilize to review how well the residents are eating and drinking. Further interview with Employees E3 and E4 revealed that the meal consumption logs are pre-populated with percentage values that nurse aides must select from to enter the meal consumption data into the system. The employees confirmed that when utilizing this system, staff are unable to document any other values other than what is preloaded into the system which limits the staff's ability to report more specific values. Further interviews with Employees E3 and E4 revealed that as dietitians they are only able to extract an approximation of how well the residents are eating and drinking in the facility. Employees E3 and E4 confirmed that based on the preloaded values entered into the electronic meal consumption system they were unable to determine if Resident CL2 consumed 0% or 25% of his meal and fluids on the dates those values were entered. Nursing progress notes dated [DATE], through [DATE], revealed no clinical documentation that nursing staff had advised Resident CL2's physician of the noted decline in the resident's intake of meals and fluids. Continued review of Resident CL2's emergency room record revealed a Consultation dated [DATE], at 7:38 a.m. which revealed Physical Exam . Skin is notable for tenting over his chest and neck consistent with severe dehydration By history he has not been eating or drinking well at the nursing home for the for the last 2 weeks. The patient presents with extremely high serum sodium and associated with neurological changes with [MEDICAL CONDITION] (acute mental disorder characterized by disorientation and altered consciousness) and these changes were (sic) not happen over many days or a week or more. Review of the clinical record for Resident CL8 revealed that the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to, chronic embolism (blood clots), muscle weakness, dementia (irreversible mental deterioration with loss of contact with reality), [MEDICAL CONDITION] disease of the nervous system, high blood pressure, [MEDICAL CONDITION] (poor circulation) and neuralgia (nerve pain). Review of the nursing admission assessment revealed that the resident had a venous (vein) ulcer on the LLE (left lower extremity) measuring 6 cm (centimeters) by 7 cm; there was no evidence of a wound on the RLE (right lower extremity). Review of the facility wound tracking form revealed that the resident had a venous ulcer on the RLE on admission with no measurement of the wound until [DATE] that was 3.5 cm by 3.5 cm. A nursing progress note dated [DATE], revealed that there was a scab on the RLE that was tender to touch and a foam dressing was applied. There was no physician's order for the foam dressing. Review of the Advanced Vascular & Wound Associates consult dated [DATE], had no mention of a wound on the RLE until another consult was completed on [DATE], when a woun(TRUNCATED)

APPEAL FILED Based on review of clinical records, facility policy and procedure, clinical documentation and interviews with staff, it was determined that the facility did not ensure that two of 28 residents reviewed (Residents CL2 and CL8) received sufficient fluid intake to maintain adequate levels of hydration, resulting in actual harm resulting in hospitalization for one resident (Resident CL2). Findings include: Review of the clinical record for Resident CL2 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment (MDS- an assessment of resident care and needs) dated April 20, 2017, noted that the resident had moderately impaired cognition (cognition- mental process of being awake, alert and aware and able to process information independently). Additionally, the MDS indicated that Resident CL2 was non-ambulatory (not walking), required extensive assistance from staff for transferring (moving from one area to another) eating, drinking, completing personal hygiene and bathing. Review of facility document, Hydration Monitoring Program, dated revised July 2015, revealed that per facility policy, The facility will follow established methods for the identification of residents who are at risk for inadequate fluid intake, so that additional interventions are provided . and identify residents at risk and to implement measures to prevent dehydration. The policy further stipulates that, the Dietitian will screen residents utilizing the hydration risk assessment in PCC (Point Click Care- an electronic medical record system) within five days 1. Of admission/ readmission and ii. When resident has exhibited a significant weight loss. Continued review of Resident CL2's clinical record revealed that the Hydration Risk Assement had been completed on April 14, 2017, following the resident's admission into the facility. The admission hydration risk assessment indicated that the resident had a score of three and identifed the resident as a hydration risk. The assessment further indicated that the resident had been placed on the hydration program and recommended that the resident receive four ounces of additional fluid three times per day. Continued review of the clinical record revealed that a second Hydration Risk Assessment had been completed on May 17, 2017, with no further documentation of additional hydration risk assessments noted in the clinical record. Review of the dietary progress notes dated June 12, 2017, through August 3, 2017, revealed the following: on 06/12/17 Resident's CBW (current body weight) is 170.4# (pounds) . triggers for significant wt (weight) loss x 1 mon (month) of -6.5% (5 (May)/-182.1#) r/t (related to) decreased PO (by mouth) intakes of 25-75% and daily diuretic of [MEDICATION NAME] ([MEDICATION NAME]- drug which pulls excess fluid from the body) 40 mg (milligram).; 07/06/17 CBW is 166.5#, Triggers for significant wt loss x 3 m of -8.7% (4 (April)/182.4#) r/t decreased po intakes of 25-75% and daily diuretic of [MEDICATION NAME] 40 mg ; 07/20/17 R/T family concern: CBW is 166.5# sig wt loss x 3 m of -8.7% and 08/3/2017 . CBW is 7(July)/166.5# sig wt loss . Interview with Employee E3, Dietitian, on August 21, 2017, at approximately 1:00 p.m. revealed that the employee was unaware that per the facility's Hydration Monitoring Program, a Hydration Risk Assessment should be completed on all residents who have experienced a significant weight loss. Further interview with Employee E3 confirmed that the employee had not conducted Hydration Risk Assessments on Resident CL2 following the documented significant weight losses noted on 06/12/17, 07/06/17, 07/20/17 and 08/03/17. A review of an individualized care plan developed for Resident CL2 dated April 14, 2017, indicated that the resident had been identified as at increased risk for an alteration in nutrition and/or hydration status. Further review of the care plan directed the staff to provide the resident with the diet and supplements as ordered, encourage the resident to consume 75-100% of all meals and to document the resident's meal consumption. Further review of the nutrition and hydration care plan revealed no further interventions developed to reduce the risk of dehydration to the resident. Further review of the Resident CL2's care plan revealed that the resident had a Foley catheter (tube that is inserted directly into the bladder to drain urine from the bladder). Interventions identified to reduce the risk of complications related to the use of the catheter included, Encourage/provide fluid intake and Report any change in color, odor, or decreased urine output to physician. A Nutrition Assessment-Admission/Readmission, dated April 14, 2017, revealed that Resident CL2 was unable to drink fluids independently and required assistance from others, had decreased oral intake, had the presence of vascular wounds (skin alterations related to poor circulation) and recommended that the resident receive four ounces of fluid q (every) shift (8 hour period) while the resident was awake. In addition, the nutrition assessment indicated that the resident should receive 2000-2900 mls (milliliters) of fluid daily to ensure that the resident received adequate hydration. A review of Resident CL2's Meal Percentage logs, dated August 1, 2017, through August 13, 2017, revealed that of 39 possible meals, the resident had been noted as having refused to eat three meals, consumed less than 25% of 18 meals and less than 50% of 9 meals in the month of August. The meal percentage data further revealed that the resident had either refused or consumed less than 50% of his meals on 30 of 39 possible meals and had not reached the meal consumption goals established in the resident's nutrition and hydration plan of care. Interviews with Employees E3, Dietitian, and E4, Regional Dietitian, on August 21, 2017, at 1:00 p.m. revealed that the meal percentage logs are the dietitians primary method that they utilize to review how well the residents are eating and drinking. Further interview with Employees E3 and E4 revealed that the meal consumption logs are pre-populated with percentage values that the nurse aides must select from to enter the meal consumption data into the system. The employees confirmed that when utilizing this system, the staff are unable to document any other values other than what is preloaded into the system which limits the staff's ability to report more specific values. Further interviews with Employees E3 and E4 revealed that as dietitians, they are only able to extract an approximation of how well the residents are eating and drinking in the facility. Employees E3 and E4 confirmed that based on the preloaded values entered into the electronic meal consumption system, they were unable to determine if Resident CL2 consumed 0% or 25% of his meal and fluids on the dates those values were entered. Nursing progress notes dated August 1, 2017, through August 13, 2017, revealed no clinical documentation that the nursing staff had advised Resident CL2's physician of the noted decline in the resident's intake of meals and fluids. Review of Resident CL2's monthly Treatment Administration Record (TAR) dated August 2017 revealed the resident had a documented daily decline in urinary output from August 8, 2017, through August 13, 2017, with no output documented on the night shift on August 12, 2017. Continued review of Resident CL2's clinical record revealed nursing progress notes dated August 11, 2017, at 1:00 p.m. which revealed that the resident had been noted with, .dark amber urine . and there was no nursing documentation that a physician had been notified of the change in the color of the resident's urine or the decrease in the volume of the resident's urine output. Nursing progress notes dated August 13, 2017, at 6:31 p.m. revealed that the resident had been found unresponsive (unable to arouse) by the staff and had severe [MEDICAL CONDITION] (low blood pressure) of 70/50. The resident was subsequently transferred to the hospital via ambulance for further evaluation and treatment. A review of Resident CL2's emergency room record revealed that the resident was admitted to the emergency roiagnom on [DATE], at approximately 8:17 p.m. Further emergency room documentation indicated that the resident appeared cachectic (emaciated) and was noted as unresponsive and malnourished. The doctor's notes dated August 13, 2017, at 9:58 p.m. revealed, patient to be admitted for [MEDICAL CONDITION] (infection of the bloodstream) . is severly dehydrated with a sodium of 161 (normal range 136-147), bun of 140 (normal range 6-25), CR (creatinine) of 5 (normal range 0.8-1.4) coupled with UTI (urinary tract infection) and [MEDICAL CONDITION] he will be admitted to the ICU. Further review of Resident CL2's emergency room record revealed .Impression and Plan Problem List: 1) Septic Shock due to urinary tract infection ., 8) Dehydration with [MEDICAL CONDITION] (elevated Sodium level), 9) Malnutrition ., and 10) Neglected elder. Continued review of Resident CL2's emergency room record revealed a Consultation dated August 14, 2017, at 7:38 a.m. which revealed, Physical Exam . Skin is notable for tenting over his chest and neck consistent with severe dehydration By history he has not been eating or drinking well at the nursing home for the last 2 weeks. The patient presents with extremely high serum sodium and associated with neurological changes with [MEDICAL CONDITION] (acute mental disorder characterized by disorientation and altered consciousness) and these changes were (sic) not happen over many days or a week or more. The facility failed to ensure that the policies, procedures and guidelines established for monitoring the hydration status in residents identifed at increased risk for dehydration was implemented and resulted in actual harm to one resident. Review of Resident CL8's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Review of the Resident CL8 weights revealed that there was a weight of 160 lbs. on admission and a weight of 157.8 lbs. the next day. There was no evidence that the resident was weighed again. Review of the initial nutritional assessment/admission assessment dated [DATE], revealed that the resident was a diabetic (inability of the body to produce insulin to utilize the blood sugar) and had high blood pressure and that the recommended diet was CCD/NAS (diabetic/no added salt) and that monitoring was required and that the resident had a wound. The hydration assessment was completed on July 11, 2017, that was scored as a 2, meaning that the resident was a hydration risk, and the assessment wrongly identified the resident as not a hydration risk. Review of the physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. The resident had been vomiting on August 5 and 6, 2017, and the nursing progress notes indicated that the resident was vomiting. Review of Resident CL8's laboratory tests reveal that on July 26, 2017, revealed that the resident's BUN (blood urea nitrogen) was 54 mg/dl (milligrams per deciliter. A normal range 6-25 mg/dl.) and the Creatinine was .9 mg/dl (normal range is .5-1.1 mg/dl. These studies indicate the resident's hydration (fluid) needs were not adequate.) The resident received IVF (intravenous (through the vein) fluids.) On July 28, 2017, the BUN was 40 mg/dl and the Creatinine .9 mg/dl. The resident's Total Protein was 5.9 mg/dl (normal is 6.3-8.2 mg/dl) and [MEDICATION NAME] was 2.8 g/dl (grams per deciliter - normal is 3.6-5.2 g/dl. The results of this study revealed low protein and poor nutrition.) A progress note dated July 25, 2017, added the [DIAGNOSES REDACTED]. The physician ordered a calorie count for three days on August 2, 2017, that was not completed by the staff. The facility did not have a nutritional assessment and monitoring for Resident CL8. This resident had two infections with antibiotic treatments, two worsening wounds, hypovolemia (low fluid volume), was treated with IVF, had diarrhea, nausea and vomiting and had abnormal laboratory results with a new [DIAGNOSES REDACTED]. Review of Resident CL8's meal consumption percentage revealed that out of three meals a day for 26 days (a total of 78 meals), the resident consumed 0-25 % of a meal 23 times and 26-50% of a meal 19 times. There was no way to determine if the resident consumed nothing or 25%. There was no fluid intake measurement. The facility failed to monitor, assess and provide interventions to ensure an adequate fluid intake was provided to this resident. The facility failed to develop and implement a comprehensive and effective system for the accurate monitoring of residents' hydration status resulting in actual harm to one resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/20/17, 01/04/17, 09/17/16, 07/26/16, 01/30/15 28 Pa. Code 201.18(a) Management Previously cited 01/30/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 01/04/17, 01/30/15 28 Pa. Code 201.18(e)(3) Management Previously cited 01/30/15 28 Pa. Code 211.5(f) Clinical records Previously cited 04/20/17, 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited 12/21/15, 01/30/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 211.11(d) Resident care plan Previously cited 12/21/15, 01/30/15 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/04/17, 12/21/15, 01/30/15

APPEAL FILED Based on review of clinical records, facility documentation, and interviews with the resident and staff, it was determined that the facility failed to be free of significant medication errors for one of 28 records reviewed (Resident R137). Findings Include: Resident R137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] Patch (an opioid pain medication)72 hours, 25 MCG/HR- Apply 1 patch [MEDICATION NAME] (on the skin) every 72 hours for pain, and remove per schedule. [MEDICATION NAME] (used to treat anxiety) tablet 2 mg - give 1 tablet by mouth every 6 hours as needed for anxiety related to anxiety disorder. [MEDICATION NAME] Capsule 30 mg - give 1 capsule by mouth as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION] at night. [MEDICATION NAME] HCI (an opioid pain medication) tablet 10 mg -give 1 tablet by mouth every 6 hours as needed for severe pain. In addition, a physician's orders [REDACTED]. [MEDICATION NAME] tablet ER (extended relief, opioid pain medication) 40 mg, to be given by mouth every 12 hours for severe pain. Review of the Nursing Admission documentation dated, August 20, 2017 revealed moderate subjective report of pain in his upper middle back that was controlled by medication. Interview with Resident R137 on August 21, 2017, at 2:00 p.m. revealed the resident complained about being in pain and not receiving his pain medications, anxiety medication and [MEDICAL CONDITION] medications. The resident was very upset and anxious, and his hands were trembling. The resident stated, I never receive my medication. They always tell me they are out of the medications. I haven't had anything for my anxiety and my nerves are shot! I haven't gotten my sleeping pills so I haven't slept in days. I take 40 mg of [MEDICATION NAME], they stopped giving that to me because they never got it from the pharmacy. What's going on? I am in a lot of pain! During the interview, it was observed that a [MEDICATION NAME] Patch dated August 15, 2017, was on the resident's right arm. The stated, Oh this is an old one, the new one never came from the pharmacy. Review of the Medication Administration Record [REDACTED]. A new [MEDICATION NAME] Patch, that should have been administered on August 18, 2017, but was never given because it was coded, Awaiting Delivery. The next [MEDICATION NAME] Patch, due that day, on August 21, 2017, was not given because it still wasn't received from the pharmacy. Further review of the MAR indicated [REDACTED]½ days because it was waiting delivery from the pharmacy. The facility's narcotic control administration form revealed the resident had a zero balance of the medication since August 16, 2017. Review of the facility's narcotic control administration record form revealed [MEDICATION NAME] 30 mg had a zero balance since August 19, 2017, and was not given when the resident requested the medication on August 20, 2017. Review of the MAR indicated [REDACTED]. Observation revealed that Resident R137 was waiting at the nurses' station at 4:00 p.m. An interview was conducted with Resident R137 after 4:00 p.m. in his room. He was out of breath and perspiring. He attempted to walk a few feet using his walker, but quickly used his wheelchair instead and immediately used his oxygen to help him breathe. The resident painfully stated, I asked for pain medication three hours ago after therapy at 1:00 p.m. and was told I wasn't able to get the medication until 4:00 p.m. Well I am still in pain and if I don't' get up and go to the nursing station myself, I'll never get my medication. The nurse will leave and I'll have to wait for the new nurse to come on, and do this all over again. I haven't had my [MEDICATION NAME] in days, that's why I am in so much pain! The doctor told me he'd take care of it yesterday, but never did. They have a Pyxis machine (electronic medication dispensing machine) but they never use it. It's like they are afraid to use it. At that time, the resident's nurse came. The nurse was questioned why the Pyxis machine was not used. The nurse said it works, but she had to go to her supervisor and her supervisor must call the pharmacy for a code to dispense the medication from the Pyxis. The above information was reviewed with the Director of Nursing (DON) on August 21, 2017, at 4:30 p.m. She agreed that the nurses did not like using the Pyxis machines because they call the pharmacy, and are put on hold and must wait too long. The DON also produced a list of medications that were available in the Pyxis machine. All the above-mentioned medications for Resident R137 were available in the Pyxis machine. The Director of Nursing agreed that Resident R137's medications have always been available in the Pyxis machine and should have been administered as ordered. The facility failed to ensure that residents were free from a medication error as determined for one resident. 42 CFR 483.45(f)(2) Resident Free of Significant Medication Errors Previously cited 01/30/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/20/17, 01/04/17, 09/17/16, 07/26/16, 01/30/15 28 Pa. Code 201.18(a) Management Previously cited 01/30/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/04/17, 12/21/15, 01/30/15 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 01/04/17, 01/30/15 28 Pa. Code 201.18(e)(3) Management Previously cited 01/30/15 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 12/21/15, 01/30/15 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 01/04/17, 12/21/15, 01/30/15

Based on review of clinical records and facility documentation, and interviews with residents, family, and facility staff, it was determined that the facility failed to provide pain medication to a resident admitted to the facility following major abdominal surgery for [REDACTED]. The facility also failed to obtain, follow and clarify physician's orders regarding medication and treatment administration for 2 of 33 residents reviewed (Residents R94 and R74). Findings include: Resident NR1 was admitted to the facility at 6:45 p.m. on January 3, 2017, from the hospital following a Whipple surgery (a surgical procedure for [MEDICAL CONDITION] involving removal of the head of the pancreas, the duodenum, the gallbladder, the end of the common bile duct, and part of the stomach) on December 13, 2016, and had [DIAGNOSES REDACTED]. Observation of the resident revealed his abdomen had six retention sutures (sutures used to relieve pressure so that a wound does not pull open during healing), three on each side of the abdomen, and a drain sutured in place from the surgical site connected to a drainage bag observed on the right lower quadrant of the abdomen. The resident had transfer orders from the hospital that included pain medications, [MEDICATION NAME] ER (an extended relief narcotic) 20 milligrams every 12 hours, and [MEDICATION NAME] 5 milligrams two tabs as needed for pain every 4 hours, that were approved by the physician, and an order for [REDACTED]. The resident reported that he called his wife and texted her throughout the night complaining of pain. An interview with Resident NR1's wife confirmed that she was in the facility until 10:30 p.m., and requested pain medication, multiple times, for her husband. The wife had further communication with her husband at 1:00 a.m., 4:00 a.m., and 5:45 a.m. which verified he still had not been medicated for pain. Nursing documentation on January 4, 2017, at 7:29 a.m. indicated that the pain medication did not arrive to the facility until 6:45 a.m. and was not given to the resident until 7:00 a.m. on the morning of January 4, 2017, over 12 hours after the resident was admitted , and resulted in actual harm to Resident NR1. Interviews with five nurses (Employees E17, E18, E19, E20, and E21) during the change of shift on January 4, 2017, at approximately 3:00 p.m. regarding the availability of PRN (as needed) narcotics, revealed that they knew they had a Pyxis machine (an automated medication dispensing system) but were not aware that narcotics were available in the machine. The nurses indicated that they had an e-box (an emergency medication box) which included emergency medications including narcotics. Interviews with the nursing staff all indicated that they were unaware that the narcotics were available in a separate box in the Pyxis system and they needed a special code to access the Controlled Drug Substance Emergency Kit that contained both [MEDICATION NAME] and [MEDICATION NAME] ER. The facility failed to provide pain medication to a resident admitted to the facility following major abdominal surgery for [REDACTED]. Review of Resident R94's clinical record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. blood vessels). Observation of Resident R94 on December 29, 2016, revealed that the resident was receiving two liters of oxygen per minute. Review of Resident R94's clinical record revealed there was no physician's order for the resident to receive oxygen. Review of Resident R94's clinical record revealed a physician's order dated December 12, 2016, for the resident to receive [MEDICATION NAME] (supplement used to prevent or treat low levels of iron) 325 mg two times a day. Further review of Resident R94's Medication Administration Record [REDACTED]. An interview on December 30, 2016, with Employee E3, a Nurse Manager, confirmed that Resident R94 was receiving two liters of oxygen per minute and there was no physician's order for the resident to receive oxygen. Furthermore, Employee E3 confirmed that Resident R94 was ordered by the physician to be administered [MEDICATION NAME] 325 mg two times a day and Employee E3 confirmed that the Medication Administration Record [REDACTED]. The facility failed to obtain, follow, and clarify physician's orders for pain medications and oxygen treatment. Review of the clinical record for Resident R74 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs) dated November 10, 2016, indicated that the resident had a BIMS (Brief Interview for Mental Status - a screening tool used to assess cognition) score of two indicating that the resident had severe cognitive (cognition-mental process of being able to learn, think and judge for oneself) impairments. Observation of Resident R74 on December 28, 2016, at 11:55 a.m. and on January 4, 2017, at 10:55 a.m. revealed during both observations that the resident was noted as receiving oxygen at 2 liters via a nasal cannula (prongs inserted into each nostril). Further review of Resident R74's clinical record revealed no physician's order for the use of [REDACTED]. The facility failed to follow and clarify physician orders for medications, showers and oxygen treatment. 42 CFR 483.24, 483.25(k) Provide Care/Services for Highest Well Being Previously cited 01/30/15, 12/21/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/30/15, 12/21/15 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 01/30/15, 12/21/15