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

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents were free from accident/hazards and received adequate supervision related to eating and medication administration for two of 33 residents reviewed (Resident R169 and R8). Findings include:Review a facility policy Interdisciplinary Care Plan Protocol, revised July 2025, revealed that the interdisciplinary team including nursing, social services, dietary, activities, rehabilitation services, physicians, residents, and family members, is responsible for assessing resident needs and developing an individual plan of care. Review of facility policy revealed care plans should be specific to resident needs and revised as changes occur. The policy emphasizes the development and ongoing revision of individualized interventions to address identified safety risks and promote resident well-being.Review of the Resident 169's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 28, 2026, revealed the resident was admitted to the facility on [DATE]. Per the MDS, Resident R169 has severe cognitive impairment and diagnoses of multiple fractures (breaks in more than one bone, often resulting in pain, limited mobility, and impaired functional ability), dementia (a progressive cognitive disorder characterized by decline in memory, thinking, reasoning, and the ability to perform daily activities), and schizophrenia (a chronic psychiatric disorder involving disturbances in thought processes, perception, emotional responsiveness, and behavior, which may include hallucinations, delusions, and disorganized thinking).Continued review of Resident R169's MDS revealed the resident requires maximal assistance with lower body dressing/footwear and requires partial assistance with transfers and sit-to-stand activities.Review of Resident R169's clinical record revealed a physician order dated May 28, 2026, for Lidocaine 4% patch to the left shoulder and lower back, applied once daily for pain, for 12-hours on and 12-hours off.Review of manufacturer labeling for Lidocaine 4% patches directs that the product be used only as directed and warns against applying additional patches beyond the recommended amount. The application of additional lidocaine patches to locations not authorized by the physician's order was inconsistent with the prescribed treatment regimen and the manufacturer's instructions for use.Review of Resident R169's Self-Medication assessment dated [DATE], revealed that the resident was assessed as unable to self-administer medications.Observation on June 9, 2026, the resident was noted sitting in a wheelchair with two Lidocaine 4% patches applied to both knees. One patch lacked any date, time, or staff initials. The second patch was labeled with a date of June 1, 2026, and a shift designation; the signature was illegible.Interview on June 9, 2026, with Nurse Aide, Employee E12 confirmed Resident R169 had Lidocaine 4% patches applied to both knees and that either Resident R169 or the wife applied the patches. Review of Resident R169's clinical record revealed no physician order was identified authorizing the application of lidocaine patches to Resident R169's knees.Review of the Resident R8's MDS dated [DATE], revealed Resident R8 was admitted to the facility on [DATE], and has diagnoses of pneumonia, dysphagia (difficulty swallowing), and sepsis. Further review of Resident R8's MDS revealed the resident requires extensive assistance with activities of daily living and requires setup and cleanup assistance with eating.Review of the resident R8's care plan revealed that the resident was at risk for respiratory distress related to aspiration and pneumonia. Interventions dated June 5, 2026, included monitoring for signs and symptoms of respiratory distress and providing supervision and feeding assistance during meals.Review of Resident R8's clinical record revealed an active physician order dated June 4, 2026, that Resident R8 needs supervision/feeding assistance with meals for aspiration.Observation on June 10, 2026, at 8:25 a.m. revealed Resident R8 was alone in his/her room with a breakfast tray placed in front of the resident. No staff members were present providing supervision or feeding assistance.Interview on June 10, 2026, at 8:25 a.m. with Resident R8, the resident stated that staff do not typically provide supervision or assistance with meals. Resident R8 further reported a recent hospitalization secondary to treatment for aspiration pneumonia.Subsequently interview on June 10, 2026, at 8:30 a.m. with Licensed Nurse, Employee E11, confirmed Resident R8 was having breakfast alone in his/her room. Licensed Nurse, Employee E11, reported that Resident R8 typically eats breakfast in his/her room and that staff periodically check in. 28 Pa. Code 201.18 (b)(3) Management.28 Pa. Code 201.20(a)(1) Staff development. 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.12 (d) 5) Nursing services.

Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure complete and accurate documentation related to a Neurological Assessment Flow Sheet for one of 33 residents reviewed (Resident 187).Findings Include:Review of facility documentation Neurological Assessment Flow Sheet Instructions revealed staff should record the date and time of each assessment then proceed to document the appropriate response as follows: level of consciousness, pupil response, motor functions (hand grasps/extremities), pain response and vitals.Per the Neurological Assessment Flow Sheet vital signs and neurological checks should be completed per protocol: every fifteen minutes for one hour, every thirty minutes for one hour, every hour for four hours, and then every four hours for twenty-four hours.Review of Resident R187's neurological assessment flow sheet revealed assessments were initiated on April 25, 2026, at 4:45 p.m.Continued review of Resident R187's neurological assessment flow sheet revealed staff failed to document pupil response and motor functions every hour for four hours, and then every four hours for twenty-four hours.Further review of Resident R187's neurological assessment flow sheet revealed staff failed to document the remaining four neurological assessments (level of consciousness, pupil response, motor functions (hand grasps/extremities), pain response, and vitals on April 27, 2026, that were due at 11:00 a.m., 3:00 p.m., 7:00 p.m., and 11:00 p.m.Interview on June 12, 2026, at 2:00 p.m. with the Corporate Director of Nursing, Employe E6, and Assistant Director of Nursing, Employee E3, confirmed Resident R187's neurological assessment flow sheet was incomplete.28 Pa. Code 211.5 (f)(iv) Medical records.

Based on review of facility policy, review of clinical records, observations, and interview with staff it was determined that the facility failed to ensure proper labeling of medications for one of 33 residents reviewed (Resident R175). Findings Include: Findings include:Review of the facility policy titled, Storage of Medication revised July 2025, revealed drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling. Observations of medication administration was conducted with Licensed Nurse, Employee E7, on June 11, 2026, at approximately 9:00 a.m. Observations during medication administration for Resident R175 revealed that the blister pack holding Resident R175's medication failed to include the physician orders specifying the route, frequency, and dose on the medication label. Instead See orders was labeled on Resident R175's medication blister pack. Interview on June 11, 2026, at 2:00 p.m. with the Assistant Director of Nursing, Employee E3, confirmed the improper labeling of Resident R175's medication. 28 Pa Code: 201.14 (a) Responsibility of licensee

Based on review of facility policy, review of clinical records, observations, and staff interviews it was determined that the facility failed to implement proper infection control practices related to enhanced barrier precautions for one of 33 residents reviewed (Resident R175). Findings include:Review of the facility policy titled, Enhanced Barrier Precautions (EBP) dated April 2024, revealed the facility implements effective measures to prevent the transmission of Multi-Drug-Resistant Organisms (MDROs). EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) by utilizing a gown and gloves during high contact resident care activities. EBP is employed when performing device care or use. Review of Resident R175's care plan dated April 17, 2025, revealed the resident was on Enhanced Barrier Precautions (EBP) due to a wound. Interventions include EBP signage posted outside the resident's room and implement EBP as ordered.Observation of medication administration on June 11, 2026, at approximately 9:00 a.m. revealed Licensed Practical Nurse (LPN), Employee E7, failed to put on a gown when obtaining blood sugar levels for Resident R175. Interview on June 11, 2026, at 2:00 p.m. with Assistant Director of Nursing/Infection Preventionist, Employee E3, confirmed LPN, Employee E7, failed to implement proper PPE related to EBP for Resident R175. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical record, observations, and interview with staff, it was determined that the facility failed to review and revise one care plan related to restorative nursing program for one of 33 residents reviewed (Resident R17). Findings Include:Review of facility policy titled Interdisciplinary Care Planning Protocol, dated July 2025, revealed that Problems established by the team with resident/family input MUST be specific and individualized meaning as resident changes are noted, the resident plan of care must be revised. Review of resident records revealed that Resident R17 was admitted to the facility on [DATE], and had diagnoses including, but not limited to, atrophy (muscles decreasing in size, typically due to disuse), muscle spasms, and periodic paralysis. Observation on June 11, 2026, at 11:17 a.m. revealed Resident R17 had multiple contractures, resulting in the inability to use or independently move any of his/her limbs, which were drawn tight into the body. Review of the Resident R17's most recent MDS (Minimum Data Set- a periodic review of resident care needs) dated February 18, 2026, Section GG, Functional Abilities, revealed that the resident was dependent on staff for all care and mobility tasks, such as eating, transferring between the bed and the chair, and repositioning. Review of Resident R17's care plan, last reviewed on March 9, 2026, revealed a care plan initiated on July 12, 2023, which stated the resident may benefit from a restorative nursing program, with an intervention to perform sit-to-stand transfer .3-5 [times per week]. Interview with Therapy Director, employee E14, on June 12, 2026, at 12:04 p.m. revealed that Resident R17 is not safe for any type of transfer, except by mechanical lift, and has been that way for years. Interview on June 12, 2026, at 3:00 p.m., Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed that the care plan for Resident R17 should have been updated to reflect current status. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, review of clinical records, review of facility policy, interview with staff and residents, it was determined that the facility failed to develop a comprehensive person-centered care plan related to COPD (chronic obstructive pulmonary disease), oxygen use and Anxiety/ Dementia Care for three of 35 residents reviewed. (Resident R22, Resident R143 and Resident 163). Findings Include: Review of facility policy on Interdisciplinary Care Planning Protocol revealed section All Admissions - Day of admission #2. Nursing Initiates Interim Care Plan – the interim care plan must address all immediate care needs. Under section Skilled Subacute Care Admissions #2. Interim care plan initiated on the day of admission must be reviewed by the IDCP team and modified by 8th day of admission. Under section Long Term Care Admissions -Within Fourteen Days #3. CAA Summary Sheet – CAA assessment is to be completed and documented in Section V and also in a CAA assessment note - triggered areas will be discussed by the team and the care plan finished no later than seven days after MDS assessment completion date. Under section Interdisciplinary Care Planning #8. Problems established by the team with resident/family input MUST be specific and individualized. Review of Resident R143's clinical record revealed the Resident R143 was admitted to the facility on [DATE], with diagnoses of COPD (Chronic Obstructive Pulmonary Disease-a lung disease that blocks airflow to the lungs making it difficult to breath) Further review of Resident R143's clinical record revealed a physician's order for O2 (oxygen) 3L (liters) via NC (nasal cannula) continuously every shift for COPD-Order Date-07/10/2024. Further, an MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) dated May 28, 2025, Section O - Special Treatments, Procedures, and Programs, C1 Oxygen therapy, reveled that resident was on oxygen. Further review of Resident R143's clinical record revealed that there was no comprehensive person-centered respiratory care plan in place. Further, there was other care plan addressing Resident R143's Oxygen use. Observation conducted on July 21, 2025, at 10:35AM during tour of the second-floor unit revealed that Resident R143 was in bed with O2 concentrator at 3 liters/minute via nasal cannula. Interview with licensed nurse, Employee E3 conducted on July 24, 2025, at 10:26 AM confirmed that there was no respiratory care plan nor any care plan addressing Resident R143's Oxygen use. Review of Resident R22's clinical record revealed the Resident R22 was admitted to the facility on [DATE], with diagnoses of but not limited to COPD. Further review of Resident R22's clinical record revealed a physician's order for Oxygen 2L via NC Continuously every shift related to Chronic Obstructive Pulmonary Disease -start date -3/12/2022. Further, an MDS dated [DATE], Section O - Special Treatments, Procedures, and Programs, C1 Oxygen therapy, reveled that resident was on Oxygen. Further review of Resident R22's clinical record revealed that there was no comprehensive person-centered respiratory care plan in place. Further, there was other care plan addressing Resident R143's Oxygen use. Observation conducted on July 22, 2025, at 8:43 AM revealed that Resident R22 was in bed on oxygen concentrator at 2 liters/minute via nasal canula. Interview with Resident R22 conducted at the time of the observation confirmed that she was on oxygen at 2 liters/minute. Interview with licensed nurse, Employee E3 conducted on July 24, 2025, at 10:26 AM confirmed that there was no respiratory care plan nor any care plan addressing Resident R22's Oxygen use. Review of Resident R3 was admitted to the facility on [DATE]. The resident had the following diagnoses: Cognitive Communication Deficit (difficulties in communication that arise from impairments in cognitive functions like attention, memory, reasoning, and problem-solving) and Depression (amental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Review of Resident R3's care plan dated July 11, 2025 did not include a care plan or interventions for the resident’s diagnosis of Depression. Review of Resident R63 was admitted to the facility on [DATE]. The resident readmitted to the facility after a hospital stay on May 24, 2025. Review of the resident’s diagnoses revealed new diagnosis is Anxiety and Dementia (a decline in mental ability severe enough to interfere with daily life) dated May 15, 2025. Review of Resident R63's care plan dated July 11, 2025 did not include a care plan or Interventions for the resident’s diagnosis of Anxiety (a normal human emotion that can range from mild unease to intense fear or panic) and Dementia. Review of Resident R143's clinical record revealed the Resident R143 was admitted to the facility on [DATE], with diagnoses of COPD (Chronic Obstructive Pulmonary Disease-a lung disease that blocks airflow to the lungs making it difficult to breath) Further review of Resident R143's clinical record revealed a physician's order for O2 (oxygen) 3L (liters) via NC (nasal cannula) continuously every shift for COPD-Order Date-07/10/2024. Further, an MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) dated May 28, 2025, Section O - Special Treatments, Procedures, and Programs, C1 Oxygen therapy, reveled that resident was on oxygen. Further review of Resident R143's clinical record revealed that there was no comprehensive person-centered respiratory care plan in place. Further, there was other care plan addressing Resident R143's Oxygen use. Observation conducted on July 21, 2025, at 10:35AM during tour of the second-floor unit revealed that Resident R143 was in bed with O2 concentrator at 3 liters/minute via nasal cannula. Interview with licensed nurse, Employee E3 conducted on July 24, 2025, at 10:26 AM confirmed that there was no respiratory care plan nor any care plan addressing Resident R143's Oxygen use. Review of Resident R22's clinical record revealed the Resident R22 was admitted to the facility on [DATE], with diagnoses of but not limited to COPD. Further review of Resident R22's clinical record revealed a physician's order for Oxygen 2L via NC Continuously every shift related to Chronic Obstructive Pulmonary Disease -start date -3/12/2022. Further, an MDS dated [DATE], Section O - Special Treatments, Procedures, and Programs, C1 Oxygen therapy, reveled that resident was on Oxygen. Further review of Resident R22's clinical record revealed that there was no comprehensive person-centered respiratory care plan in place. Further, there was other care plan addressing Resident R143's Oxygen use. Observation conducted on July 22, 2025, at 8:43 AM revealed that Resident R22 was in bed on oxygen concentrator at 2 liters/minute via nasal canula. Interview with Resident R22 conducted at the time of the observation confirmed that she was on oxygen at 2 liters/minute. Interview with licensed nurse, Employee E3 conducted on July 24, 2025, at 10:26 AM confirmed that there was no respiratory care plan nor any care plan addressing Resident R22's Oxygen use. Review of Resident R3 was admitted to the facility on [DATE]. The resident had the following diagnoses: Cognitive Communication Deficit (difficulties in communication that arise from impairments in cognitive functions like attention, memory, reasoning, and problem-solving) and Depression (amental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Review of Resident R3's care plan dated July 11, 2025 did not include a care plan or interventions for the resident’s diagnosis of Depression. Review of Resident R163 was admitted to the facility on [DATE]. The resident readmitted to the facility after a hospital stay on May 24, 2025. Review of the resident’s diagnoses revealed new diagnosis is Anxiety and Dementia (a decline in mental ability severe enough to interfere with daily life) dated May 15, 2025. Review of Resident R163's care plan dated July 11, 2025 did not include a care plan or Interventions for the resident’s diagnosis of Anxiety (a normal human emotion that can range from mild unease to intense fear or panic) and Dementia. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.Findings include: A tour of the Food Service Department was conducted on July 21, 2025, at 9:30 a.m. January 28, 2025, at 10:00 a.m. with Employee E7, Food Service Director (FSD), revealed the following concerns:Observation in the dry storage area revealed no designated area for dented cans.Observation in the walk-in freezer revealed an open box of chocolate chip cookie dough with the inner plastic bag open, and a box of pizza shells with the inner plastic bag open and a box of bacon with the inner plastic bag open to the circulating air.Interview with the FSD on July 21, 2025, at 9:40 a.m. confirmed the above findings and that he had slipped and fallen in the dish room getting bleach on his clothing.Observation during a follow up visit to the kitchen on July 23, 2025, at 9:40 a.m. revealed that when the dish machine drained between the wash and rinse cycle the water overflowed the open floor drain trough and splashed all over the floor causing an unsafe surface with soapy water up to an inch deep. The grout around the floor tiles in this area was wearing away and the water was leaking into the grease trap which was missing a plug. Observations on July 23, 2025, at 12:10 p.m. during tray-line operation the FSD slipped on the wet floor, the milk was in an ice bath in a plastic pan that was leaking and dripping onto the floor causing a slipping hazard.Interview with the FSD on July 23, 2025, at 9:40 a.m. and 12:10 p.m. confirmed the above findings.28 Pa. Code 201.14(a) Responsibility of licensee

Based on staff interview, review of hospice documentation and review of clinical records, it was determined that the facility failed to ensure that a recommendation from the contracted hospice agency related to a resident's medication management was addressed and/or implemented for 1 out of 1 hospice record reviewed (Resident R90). Findings include: Review of the facility policy, Hospice Program dated 3/25, indicated that when a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.Review of Resident R90's July 2025 physician orders included the following diagnosis: multiple sclerosis (a disease that causes breakdown of the protective covering of nerves and can cause numbness, weakness, trouble walking, vision changes and other symptoms), chronic obstructive pulmonary disease (COPD- a term for lung and airway diseases that restrict an individual's breathing); dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities, and anxiety (includes persistent and excessive anxiety and worry about activities or events).Continued review of the physician orders included a physician's order for hospice services with a start date of July 3, 2025. Admit to Hospice. Admitting DX (diagnosis) Senile degeneration of the brain. Review of the hospice communication sheet from the hospice agency, Recommendations for Symptom Management, dated February 14, 2025, included a recommendation from the hospice agency nurse for Ativan 1milligram (mg) (0.5ml) po (by mouth /SL (sublingual) q (every) 2 h (hours) prn (as needed) for breakthrough agitation. Review of the physician orders obtained on July 22, 2025, included no indication that the medication Ativan was order by the physician.During an interview with the Assistant Director of Nursing, Employee E3 on July 24, 2025, at 11:25 a.m. it was confirmed by the Assistant Director of Nursing that that there was no indication in the clinical record that the recommendation for Ativan by the hospice nurse was addressed and/or implemented by the facility. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of facility documents and interviews with staff, it was determined that the facility failed to ensure that terms of a binding arbitration agreement included required language to protect the rights of the resident or resident representative.Findings include: Review of Binding Arbitration Agreement, enclosed in the admission Agreement revealed that the agreement did not contain language that would allow the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.Interview on July 24, 2025, at 11:45 a.m. with Employee E1, Nursing Home Administrator and Employee E8, Regional Operations Director confirmed that the arbitration agreement did not contain the required language as state above.28 Pa. Code: 201.14(a)(b) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of 35 residents reviewed (Residents R18, R22, R60, R104, and R187). Findings include: A review of the undated Room Test Tray Evaluation form from Nutrition Services, Inc., revealed that the Standard for cold food is 40-55 degrees and for hot food 135-160 degrees.Interview with Resident R60 on July 21, 2025, at 10:30 a.m. revealed that he did not like that the hot food was often cold and the milk could be colder.Interview with Resident R187 on July 21, 2025, at 10:35 a.m. revealed that he is at the end of the hallway and his food is always cold, and that the French fries the other day were not even cooked, and that the eggs are terrible when they are cold. Interviews were held on July 23, 2024 with 12 alert, and oriented residents during resident council. Residents had complaints about the food served at the facility. Resident R18 stated, the food is cold, just about every day. Resident R22 stated, the food it cold, especially breakfast who wants cold toast or eggs. Resident R104, the food is garbage on a plate, it's always cold.Observations during a test tray conducted on July 23, 2025, at 12:45 p.m. revealed that the tray cart left the kitchen at 12:20 p.m. and the last tray was passed at 12:45 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E7, revealed that the chicken was only 110 degrees, the rice was only 122 degrees, the mixed vegetable was only 122 degrees, the mixed fruit cup was 78 degrees, the apple juice was only 67 degrees and the whole milk was 58 degrees all outside the acceptable temperature range for palatability. An interview with the FSD, on July 23, 2025, at 12:55 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E7). Findings include: An interview on July 21, 2025, at 9:45 a.m. with Employee E7, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; and that he had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E3's credentials revealed that Employee E7 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on July 24, 2025, at 11:15 a.m. with Employee E1, Administrator, the FSD's personnel file and his qualifications were discussed which revealed he had been working at the facility for several years and was not a Certified Dietary Manager or Certified Food Manager. Employee E1 confirmed that the FSD had not completed these requirements. The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department.28 Pa. Code 211.6(c)(d) Dietary services28 Pa Code 201.18(e)(1)(6) Management

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were properly labeled and dated for two of three units reviewed (Second floor unit, First floor St. [NAME] unit) and properly stored for one of one resident observed with medication in the room. (Resident R160) Findings include: Review of facility policy on Storage of Medication 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 #4. The faciality shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Observation of the Second-floor medication room conducted with licensed nurse Employee E14 and Unit Manager, Employee E13 conducted on July 21, 2025, at 11:46AM reveled that two opened vials of Tuberculin Purified Protein Derivative vials (PPD-a substance injected into the skin to test for tuberculosis exposure) was in the medication refrigerator. Further observation revealed that one of the opened vials was inscribed 4/2 and the other opened PPD vial was not labeled or dated.Interview conducted at the time fo the observation with Unit Manager, Employee E13 confirmed that that 2 opened Tuberculin Purified Protein Derivative vials (PPD-a substance injected into the skin to test for tuberculosis exposure) was in the medication refrigerator. Further unit manager confirmed that one of the opened vials was inscribed 4/2 and the other opened PPD vial was not labeled nor dated. Further interview with unit manager, Employee E13 revealed that multidose vials are discarded 30 days after opening. Observation of the St. [NAME] Medication room with Unit Manager, Employee E15 conducted on July 22, 2025, at 12:38PM revealed one unopened bottle of Pedialyte with an expiration date of [DATE].Interview with unit Employee E15 confirmed that the bottle of Pedialyte had an expiration date of October 1, 2021 Review of Resident R160 July 2025 physician orders included the diagnoses of transient ischemic attack (TIA- a mini stroke); seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); kidney failure (a condition in which one or both of your kidneys no longer work on their own); diabetes (a group of diseases that affect how the body uses blood sugar glucose), and xerosis cutis(excessive dry skin).Review of Resident R160's July 2025 physician orders included an order dated February 13, 2025 and monthly thereafter, for the resident to have a medicated lotion (Ammonium Lactate External Lotion 12%) applied to her legs in the evening as follows Ammonium Lactate External Lotion 12% applied to her legs in the evening: Apply B/L LE (bilaterally legs) topically in the evenings related to XEROSIS CUTIS (L85.3) Wash legs with soap and water pat dry, apply lotion.During an observation on July 23, 2025, at 11:33 a.m. in the resident's room, the resident was asked where all her items were that were on top of her dresser the other day and reported that someone came in and put it in her drawer. Observation confirmed that the above referenced medicated lotion was stored in the resident the resident's unlocked drawer, along with the resident's personal belongings that had been on the top of her dresser 2 days ago. This bottle of medication found in the unlocked drawer with no name or properly labeling on it had room [ROOM NUMBER] W written on it with a black marker. Resident R160's room number is in room [ROOM NUMBER]. During an observation with the Unit Manager on July 23, 2025 at 11:33 a.m. the Unit Manager observed the medication in the unlocked drawer and retrieved it from the drawer and removed it from out of the resident's room.28 Pa Code 211.9(a)(1) Pharmacy services28 Pa Code 211.12(d)(2) Nursing services

Based on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that resident was administered oxygen according to physician's order for one resident of one resident reviewed on oxygen therapy. (Resident R158) Findings include: Review of facility policy on Oxygen Therapy revealed that under section POLICY: Oxygen is administered appropriately to resident to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Oxygen is administered by licensed staff and with a physician's order. Under section PROCEDURE: #12. To use oxygen with a resident: a. Turn on the Oxygen. Start the flow of Oxygen s ordered by the physician. Review of Resident R158's clinical record revealed that Resident R158 was admitted to the facility on [DATE], with diagnoses of but not limited to Asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breath). Further review of Resident R158's clinical record revealed a physician's order for O2 (oxygen) @ 2L via N/C (nasal cannula) PRN(as needed) for SOB (shortness of breath) Review of Resident R158's MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated June 6, 2025, Section O - Special Treatments, Procedures, and Programs, C1 Oxygen therapy, reveled that Resident R158 was on Oxygen. Observation conducted on the second-floor dining area on July 21, 2025, at 1:28 PM revealed that Resident R158 was in a wheelchair with oxygen concentrator at 3 liters/minute via nasal cannula. Interview with unit manager, Employee E13 confirmed that resident's oxygen was at 3 liters/minute. Further, Unit Manager proceeded to adjust Resident R158's Oxygen to 2 liters/minute. 28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of facility policies, clinical record review and interview with staff and residents, it was determined that the facility failed to ensure that resident significant weight gain was assessed in a timely manner for one resident (Resident R160), and failed to ensure that the nutrition and hydration status were properly assessed related to the use of a PEG tube (feeding tube inserted into stomach) for another resident (Resident R10) for 2 out of 35 residents reviewed.Review of the facility policy Weight Assessment, Management and Intervention Procedure, with a date of 3/25, indicated that nursing staff will measure resident weight on admission and monthly or as ordered by physician and that any weight change of 5% or more since the last monthly weight assessment will be retaken for confirmation, and if the weight is verified, nursing will notify the Dietitian. The policy also indicated that the Dietitian will respond within 24-72 hours of receipt of notification.Continued review of the policy indicated that resident assessment information shall be analyzed by the interdisciplinary team and conclusions shall be made regarding: Resident's target weight range (including rationale if different from ideal/usual body weight); approximate calorie, protein, and other nutrient needs compared with the resident's current intake; whether and to what extent weight stabilization or improvement can be anticipated, the resident cognitive status, in addition to analyzing the relationship between the resident's current medical condition or clinical situation, and recent fluctuations in weight.Review of Resident R160's July 2025 physician orders for the resident included the following diagnosis: transient ischemic attack (TIA- a mini stroke); seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); kidney failure (a condition in which one or both of your kidneys no longer work on their own); diabetes (a group of diseases that affect how the body uses blood sugar glucose); shortness of breath, and congestive heart failure ( CHF-a condition that affects the heart's ability to pump blood often leading to fluid retention in the body, symptoms of swelling, shortness of breath, rapid weight gain, and requires careful management through medications and lifestyle changes).Review of Resident R160's July 2025 physician orders included a physician's order dated February 13, 2025, and monthly thereafter for the administration of the medication, Furosemide 40 milligrams five 1 tablet by mouth every 24 hours for shortness of breath and for the treatment of congestive heart failure; increase weight >2 pounds. related to chronic congestive heart failure. Review of the resident's Weight Summary report indicated that on June 26, 2025, the resident's weight was recorded by nursing staff as being 125.6 pounds. On July 2, 2025, 7 days later, the resident's weight was recorded by nursing staff as being 137.2 pounds, indicating a 11.6 pound weight gain, and a significant weigh gain of 9.2% in 6 days. Continued review of the clinical record did not show evidence that the resident significant weight gain was acknowledged and/or addressed/assessed by the facility's dietician. During an interview with the Regional Dietician (Employee E12) on July 24, 2025 at 11:25 a.m. the resident's weights were reviewed and it was confirmed by the Regional Dietician that the resident had a significant weight gain of 9.2% and gained 11.6 pounds in 6 days. During the above referenced interview, the Regional Dietician confirmed that the significant weight gain was not acknowledged and/or addressed by the facility dietician. Review of Resident R10's clinical record revealed resident was admitted to the facility on [DATE] with the diagnoses of, Dysphasia (swallowing difficulties), Type 2 Diabetes, and muscle weakness.Review of Resident R10's nutrition assessment dated [DATE], resident continues to receive bolus tube feeds via PEG tube (feeding tube that goes through the stomach wall) 2 times a due to need for additional nutrition and combat weight loss. Further review revealed resident is tolerating tube feed, will continue with current regimen. Tube feed provides 40% calorie needs, 55% protein needs, 43% fluid needs. Need for nutritional support via PEG.Review of Resident R10's nursing progress notes, dated December 28, 2025, revealed was called in by CNA (nurse aide), nurse went to observe patient feeding tube on her belly, patient did not seem in any discomfort or pain, patient smiling at nurse. Nursing Supervisor notified, 16F foley inserted, MD notified explained that patient eats all three meals being fed by nursing staff, MD and nursing supervisor agreed to remove feeding tube, nursing care continued.Review of Resident R10's nursing notes, dated December 28, 2025 revealed notified by charge nurse, resident had G-tube dislodgement. On assessment, resident stoma had no signs of bleeding. G-tube was found with balloon inflated. Resident had no signs or symptoms of pain or discomfort. 16 F foley was inserted while awaiting orders. New order given by doctor to discontinue G-Tube. Stoma site is cleaned and covered. Resident was made comfortable. Care plan updated.Review of Resident R10's comprehensive care plan dated September 18, 2024, revealed resident has the potential for alteration in nutrition and hydration related to past medical history, aphasia (loss of ability to understand or express speech), need for mechanically altered and therapeutic diet, and history of significant weight loss.Review of Resident R10's clinical record revealed no significant weight changes between December 2024 and July 2025.Interview with Employee E2, Director of Nursing on July 23, 2025 at 12:00pm, revealed that resident's PEG tube and tube feedings were discontinue on December 28, 2024.Interview with Employee E12, Regional Dietitian, confirmed that nutrition assessments completed by Registered Dietician, dated December 28, 2024 through June 25, 2025, have stated that resident is receiving nutrition via PEG tube and resident has not had a PEG tube in place.

Based on the review of clinical records, observations and staff interviews, it was determined that the facility failed to develop and implement interventions such as turning and repositioning or offloading of heels for resident with total dependence to prevent the development of a pressure ulcer for one of three residents reviewed (Resident R17).Review of Resident R17's clinical record revealed Resident R17 was readmitted to the facility on [DATE] with diagnoses of, but not limited to, Dementia (progressive degenerative disease of the brain) and Chronic Kidney Disease.Review of Resident R17's quarterly Minimum Data Set assessment (MDS-federally mandated standardized assessment process conducted periodically to plan resident care) dated June 13, 2025, revealed Resident R17 required extensive assistance and 2- person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture).Review of Resident R17'S care plan initiated on April 28, 2025, revealed that resident is at risk for alteration in skin integrity related to impaired mobility, incontinence, blanchable redness sacrum.Review of Resident R17's clinical record failed to reveal documented evidence that facility provided turning and repositioning for resident at high risk of developing pressure ulcers.Review of Resident R17's nursing progress note dated July 7, 2025, revealed that resident's sacrum and coccyx redden. Treatment ordered for redden area.Review of Resident R17's physician order dated July 8, 2025, revealed order for Balsam Peru Castor Oil External Ointment, apply to sacrum.Review of Resident R17's clinical record revealed no documented evidence of wound team consult after reddened area noted.Review of Resident R17's body check dated July 9, 2025, revealed no newly identified issues.Review of Resident R17's nursing progress note dated July 17, 2025, revealed that resident has change in skin condition and wound care consulted.Review of Resident R17's Skin/ Wound care notes dated July 18, 2025, revealed that resident had an open area on the sacrum 5 cm x 3cm. Wound bed with visible slough, no active bleeding. Surrounding skin with mild erythema. No signs or symptoms of infection. Area cleansed with Normal Saline, patted dry and applied calcium alginate, covered with bordered gauze.Review of Resident R17's wound evaluation and management summary dated July 23, 2025 revealed resident has end-stage skin failure sacrum full thickness, wound measurements of 3.2 cm x 4 cm x 0.5 cm.Interview with Employee E16, Licensed Practical Nurse on July 23, 2025 at 11:15am confirmed she is the nurse assigned to Resident R17. Interview further revealed that resident R17 is a total assist with turning and repositioning. Confirmed that resident is not on a turning and repositioning program and there is no way to document or confirm when resident was last turned and repositioned.Review of Resident R17's physician orders dated July 7, 2025, revealed offload heels with pillow every shift.Observation of Resident room on July 23, 2025 at 11:15am revealed resident laying in bed with head of bed flat on back and resident's heels are offloaded.Interview with Employee E16, Licensed Practical Nurse on July 23, 2025 at 11:15 am confirmed Resident R17's heels were not being offloaded while in bed.Review of Resident R17's Comprehensive Care Plan revealed no evidence of off-loading heels intervention in place.Interview with Employee E2, Director of Nursing on July 23, 2025 at 12:20 pm confirmed that facility does not have policy in place for turning and repositioning of residents that require total dependence. All residents are expected to be turned and repositioned by staff every 2 hours. Confirmed no documented evidence of this intervention for Resident R17.Interview with Employee E17, Nursing Aide on July 24, 2025 at 12:00pm revealed there was no set schedule to turn and reposition Resident R17, I try to do it before breakfast, lunch and before I leave for the day. Further revealed that there was no documentation involved in turning and repositioning of resident.Observation of resident's room on July 24, 2025 at 12:10pm revealed the resident in bed sitting with head of bed at 90 degrees and resident's heel not being offloaded.Interview with Employee E17, Nursed Aide on July 24, 2025 at 12:10pm confirmed resident heels were not offloaded. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that that the facility failed to ensure that a physician was notified of a rapid and significant weight gain, and failed to clarify a physician's order for 1 out of 35 residents reviewed (Resident R160) Findings include:Review of the facility policy Weight Assessment, Management and Intervention Procedure, with a date of 3/25, indicated that nursing staff will measure resident weight on admission and monthly or as ordered by physician and that any weight change of 5% or more since the last monthly weight assessment will be retaken for confirmation, and if the weight is verified, nursing will notify the Dietitian. The policy also indicated that the Dietitian will respond within 24-72 hours of receipt of notification.Continued review of the policy indicated that resident assessment information shall be analyzed by the interdisciplinary team and conclusions shall be made regarding: Resident's target weight range (including rationale if different from ideal/usual body weight); approximate calorie, protein, and other nutrient needs compared with the resident's current intake; whether and to what extent weight stabilization or improvement can be anticipated, the resident cognitive status, in addition to analyzing the relationship between the resident's current medical condition or clinical situation, and recent fluctuations in weight.Review of Resident R160's July 2025 physician orders included the following diagnoses: transient ischemic attack (TIA- a mini stroke); seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); kidney failure (a condition in which one or both of your kidneys no longer work on their own); diabetes (a group of diseases that affect how the body uses blood sugar glucose), xerosis cutis(excessive dry skin); shortness of breath, and congestive heart failure ( CHF-a condition that affects the heart's ability to pump blood often leading to fluid retention in the body, symptoms of swelling, shortness of breath, rapid weight gain, and requires careful management through medications and lifestyle changes).Review of the resident's July 2025 physician orders included a physician's order dated February 13, 2025, and monthly thereafter for the administration of the medication, Furosemide tablet 40 milligrams give 1 tablet by mouth every 24 hours as needed for shortness of breath, increase weight over 2 pounds related to chronic systolic ( congestive) heart failure.Review of the resident's Weight Summary report indicated that on June 26, 2025, the resident's weight was recorded by nursing staff as being 125.6 pounds. On July 2, 2025, 7 days later, the resident's weight was recorded by nursing staff as being 137.2 pounds, indicating a 11.6 pound weight gain, and a significant weigh gain of 9.2% in 6 days. During an interview with the Regional Dietician (Employee E12) on July 24, 2025 at 11:25 a.m. the resident's weights were reviewed and it was confirmed by the Regional Dietician that the resident had a significant weight gain of 9.2% and gained 11.6 pounds in 6 days.Review of the clinical record provided no evidence that the physician was notified of the resident significant weight gain that occurred within a 6 day time period. During an interview with the Assistant Director of Nursing (ADON), Employee E3 on July 25, 2025 at 11:25 a.m. it was confirmed that no information could be produced to show evidence that the physician was notified of the resident's significant weight gain. Further, review of the physician's orders for Furosemide did not include any instructions for how often the physician wanted the resident weighed and when the resident should be administered the Furosemide (e.g. administer if the resident weight increased greater that 2lbs overnight/2 days/1 day). During an interview with the ADON, Employee E3 on July 25, 2025 at 11:25 a.m. the physician's order for Furosemide was reviewed with the ADON and it was confirmed during this time that the physician order was no clarified so that staff would know the frequency to administer the Furosemide when weight gain was recorded for the resident.The facility failed to ensure that a physician was notified of a rapid and significant weight gain and failed to clarify a physician's order for Resident R160.

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one out of 35 residents sampled (Residents R60).Findings include:A review of Resident R60's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses including end stage renal disease (is the final stage of chronic kidney disease, where the kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival) and dependance on dialysis. Review of July 2025 physician order revealed that Resident R60 was receiving dialysis on Tue, Thu, Sat at 10:30 a.m. at a local dialysis center.Review of Resident R60's admission Minimum Data Set did not identified the resident has receiving dialysis services.Interview with the Director of Nursing (DON) on July 23, 2025, at 1:45 p.m. confirmed that Resident R60 was admitted on dialysis that Section O of the MDS should have been triggered for dialysis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on observations, staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a resident was properly assessed for the self-administration of a medication that was located in the resident's room for 1 out of 35 residents reviewed (Resident R160) Findings include:Review of the July 2025 physician orders for Resident R160 included the diagnoses of transient ischemic attack (TIA- a mini stroke); seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness); kidney failure (a condition in which one or both of your kidneys no longer work on their own); diabetes (a group of diseases that affect how the body uses blood sugar glucose), and xerosis cutis(excessive dry skin)Review of the July 2025 physician orders included an order dated February 13, 2025 and monthly thereafter, for the resident to have a medicated lotion Ammonium Lactate External Lotion 12% applied to her legs in the evening: Apply B/L LE (bilaterally legs) topically in the evenings related to XEROSIS CUTIS (L85.3) Wash legs with soap and water pat dry, apply lotion.During an observation in the resident's room on July 21, 2025, at 11:35 a.m. a bottle of the medication was observed lying on the resident's dresser along with personal items that belonged to the resident. The resident was asked about the lotion and reported that it belonged to her, and stated, that goes on my legs. They keep it up there (referring to it being on top of her dresser). During an observation on July 23, 2025, at 11:33 a.m. in the resident's room, the resident was asked where all her items were that were on top of her dresser and reported that someone came in and put it in her drawer. During an observation with the Unit Manager on July 23, 2025, at 11:33 a.m. the Unit Manager observed the medication in the unlocked drawer and retrieved it from the drawer and removed it from out of the resident's room.Review of the resident's clinical record provided no evidence that the resident had been assessed by the facility to self-administer any of her medications.During an interview with Employee E3, Assistant Director of Nursing (ADON) on July 24, 2025 at 11:25 a.m. it was confirmed by the ADON that there were no physician orders or assessment completed that indicated that the resident was able to self administer medication.28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, interview with facility staff, it was determined that the facility failed to provide care and services to enhance residents' dignity related to serving meals on disposable paperware and plasticware for one of three units (3rd Floor) and for one of 35 residents reviewed (Resident R8) Findings include: A review of the facility policy and procedure, titled, Resident Rights, revised March 2025, states that it is the facility's policy that employees shall treat all residents with kindness, respect, and dignity. Observations during a follow up visit to the kitchen on July 23, 2025, at 12:05 p.m. revealed that on the tray line all the desserts consisting of mixed tropical fruit and vanilla pudding were prepared in a 4-ounce portion control disposable plastic cup with a plastic lid were being placed on all the trays going to all resident floors. Observations in the third-floor dining room on July 23, 2025, at 12:30 p.m. revealed that all residents' trays had the disposable plastic cups of fruit and pudding. It was noted that two residents at the first table closest to the nursing station also had white plastic forks and spoons on their tray. One resident was eating with her fingers and when the Food Service Director (FSD) put the plastic spoon on her plate she used it to push the food together and then set it down and continued to eat with her fingers. Nursing staff in the dining room did not intervene to help or redirect the resident. Interview with the FSD on July 23, 2025, at 12:30 p.m. confirmed the use of disposable cups and plasticware. Review of Resident R84's clinical record revealed the resident was admitted to the facility on [DATE]. The resident has the following diagnosis: Alzheimer's (a progressive brain disorder that gradually impairs memory, thinking, and reasoning skills), Dementia with behavioral disturbance (neuropsychiatric symptoms that often accompany dementia, including agitation, aggression, delusions, hallucinations, and more), Anxiety (feelings of worry, nervousness, or unease) , and a Cognitive Communicative Deficit(difficulties in communication arising from impairments in cognitive functions like attention, memory, and executive functions).Review of Resident R84's physician orders showed an active order dated April 22, 2025 which stated the resident had an order for Regular Diet, Regular texture, Thin consistency and the directions listed were Disposable Utensils. On July 21, 2025 Resident R84 was observed in the third-floor dining room waiting for her lunch. At 1:06 p.m. Resident R84 was served her lunch. The resident was observed with a meal ticket that had Disposable Utensils listed and the resident was using a plastic fork. Observation of the third-floor dining room during lunch on July 23, 2025 at 1:13 p.m. revealed Resident R84 was again served her lunch meal with plastic utensils. The resident was observed putting down her utensils and using her hands to scoop her chicken, rice, and vegetables.Further review of Resident R84's clinical record revealed no documentation over the past year of any behaviors related to utensils during dining. The facility was unable to provide documentation on when the last behavior related to utensils during dining was. Review of the July physician orders for Resident R8 included the following diagnosis: history of falls; macular degeneration (a medical condition that affects the central part of the retina, leading to blurred or no vision in the center of the visual field); diabetes (a group of diseases that affect how the body uses blood sugar glucose), and depression.During an observation on July 21, 2025 at 10:06 a.m. the resident came up to the nursing station and asked if he could have a cup of ice. When asked, the resident was told by licensed nurse (Employee E19) that he could not have ice and stated the following: no you ask for ice all day every day. You know you can't have ice. He always asking for ice.Review of the resident's clinical record did not include any clinical restrictions to the resident having ice/beverages.During an interview with the Unit Manager (Employee E18) on [DATE] at 10:20 a.m. regarding the incident, the unit manager confirmed that there are no restrictions on any ice/beverages that the resident can have. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(a) Resident rights

Based on observations and staff interview, it was determined that the facility failed to dispose of garbage and refuse properly where food and laundry is received. Findings Include: On September 27, 2024, 11:27 a.m., reviewed the dumpster area in the presence of the Director of Environmental Services, Employee E16 (dumpster is a large trash receptacle designed to be hoisted and emptied into a truck). The dumpster was leaking and oozing creamy colored, foul odorous liquid, through the sides of the dumpster, over the floor, around the dumpster, where the floor was irregularly covered with dark greasy appeared substances. At the time of the finding, E16 confirmed the observation. 28 Pa. Code 201.18(b)(3) Management

Based on observation, review of clinical record, review of facility policy, facility documentation and staff interviews, it was determined that the facility failed to timely assess the residents risk for factors for skin breakdown and failed to monitor a resident who was identified at risk for developing presure ulcers, resulting in harm related to the development of a pressure ulcer for one of 36 residents reviewed (Resident R152). Findings include: Review of facility policy titled Pressure Ulcer/Skin Breakdown Revised March, 2014, stated that the nursing staff and physician will assess and document an individual's significant risk factors for developing pressure sores; for example immobility, recent weight loss, and a history of pressure ulcers. It stated further that The staff will examine the skin of a new admission for ulcerations or alterations in skin. Review of Resident R152's clinical record revealed physician admission orders [REDACTED]. In addition, the physcian orders included that a weekly skin assessment was to be completed by a licensed nurse in the morning every Saturday. There were no skin assessments available for review at the time of the survey. An admission MDS (Minimum Data Set -assessment of resident needs) dated January 5, 2018, indicated that Resident R152 was severely cognitively impaired, required extensive physical assistance of two plus, staff members for bed mobility and transfers, extensive physical assistance of one staff for eating, was incontinent of bowel, frequently incontinent of urine, was noted to be 70 inches and weight 181 pounds and indicated that the resident was at risk for pressure ulcers. Review of Nursing Notes for Resident R152 dated January 5, 2018, at 9:00 a.m. revealed that staff had identified two open areas on the resident's scrotum (external male genitalia); proximal (closer to the center of the body) Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area) that measured 5.0 centimeter long (approximately 2 inches) x 0.5 centimeter wide x 0 centimeter depth) and distal (further away from the center of the body) Stage II (an ulcer involving the loss of the top layers of skin) that measured 1.0 centimeter long x 0.5 wide centimeter x 0.1 centimeter depth. Physician orders dated January 5, 2018 stated to cleanse the posterior scrotum with wound cleanser to apply [MEDICATION NAME] wound dressing gel topically every day and night shift and after incontinence care. It stated further to cleanse the distal area of the scrotum with wound cleanser, to apply [MEDICATION NAME], cover with a Xeroform dressing and ABD dressing twice daily every day. The Director of Nursing stated in an interview on January 26, 2018, at 10:00 a.m. that the cause of the wounds to the scrotum was identified as skin on skin. A plan of care to address alteration in skin integrity related to the open areas developed on January 5, 2018, included interventions such as to assess the area for signs and symptoms of infection and notify the physician for redness, warmth, swelling of the area of the wound, call the physician with any concerns, consult with wound care nurse as needed, to ensure proper positioning off area of concern, follow physician orders for wound care, re-evaluate treatment as needed, incontinent care as needed. Nursing Notes on January 11, 2018, at 9:51 p.m. stated that during wound care that morning the nurse had observed fresh blood on the sheet, that the nurse had assessed the left leg and found a broken superficial blister on the left foot. Wound documentation noted a Stage II blister (1.3 centimeter long x 1.5 centimeter wide x 0.1 centimeter depth) to the left foot that ruptured. The note stated further that the daughter had stated that the resident is restless and moves frequently in and out of bed. The physcian was notified and orders were obtained to cleanse the left heel with wound cleanser, to apply [MEDICATION NAME] wound dressing gel topically every shift, apply an oil [MEDICATION NAME] dressing and cover with a foam heel pad ABD dressing every day. In addition, staff were to keep legs elevated when in bed to offload heels every shift for wound care. On January 15, 2018 the physcian ordered an air mattress to the bed and to check for proper inflation on each shift for wound care, The Director of Nursing stated in an interview on January 26, 2018, at 10:00 a.m. that the foot wound was caused by rubbing his foot on the sheet. An incident committee review of the event noted that the resident was observed rubbing his heel up and down on the bed during wound care, that the root cause analysis is a self inflicted rub against a fitted sheet. On January 15, 2018, a wound consultation was completed and noted one wound to the posterior scrotum that measured 2.0 centimeter long x 0.3 wide centimeter x 0 centimeter depth. A Stage III pressure ulcer (ulcer involving full thickness loss exposing tissue) of the left heel with greater than one day duration that measured 3.5 centimeter long x 4 centimeter wide x depth not measurable, that the wound had 30% thick adherent devitalized necrotic tissue (dead tissue/skin that is black in color), 70% granulation tissue (new tissue growth). The wound consultant noted that the wound was cleansed, anesthetized with topical [MEDICATION NAME] (pain medication) and debrided (removal of dead tissue to promote healing). Observation of wound care on January 24, 2018, at approximately 1:00 p.m. revealed the resident in bed, left heel wound approximately 1.5 inches wide with a necrotic center. There was no evidence available for review at the time of the survey that licensed nursing staff had been completing and documenting the weekly skin assessments every Saturday morning as the physician had ordered or that interventions were developed to prevent new wounds. The facility failed to institute measures to prevent the development of pressure ulcers for a resident who was at risk of skin breakdown and failed to assess and monitor the resident with pressure ulcers and prevent new ulcers from developing causing actual harm. Treatment/Services to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) Previously cited 12/01/16 28 Pa. Code 201.14(a) Management Previously cited 12/01/16 28 Pa. Code 201.18(b)(1) Management Previously cited 02/08/17, 12/01/16 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 08/30/17, 12/01/16 28 Pa Code 211.5(f) Clinical records Previously cited 08/30/17, 12/01/16 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.11(d) Resident care plan Previously cited 08/30/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 08/30/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/01/16 28 Pa Code 211.12(c)(d)(2) Nursing services Previously cited 12/01/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 02/08/17, 12/01/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 08/30/17, 02/08/17, 12/01/16, 03/12/16

Based on clinical record review, facility documentation, facility policies and procedures and staff interviews, it was determined that the facility failed to provide adequate and safe supervision during a transfer resulting in actual harm with transfer to the hospital resulting in a skin tear to the left temple area and a fracture of the lumbar back for one of 27 residents reviewed (Resident R2). This was identified as Immediate Jeopardy for past non-compliance for one resident. Finding include: A review of the facility policy and procedure titled, Safe Lifting and Transfer, revised October 2014, revealed the following instructions when using a mechanical lift: - staff are to check for the appropriate sling size, - position the resident in the sling, loops on the outside, bottom of sling just above buttocks, - position chair for proper transfer in or out of bed, ensuring the chair is locked, - position the lift over the resident with the open base facing resident, - attach the sling to the crossbars using the appropriate loop and ensuring the sling extensions are crossed under the thighs prior to attachment, - cross the residents arms over their chest and support their head if necessary, - press the up button to lift the resident until the resident and the sling are free from the bed, - the second assistant should support the legs, head and or back as needed as the resident is moved away or towards the bed, - position the resident so that their back is toward the chair/bed, - lower the sling by pushing the down button until the resident is in the desired position, - unhook the sling and remove the lift, make the resident comfortable, ensuring the sling is smooth and free of the elevations. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE]. Further review of the physician's recap orders for November 2016, with an original order dated August 19, 2013, revealed that the resident was to be transferred by a Hoyer lift (a mechanical lift that uses a cloth sling to move a resident from one area to another) and with the assist of two caregivers every shift. A review of Resident R2's clinical record revealed [DIAGNOSES REDACTED]. repair and anxiety disorder. Further review of Resident R2's clinical record revealed an annual MDS ( Minimum Data Set- a periodic review of the residents needs) dated March 28, 2016, which revealed that the resident was severly impaired cognitively (unable to be understood or understand) and the resident required extensive assistance with transfers, dressing, eating and hygiene. A review of facility documentation revealed that on August 21, 2016, Resident R2 was being transferred from her bed to the wheelchair by two caregivers (nursing assistants) using the Hoyer lift. Further review revealed that the resident fell from the Hoyer lift sling. The resident sustained [REDACTED]. The hospital reported that the resident sustained [REDACTED]. Review of the nurses' notes dated August 21, 2016, stated that the resident was being transferred from her bed to the wheelchair, when she fell to the floor. The Supervisor was called and the resident was checked and placed back into bed. She had a 1.9 centimeter skin tear on her left forehead, the wound was cleaned and triple antibiotic ointment was applied. The resident was sent to the hospital for evaluation. Review of a nurses' note dated August 22, 2016, stated that the resident returned from the hospital at 12:45 a.m. The resident had a hematoma (a localized collection of blood outside the blood vessel due to disease or trauma) to the left temple (3.5 centimeters by 4 centimeter), a skin tear to the left temple (0.5 centimeters by 1.5 centimeters) and a bruise to the right posterior hand (back of hand) (8 centimeter by 7.5). The resident was awake, alert times one (alert to self only) and non-verbal. The nurses' note also indicated that neurological checks (assessed frequently for vital signs and level of consciousness) were started immediately upon the resident's return. The [DIAGNOSES REDACTED]. Will continue to monitor. Further review of nurses' notes dated August 22, 2016, revealed that the nurse from the hospital stated the resident did not have a brain bleed. A review of the facility investigation dated August 22, 2016, revealed that the nursing assistants involved in the transfer performed the transfer improperly. An interview with Employee E3, a Nurse Assistant (NA), on August 23, 2016 revealed that she applied the Hoyer lift sling improperly. Employee E3 did not cross the straps of the sling (the sling used for this transfer requires that the strap on the sling that go under the legs/buttocks need to be crossed between the legs and hooked to the Hoyer lift). Employee E4 (the second NA) did not guide the resident into the wheelchair as she stood holding the wheelchair while Employee E3 attempted to guide the resident to the wheelchair. It was mid-transfer that the resident fell out of the sling. Further review of the facility investigation revealed a statement by Employee E5, a Charge Nurse, dated August 21, 2016, which indicated that Employee E3 and Employee E4 were transferring the resident and she slipped out of the Hoyer pad (sling). Employee E5 came into the room and stated that the resident fell because the straps for the Hoyer lift pad (sling) had not been crossed. Further review of the facility investigation revealed a statement by Employee E3 dated August 23, 2016. The statement revealed that Employee E3 put the Hoyer pad (sling) underneath the resident and attached the straps to the Hoyer lift and , I moved the Hoyer lift closer to the wheelchair and while a few inches away the resident slipped out of the Hoyer pad (sling) and fell to the floor. I checked her and called for the nurse. Review of the written statement by Employee E4 dated August 23, 2016, revealed that she was holding the wheelchair instead of guiding the resident to the wheelchair. An interview with Employee E5, on November 29, 2016, at 1:00 p.m. revealed that she was sitting at the nurses' station when she heard a thump. She proceeded into the resident's room and observed the resident on the floor between the legs of the Hoyer lift. Employee E5 stated that she knew immediately that the sling straps had not been crossed and that was the cause of the resident falling out of the sling. Employee E5 called the Nursing Supervisor. Employee E5 stated in the interview that that particular sling, which needs to have straps crossed, is rarely used. An interview with Director of Nursing (DON) on November 29, 2016, at 11:00 a.m. revealed that the two employees involved with this incident had training on the use of the Hoyer lift. A review of the orientation sheet for Employee E3 revealed that she was hired on April 7, 2015, and Employee E4 was hired on September 9, 2015. A review of the orientation schedule for each employee revealed that the Director of Staff Development taught the following areas: one person transfer, two person transfer, gait belt, if applicable, mechanical lifts, types of wheelchairs, hip precautions, sternal precautions, safe transfer lifting policy/decision tree and transfer competencies. An interview with the Staff Development Coordinator on December 1, 2016, at 12:45 p.m. revealed that she has been in this position since June 2016, so she could only state what she has taught in that section of the orientation, which included the Hoyer lift, sling determination, and resident weight that determines which sling is used. Employee E6 stated that the facility rarely uses that particular sling and she does not know where the two CNA's obtained the sling. An interview with Employee E7, a Laundry Supervisor, on November 29, 2016, at 1:00 p.m. revealed that the laundry receives the Hoyer pad/sling from the nursing units when they are soiled and returns them to the unit clean for the residents. Employee E7 was unsure whether the facility still used a sling that has to be crossed between the legs. An interview with the Director of Nursing on December 1, 2016, at 1:00 p.m. confirmed that the two employees involved in this incident did not properly apply the Hoyer pad/sling causing the resident to fall out of the sling and sustain a L2, L3 fracture. The DON also confirmed that it is unknown where the employees retrieved that particular sling. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 1, 2016, at 11:25 a.m. related to Resident R2 who fell out of a Hoyer lift sling resulting in actual harm on August 21, 2016. The Immediate Jeopardy was identified as a past non-compliance for the incident on August 21, 2016. The Immediate Jeopardy was in place from August 21, 2016, to August 26, 2016. A corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on the in-service that was provided to Registered Nurses, Licensed Practical Nurses and all Nursing Assistants. The in-service entailed mechanical lift transfer and the in-service began on August 23, 2016. The Immediate Jeopardy was lifted on December 1, 2016, at 4:09 p.m. after the facility submitted an acceptable corrective action plan and it was verified that the action plan had been implemented by the staff educator by August 26, 2016. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 03/12/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/16/14 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/06/14, 12/29/15, 03/12/16