Every finding on record at Statesman Health & Rehabilitation Center

Based on interviews and the review of facility documentation, it was determined that the facility failed to ensure that proper notice was provided for a room change for 1 out of 22 residents reviewed (Resident R4). Findings include: Review of Resident R4's clinical record included the following diagnoses: end stage renal disease (a condition that occurs when the kidneys no longer work well enough to meet the body's needs); dysphagia (difficulty swallowing); hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the facility policy IX Room Assignments & Changes, revised of July 14, 2011, indicated that during the course of a resident's stay, room changes may be necessary for the welfare of each resident, and that the facility reserves the right to make the necessary room changes. Continued review of the policy indicated that the facility will try to give the resident and the resident's representative reasonable notice prior to the change, including an explanation for the change, however, the policy indicated that facility may deliver such notice after the fact. During an interview with Resident R4 on August 5, 2026, at 10:00 a.m. the resident reported that his/her room was changed a few months ago and did not understand why he/she had to move from that room, that he/she liked. The resident reported that he/she only had 1 roommate in the old room and now has three roommates in the new room. The resident further explained that the current roommates are not the cleanest. When the resident was asked if a written notice was provided from anyone from the facility prior to the room being changed, Resident R4 denied receiving anything. Review of a nursing notes dated April 17, 2026, at 4:41 p.m. indicated that the resident was transferred to another room in the facility. Review of Resident R4's clinical record indicated a Room Change Notice document also dated April 17, 2026. The Effective date room change to occur. was documented as April 17, 2026. Continued review of the Room Change Notice, indicated that the Reason for the room change was documented as room management, with no further explanation. During an interview with the Director of Nursing (DON) on August 7, 2026, at 10:03, the DON confirmed that the resident's room was changed the same day of the Room Change Notice document in the resident's clinical record. The DON also reported that the resident's room was changed because the resident finished receiving rehabilitation services at the facility, and it was determined that the resident would need to stay at the facility for long-term care and was relocated to the facility's long-term care unit. 28 Pa. Code 201.18 (b)(1) Management 28 Pa Code 201.29 (c.3)(1)(2)Resident rights

Based on review of the clinical records and interviews with staff, it was determined that the facility failed to ensure that a person-centered plan of was developed for a personal pet and a resident with suicide ideation for 2 out of 21 residents reviewed (Resident R88 and R14). Findings include: Review of the facility policy, Pet Protocol, with a revision date of August 18, 2025, indicated that all animals residing in or visiting the community will have preventive care to ensure that they do not pose a risk to the health, safety, or rights of all residents. The policy also stated that the admission coordinator or a member of the life enrichment community at the facility (activity department) should be contacted to request policies/ forms should a resident want to bring a pet into the facility. Continued review of the policy indicated that a pet care plan will be completed for each pet residing in the community. Review of Resident R88's clinical included the following diagnoses: anxiety, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), high blood pressure, seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness); hyperlipidemia (high cholesterol); agoraphobia (involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed) with panic disorder (a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause); pain; repeat falls, and alcohol abuse. Review of Resident R88's clinical record indicated that the resident had been receiving care at the facility since May 2025. During an interview with Resident R88 on August 7, 2026, at 9:00 a.m. the resident was observed in his/her room with a dog. The resident reported that the dog lives at the facility and that he sleeps in his/her bed at night. Review of Resident R88's person-centered plan of care did not include a plan of care for the resident's dog who was residing at the facility to ensure proper care, services, safety measures implemented for the dog, and other residents at the facility. During an interview with the Director of Nursing (DON) on August 7, 2026, at 10:03 a.m. it was confirmed that the dog was residing at the facility with Resident R88. It was also discussed that there was no person-centered plan of care for the dog who had been residing at the facility. Review of Resident R14's clinical record included the following diagnoses: end stage renal disease (happens when the kidneys no longer work well enough to meet the body's needs); hypertension (high blood pressure); heart failure ( a condition where the heart muscle doesn't pump blood as well as it should often causing blood to backs up, fluid buildup in the lungs and shortness of breath; chronic pain (pain that lasts for over three months, may be felt all the time, may come and go, can happen anywhere in an individual's body, and has countless causes), and adjustment disorder (a strong emotional or behavioral reaction to stress or trauma) with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R14's clinical record revealed a note from the resident's psychologist dated April 11, 2026, at 11:40 a.m. which indicated that the resident was being seen on the above-referenced day due to impaired judgement, medical nonadherence, family stressors, and emergence of passive death wishes, impacting safety and functioning. Continued review of the psychologist note dated April 11, 2026, indicated that Resident R14 admitted that he/she has passive death wishes. The note stated, Midway through the session admitted occasional passive death wish but denied plan or intent. Continued review of Resident R14's person plan of care included no person-centered plan of care related to the resident's suicide ideation to ensure appropriate care, services and to ensure that any interventions are implemented. During an interview with the Director of Nursing (DON) on August 7, 2026, at 9:10 a.m. the psychologist's note from April 11, 2026, was reviewed, and it was discussed that there was no person-centered plan of care related to the resident's suicidal ideation. 28 Pa. Code 201.18 (b)(1) Management 28 Pa Code 211.12 (d)(5) Nursing services 28 Pa Code 211.10 (c) Resident care policies

Based on review of clinical records, facility policy, and interview with staff, it was determined the facility failed to ensure PRN (as needed) pain medication was administrated according to the physician orders for two of two residents reviewed for pain management (Resident R74 and R25).Findings include: Review of Resident R74's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of hypertensive emergency (significantly elevated blood pressure), chronic pain, and muscle weakness. Review of Resident R74's physician order revealed an order for Oxycodone 5mg 1 tablet every 4 hours as needed for moderate-severe pain (4-10). Review of Resident 's Medication Administration Record (MAR) for the month of August revealed the resident received PRN Oxycodone 5mg with following pain scales:August 4, 2026 - pain scale 3August 4, 2026 - pain scale 2August 4, 2026 - pain scale 2 Review of Resident R25's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of chronic pain syndrome, hypertension (high blood pressure), and muscle weakness. Review of Resident R25's physician order revealed an order for Tramadol 50mg 1 tablet PRN every 8 hours for moderate-severe pain (4-10). Review of Resident 's Medication Administration Record (MAR) for the month of July revealed the resident received PRN Tramadol with following pain scales:July 9, 2026 - 3July 9, 2026 - 2July 10, 2026 - 2July 10, 2026 - 0July 11, 2026 - 2July 11, 2026 - 2July 12, 2026 - 2July 14, 2026 - 3July 14, 2026 - 0July 16, 2026 - 3July 16, 2026 - 2July 17, 2026 - 0July 17, 2026 - 3 Interview on August 6, 2026, at 11:30 a.m. with Employee E2, Director of Nursing, confirmed Resident R74's and R25's pain medications were not given according to physician orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and staff and resident interviews, it was determined that the facility failed to honor resident food preferences and failed to serve foods that accommodate a resident's allergies for three of six residents reviewed during dining (Resident R37, R5, and R28).Findings Include: Observations on August 6, 2026, at 8:58 a.m. revealed Resident R37's meal ticket revealed allergic to orange juice. Further observation of Resident R37's meal tray revealed he/she had orange juice on his/her tray. Interview on August 6, 2026, at 8:59 a.m. with Resident R37 revealed he/she has been receiving orange juice with her breakfast despite his/her allergies. Observations on August 6, 2026, at 9:02 a.m. revealed Resident R5's meal ticket stated eggs, scrapple, and cereal of choice. Further observation of meal tray revealed no cereal was on Resident R5's tray. Interview on August 6, 2026, at 9:03 a.m. with Resident R5 revealed he/she did not request scrapple when selecting her meal for the week. Observations on August 6, 2026, at 9:05 a.m. with Resident R28 revealed Resident 28's meal tray had eggs and scrapple on his/her tray. Interview on August 6, 2026, at 9:06 a.m. revealed Resident R28 does not eat eggs and did not request scrapple. Interview on August 6, 2026, at 9:08 a.m. with Director of Nursing, Employee E2, confirmed Resident R37's meal ticket revealed the resident was allergic to orange juice and the resident had orange juice on her plate. 28 Pa. Code 201.18(b)(3) Management 28 Pa Code 211.6(a) Dietary services

Based on interviews, it was determined that the facility failed to ensure that a dog residing at the facility obtained immunizations for 1 out of 1 dog residing at the facility belonging to Resident R88. Findings include: Review of the facility policy, Pet Protocol, with a revision date of August 18, 2025, indicated that all animals residing in or visiting the community will have preventive care to ensure that they do not pose a risk to the health, safety, or rights of all residents. The policy stated that the admission coordinator or a member of the life enrichment community at the facility (activity department) should be contacted to request policies/ forms should a resident want to bring a pet into the facility. Review of the August 2026 physician orders for Resident R88 included the following diagnosis: anxiety, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), high blood pressure, seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness); hyperlipidemia (high cholesterol); agoraphobia (involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed) with panic disorder (a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause); pain; repeat falls, and alcohol abuse. Review of the clinical record indicated that Resident R88 has been receiving care at the facility since May 2025. During an interview with the resident on August 7, 2026, at 9:00 a.m. the resident was observed in his/her room with a dog in her room. The resident reported that the dog lived at the facility and that he sleeps in her bed at night. During an interview with the Nursing Home Administrator (NHA) on August 7, 2026, at 10:37 a.m. it was confirmed the dog is residing at the facility, and that the facility could not produce any vaccination records for the dog. 28 Pa. Code 201.18 (b)(1) Management28 Pa Code 211.12 (d)(5) Nursing services28 Pa Code 211.17 (5.51)(6)(7) Pet therapy

Based on observations and staff interview, it was determined that the facility failed to maintain a safe and home-like environment for one of three nursing units observed. (C wing)Findings Include: On September 2, 2025, at 12:02 p.m., observation conducted on C wing of the bathroom of Resident R80's room, revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:01 a.m., on September 4, 2025, at 10:31 a.m., and on September 5, 2025, at 9:31 a.m.On September 2, 2025, at 12:22 p.m., observation made of the hallway in front of Resident R8's room revealed that the covering of the heater/cooler- outlet- was not properly fixated to the heater/cooler- outlet and the rusted metal pieces were exposed around the base of the wall. The same observation was noted on September 3, 2025, at 10:11 a.m.Interview and observations made with the Assistant Director of Nursing on September 5, 2025, at 9:47 a.m., confirmed the above findings.28 Pa. Code 207.2 (a) Administration responsibility

Based on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required.Findings Include:On September 5, 2025 at 10:34 a.m. observations at the front lobby area revealed staffing was posted is a spot behind the front desk receptionist on the wall in a clear sleeve. Observation of the posting revealed the posting would be difficult to access for people with mobility issues due to the height of the posting and the position behind the receptionist desk. Employee E7 the front desk receptionist, was asked if this was the only placed that the staffing was posted and Employee E7 replied, I believe so. The form in the clear sleeve on the wall was from September 4, 2025 and the form was left blank without any of the staffing information filled in. The only portion of the form that filled it was the date, written in pencil. Further observation of three wings (A, B, C) revealed there was no other staffing posted throughout the building. On September 5, 2025 at t 10:37 a.m. an interview was held with the Assistant Director of Nursing Employee E3 came into the lobby and confirmed that staffing for each shift and each day should be posted. Employee E3 stated that the overnight shift supervisor would have been responsible for posting the staffing prior to the first shirt on September 5, 2025. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing Services

Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure residents received quality care related to incontinence care for and medication administration for three of twenty-one residents reviewed (R5, R57, R114) Findings include: Review of facility policy “Medication Administration/ Disposition”, revised September 2023, revealed medications should be administered in a safe and timely manner, and as prescribed. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician or the physician's designee. Clinical record review revealed Resident R5 was admitted to the facility on [DATE] with a diagnosis that included Rhabdomyolysis (muscles break down and release toxins into blood and kidneys), hypertension (high blood pressure), and congestive heart failure (condition that happens when your heart can't pump blood well enough to meet the body's needs). Interview with Resident R5 on September 3, 2025 at 9:40 a.m. revealed he/she has been receiving his/her evening medication late. Review of Resident R5 medication administration record (MAR) from August 20, 2025 – August 26, 2025 revealed the following medications being administered late: - Atorvastatin to be given at 9:00 p.m. for hyperlipidemia o 8/22/25 documented on 8/23/25 at 12:20 a.m. - Carvedilol 3.125 mg to be given at 9:00 p.m. for hypertension o 8/21/25 documented at 12:20 a.m. - Cyclobenzaprine 5 mg to be given three times day for muscle spasm o 8/21/25 scheduled for 9:00 p.m. and documented at 12:20 a.m. - Eliquis 5 mg every 12 hours a -fib o 8/21/25 scheduled for 9:00 p.m. and documented on 8/23/25 at 12:20 a.m. The reasoning for the late medication administration was documented as “charted late”. Clinical record review revealed Resident R114 was admitted to the facility on [DATE] with a diagnosis that included hypertension, neuropathy (nerve damage that affects hands and feet), and muscle spasms. Interview on September 3, 2025 at 9:55 a.m. revealed he/she has been receiving his/her evening medication late, which has resulted in poor sleep. Review of Resident R114 medication administration record (MAR) from August 20, 2025 – August 26, 2025 revealed the following medications being administered late: - Atorvastatin 10 mg to be given at 9:00 p.m. for hyperlipidemia o 8/29/25 documented on 8/30/25 at 12:47 a.m. o 8/21/25 documented at 10:49 p.m. - Cardizem 240 mg to be given at 9:00 a.m. for hypertension o 8/27/25 documented at 10:21 a.m. o 8/30/25 documented at 11:21 a.m. - Gabapentin 600 mg three times a day for nerve pain o 8/29/25 scheduled for 9:00 a.m. given at 10:21a.m. o 8/29/25 scheduled for 1:00 p.m. given at 3:01p.m. - Glipizide 5 mg to be given at 8:00 a.m. for Diabetes Mellitus o 8/27/25 documented at 10:21 a.m. o 8/28/25 documented at 9:44 a.m. o 8/20/25 documented at 11:21 a.m. o 9/1 documented at 9:22 - Paroxetine 10 mg to be given at 9:00 p.m. for depression o 8/29/25 documented at 8/30/25 at 12:47 p.m. o 8/31/25 documented at 10:29 p.m. - Ropinirole 1 mg to be given at 9:00 p.m. for restless leg o 8/29/25 documented at 8/30/25 at 12:47 a.m. o 8/30/25 documented at 10:49 p.m. The reasoning for the late medication administration was documented as “charted late”. Resident Council meeting was held on September 4, 2025 at 10:30 a.m. with 10 residents in attendance. Three residents (R72, R100, R92) reported receiving their evening medications late/or missed doses of medications. Interview with Employee E2, Director of Nursing, on September 4, 2025 at 10:16 a.m. confirmed Resident R5 and Resident R114 MAR's were not documented in a timely manner and medications are allowed to be administered an hour before and an hour after the scheduled medication time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, resident interviews, and staff interviews it was determined that the facility failed to ensure required posting for the Department of Health were displayed at the facility. Findings Include: Observation on September 2, 2025 at 10:05 a.m. revealed the main lobby, A wing, B wing, and C wing did not have any postings or signage for the Department of Health. This was confirmed by the front desk receptionist Employee E7 at 10:09 a.m. An interview was held with the Nursing Home Administrator, Employee E1 at 10:10 a.m. The interview revealed that there was one spot outside of the lobby area where the name and phone number are posted and stated, it must have been taken down by one of the residents. Employee E1 confirmed that this is the only place where the Department of Health reporting phone number is posted in the facility. Review of the posting after is was placed back up revealed there was no information other than the phone number.28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

Based on observations, clinical record review, review of facility policy and interviews with staff, it was determined that the facility did not ensure a care plan was developed for one of twenty-two residents reviewed. (Resident R57)Findings Include: Review of facility policy titled, Comprehensive Care Planning Policy with a revision date of March 20, 2025 states, Policy- An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. Further review of the policy revealed, Procedure- the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining and improving resident functional abilities and quality of life. Interview held with Resident R57 on September 3, 2025 at 12:41 p.m. During the resident interview the resident talked about feeling frustrated and down about not being able to get help from staff for his incontinence care. Review of Resident R57's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis on Major Depressive Disorder from July 31, 2020. Further review of the resident's clinical record revealed the resident has a Brief Interview for Mental Status (BIMS) assessment completed on May 27, 2025 with a score of 14 indicating the resident is cognitively intact. Interview with licensed nursed Employee E6 on September 3, 2025 at 1:04 p.m. revealed the resident is incontinent. An interview with the Assistant Director of Nursing, Employee E3 on September 5, 2025 at 12:23 p.m. revealed the resident did have depression. Employee E3 confirmed the above findings, that Resident R57's care plan did not include a focus area for the diagnosis of depression. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a rational was provided for the discontinuation of blood sugar monitoring for 6 of 6 residents reviewed who were insulin dependent (Resident R1, R2, R3, R4, R5, R6). Findings include: Interview with the Assistant Director of Nursing conducted on April 8, 2025, at approximately 12:00 p.m. revealed that the facility is discontinuing blood sugar check orders related to resident blood sugar trends and A1C blood test (blood test that provides an average of your blood sugar levels over the previous 2- 3 months). Continued interview revealed that there is no facility policy regarding discontinuing blood sugar checks for residents with diabetes diagnosis and receiving insulin. Interview with the Director of Nursing conducted on April 8, 2025, at approximately 1:00 p.m. revealed the facility is discontinuing blood sugar check orders related to resident blood sugar trends and A1C blood test. Further interview confirmed that there is no facility policy regarding discontinuing blood sugar checks for residents with diabetes diagnosis and receiving insulin. Continued interview revealed that upon discharging Accu-Chek (blood glucose measuring system used for home monitoring of glucose) orders, practitioners must document the clinical reasoning to support why the order was discontinued. Documentation must occur in the resident's progress notes. Phone interview with the Medical Director, Employee E4, conducted on April 8, 2025, at 1:22 p.m. revealed that he was not aware that blood sugar check orders were being discontinued for residents with standing insulin orders, and that he was informed of this two hours ago. Further interview revealed that blood sugar checks need to be checked on regular intervals no matter the trends. A statement received on Wednesday April 9, 2025, via electronic communication, from the Facility Administrator, confirmed that when modifying or discontinuing blood sugar checks and after reviewing and confirming the orders with the MD(s) a progress note should have been placed identifying that this had occurred. Clinical record review and interview conducted with the Assistant Director of Nursing, Employee E3, on April 8, 2025, at approximately 2:30 p.m. confirmed that blood sugar check orders have been discontinued for Resident R1, R2, R3, R4, R5, R6 while receiving insulin. Continued interview confirmed there was no documented evidence identifying that the blood sugar check order has been discontinued. Further interview confirmed the residents' clinical records failed to reveal clinical reasoning identified for the discontinued blood sugar check orders for Resident R1, R2, R3, R4, R5, R6. 28 Pa Code 211.12(d)(5) Nursing services

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician regarding a change in Resident R61's meal and fluid consumption for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of the facility policy, Change in Condition, with a revision date of June 27, 2024, indicated that a resident's significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one are of the resident's health status and or requires interdisciplinary reviewed and /or revision to the care plan. The policy also indicated the physician and the resident/family and responsible party will be notified when there has been an accident involving the resident .a significant change in the resident's physician/emotional/mental condition and a need to alter the resident's treatment, including a change in provider orders .when there is a consistent refusal of treatment or medications. Continued review of the policy indicated that the nurse will gather information prior to contacting the physician with information that includes, but not limited to resident vital signs (temperature, pulse, respirations and pulse ox), most recent labs, a description of the problems and information on when the change in condition started. The policy also stated that the nurse will record d the information related to the change in condition and subsequent events and notifications in the resident's health records. Review of October 2024 physician orders for Resident R61 indicated that the resident was admitted into to the facility on [DATE] with diagnoses of muscle weakness and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), pancreatitis (a condition in which the pancreas becomes inflamed); anemia (an individual does not have enough healthy red blood cells which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk) and heart failure (an individual's heart can't supply enough blood to meet the body's needs). The resident also had a diagnosis of deep vein thrombosis and end stage renal disease (the gradual loss of kidney function) that required hemodialysis treatment 3 times a week. Review of the resident's Admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated July 7, 2024, indicated that the resident was alert and oriented. Review of the resident's clinical record indicated that the resident did not consume any meals on October 18, 2024. Breakfast was documented as not taken, Lunch was documented as not taken, and dinner was documented as not taken by the resident's nursing assistant. The resident was also documented as having consumed a total of 2 liquid supplements of 120 milliliters each (240 milliliter), and 2 servings of a fluid that equaled total 110 milliliters each (220 milliliters), which is a total of 15.5 ounces of a combination of fluids/supplements for that day. Review of the resident's meal consumption log for October 18, 2024, also documented the resident as consuming, 76-100% of a third supplement. Continued review of the clinical record did not show evidence that the physician was notified of the resident's meal and fluid consuptions so any instructions, orders, and/or further assessments could be provided. During an interview on November 12, 2024, at 12:49 p.m. with the registered nurse supervisor (Employee E14) for Resident R61, Employee E14 reported that he worked 7:00 a.m. on October 18, 2024 until 7:00 p.m. on October 14, 2024. Employee E13 reported that the resident was transferred to his unit on October 18, 2024, and that he was not notified that he did not eat breakfast from the unit that he transferred from. It was discussed with Employee E14 that the resident was transferred to Employee E14's unit prior to lunch. Employee E14 also reported that he was not made aware by the resident's assigned nurse aide (Employee E15) that the resident did not eat lunch or dinner on October 18, 2024. 28 Pa Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of seven residents' medication administration observed, resulting in a significant medication error (Resident R21). Findings include: On November 6, 2024, at 10:28 a.m., observed that Employee E12, a Registered Nurse, administered to Resident R21, the medicine, Furosemide tablet 40 mg, one tablet by mouth. Review of physician order for R21, revealed an order to administer Furosemide tablet 40 mg, two tablets, by mouth, for Obstructive and Reflux Uropathy (Obstructive Uropathy occurs when urine cannot drain through the urinary tract; urine backs up into the kidneys and may cause them to become swollen. Obstructive Uropathy is a prevalent cause of acute kidney injury that can potentially lead to death or irreversible and permanent tissue damage leading to chronic kidney disease). At the time of the observation, interview with Employee E12, confirmed the above findings. The facility incurred a medication error rate of 3.85%. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on staff and family interviews and the review of clinical records, it was determined that the facility failed to ensure that residents had the right to participate in the development and implementation of a person-centered plan of care for 2 out of 20 residents reviewed (Resident R61 and R71). Findings include: Review of October 2024 physician orders for Resident R61 indicated that the resident was admitted into to the facility on [DATE] with diagnosis of muscle weakness and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), pancreatitis (a condition in which the pancreas becomes inflamed); anemia (an individual does not have enough healthy red blood cells which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk), heart failure (an individual's heart can't supply enough blood to meet the body's needs), deep vein thrombosis and end stage renal disease (the gradual loss of kidney function). Review of the resident's Admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated July 7, 2024 indicated that the resident was alert and oriented. During a phone interview with Resident R61's mother/responsible party, on November 5, 2024 at 9:36 a.m. the resident's mother reported that she spoke with the social worker (Employee E13) in July 2024 regarding having the resident transferred closer to where the resident is from. The resident's mother reported that she never heard anything back from the social worker at the facility, so when she came up to the facility the Tuesday, Wednesday, and Thursday after Labor Day the resident's mother stated that she provided the social worker with a list of 6 facilities that are in the area of where the resident and his family resided, in addition to the names of and the names 3 dialysis centers. The resident's mother stated that she was calling up everyday and left voicemail messages for the social worker and the Director of Nursing (DON) to call her back to get an update on the status of Resident R61's discharge, but the resident's mother reported that she did not receive any phone calls back. The resident's mother was asked if she ever received a verbal notification from the social worker or anyone else from the facility regarding a care plan meeting, or a written notification from the facility for a care plan meeting regarding here son's care at the facility. Review of the resident's clinical record did not show evidence of any documentation of the resident and/or his responsible party ever receiving any notification of a care plan meeting, or that any care plan meeting ever occurred since his admission on July 1, 2024. Review of the November 2021 physician orders for Resident R71 included the following diagnosis's: diabetes (a medical condition that occurs when an individual's blood sugar is too high); respiratory failure (a condition when an individual does not have enough oxygen in their blood and can result in symptoms that include, shortness of breath, confusion and fatigue) morbid obesity, in addition to heart failure, and end stage renal disease. Review of the resident's August 21, 2024 Quarterly MDS indicated that the resident was alert and oriented. During an interview with Resident R71 on November 8, 2024 at 2:13 p.m. reported that she has not had a care plan meeting in a while. Review of the resident's clinical record from February 2024 through November 2024 did not show evidence of any documentation of the resident and/or her responsible party ever receiving any notification of a care plan meeting, or that any care plan meeting ever occurred since his admission on July 1, 2024. During an interview with the social worker (Employee E13) on November 12, 2024 at 12:05 p.m. regarding the process for notifying residents and their responsible parties regarding care plan meetings, the social worker reported that she tries to give the resident and/or responsible party at least 30 days' notice, and will adjust the date/time as needed if it does not work for them. It was discussed with the social worker that there was no documentation regarding care plan notifications for Resident R61 and R71, or that a care plan occurred for Resident R61 and Resident R71. It was also discussed that Resident R61's mother reported that she had never been invited to one or attended one at any time during her resident's stay at the facility. It was also discussed with the social worker that Resident R71 reported that she was never invited to one or attended one anytime this year. It was confirmed by the social worker that no information could be produced to show evidence that either resident were invited to a meeting and had the right to participate in the development and implementation of his or her person-centered plan of care. The facility failed to ensure that Resident R61 and Resident R71 had the right to participate in the development and implementation of their person-centered plan of care. 28 Pa Code 201.29 (c) Resident rights.

Based on observations of care and services, reviews of clinical records and interviews with residents and staff, it was determined that the facility failed to provide care preferences and reasonable accommodations for the adaptive equipment used to enhance mobility and bathing for one of three residents reviewed. (Resident R10) Findings include: Review of Resident R10 annual comprehensive assessment (MDS-an assessment of care needs) dated August 16, 2024 indicated that Resident R10 was cognitively intact with impairments on both sides of lower extremities. The assessment revealed that the resident required maximal assistance with functional abilities for showering and bathing, the use of a wheeelchair for ambulation. The resident was occasionally incontinent of bladder and occasionally experiencing pain. Continued review of the MDS revealed that the resident had a Stage II (ulcer involveing loss of the top layers of the skin) pressure sore, the resident received physical therapy and that the established goal set was for the resident to be discharge to the community. Interview with Resident R10 at 11:00 a.m., on November 4, 2024 revealed that the resident did not get out of bed into his wheel chair; because he was not able to be positioned upright or properly with his back aligned and supported by the back of the chair, the mechanical lift sling that was used to transfer him from the bed to the wheel chair was small and rubbing against his skin during a transfer causing skin irritation. The resident verbalized that the chair itself was too small and uncomfortable; evidenced by getting caught as the nursing staff began a transfer with the mechanical lift either from the bed to the wheel chair or from the wheel chair to the bed. Further interview with Resident R10 revealed that the residenthad not been accommodated with a shower for several months. The resident was informed by the nursing and physical therapy staff that he would not be able to fit through the doorway into the central shower room on the C wing nursing unit. Clinical record review revealed that the physical therapy staff evaluated Resident R10 on January 18, 2024 and indicated that this resident was able to sit in a wheel chair with an upright posture with elevating leg rests. At this time the therapy department indicated that Resident R10 was receiving range of motion exercises of the bilateral lower extremities to prevent joint contractures. Clinical record review revealed that the physical therapy department evaluated Resident R10 on August 15, 2024 and indicated that Resident R10 was able to use a draw sheet under legs while in bed with staff assistance and safely move to the edge of the bed foe edge of the bed sitting. Clinical record review revealed that on August 22, 2024 the physical therapist assessed and educated Resident R10 and staff to institute bed mobility exercises to strengthen core muscles while in bed. The assessment indicated that modified abdominal crunches, throwing and catching a ball forward side to side and reaching for a ball from each side of the bed. Clinical record review for Resident R10 indicated that this resident was evaluated by the wound practitioner on October 29, 2024 and the evaluation indicated that this resident had a stage II pressure area located on the left buttock; measuring .8cm by .6 centimeters (cm) by .1 cm with 100% epithelialized tissue. The practitioner's recommendations for the nursing staff were to cleanse all skin folds with bathing. The practitioner also indicated that the importance of daily bathing was discussed with Resident R10 to prevent skin breakdown and infections of the tissues. Clinical record review revealed that on November 25, 2023 the physicial therapy department measured Resident R10's body from hip to hip and the Resident was 35 inches. At this time the therapy department indicated that the bariatric wheel chair was 30 inches wide. Resident R10 reported to the therapy department that this bariatric wheel chair was too tight for him. Interview with the nursing staff ( Employees E7, E8, E9 and E10) between 9:30 a.m. and 11:00 a.m., on November 4 through November 8, 2024 revealed that Resident R10 did not fit in the wheel chair provided for him by the physical therapy department. The nursing staff reported that it was too snug around the hip/waist area for Resident R10. The nursing staff also reported that they had not offered Resident R10 a shower with a bariatric shower chair; because the chairs they have on the C wing nursing unit were not bariatric designed. Observations of the bariatric shower chair that the facility had on the B wing nursing unit confirmed that this chair when used with Resident R10 was too large to fit through the shower room doorway on the nursing unit. Interview with the physical therapist, Employee E4 at 1: 00 p.m., on November 5, 2024 confirmed that the wheel chair as assigned to Resident R10 by the physical therapy department was trialed and tested on [DATE]. The results of the attempted seating were that the chair was too tight, not comfortable and ill-fitting for proper positioning and use by Resident R10. Clinical record review for Resident R10 revealed that there was no care plan developed to address accommodation of medical and physical needs for adaptive equipment to enhance mobility and bathing for Resident R10. Interview with Nursing Home Administrator, Employee E1 and the Director of nursing, Employee E2 at 2:00 p.m., on November 5, 2024 confirmed the lack of care plan development and implementation for the adaptive equipment (wheel chair and shower chair) and a restorative exercise program for bed mobility, draw sheet repositioning, turning and exercising upper and lower extremities and core strengthening with weighted ball tossing and lifting for Resident R10. 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 PA Code 201.18(b)(1)(3)(e)(1) Management 28 PA Code 211.5(f)(ii)(iii)(viii)(ix) Medical records

Based on staff interview and the review of the clinical record, it was determined that the facility failed to ensure that a person-center plan of care was developed for a resident with a history of deep vein thrombosis (blood clots) and anticoagulant medications for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of October 2024 physician orders for Resident R61 include the diagnose of muscle weakness, seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), pancreatitis (a condition in which the pancreas becomes inflamed); anemia (an individual does not have enough healthy red blood cells which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk) and heart failure (an individual's heart can't supply enough blood to meet the body's needs). The resident also had a diagnoses of deep vein thrombosis and end stage renal disease (the gradual loss of kidney function). Review of September 2024 physician's order included a physician's order for Eliquis (a medication used to prevent serious blood clots from forming due to a certain irregular heartbeat) with a start date of August 30, 2024 and a discharge date of [DATE]. Review of a nursing note dated September 18, 2024 at 2:02 p.m. indicated that the resident complained of being in pain and feeling uncomfortable while at dialysis. A review of a nursing note on September 18, 2024 at 9:40 p.m. indicated that the resident was admitted to the hospital with partial bowel obstruction. Review of the resident's hospital discharge summary dated September 27, 2024, indicated that the resident's Eliquis was held due to concerns to having low hemoglobin levels. The hospital indicated in the above referenced discharge summary that the resident's Eliquis management should be followed up with the resident's primary care physician. Follow up with PCP (primary care physician) regarding Eliquis management. Review of the resident's person-centered plan of care did not include an updated plan of care documenting that the resident was no longer being treated with any anticoagulants and did not include any services, treatments or interventions that may have needed to be implemented related to the changes in the resident's physician's orders. During a discussion with the Director of Nursing (DON) on November 12, 2024 at 4:00 p.m. that there was no person-centered plan of care for the resident related to the discharge of the resident's anticoagulant that was being prescribed to prevent blood clots. 28 Pa. Code 211.12(c(1) )Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to develop and implement an effective discharge planning process for 1 out of 20 residents reviewed (Resident R61). Findings include: Review of the facility policy, Discharge Planning Policy, with a revision date of September 24, 2024, indicated that the discharge needs of each resident will be identified and will develop a discharge plan that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition the resident to post discharge care, and the reduction of factors leading to preventable readmissions. The policy also stated that the discharge plan will include: the regular re-evaluation of residents to identify changes that need to be made in the resident's discharge plan; the involvement of the interdisciplinary team (the physician, nurse, nurse aide, food and nutritional services staff), in addition to the resident and/or his/her responsible party. Review of October 2024 physician orders for Resident R61 indicated that the resident was admitted into to the facility on [DATE] with diagnosis that included muscle weakness, seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness); pancreatitis (a condition in which the pancreas becomes inflamed); anemia (a medical condition in which an individual does not have enough healthy red blood cells, and can which can result in fatigue and unexplained weakness); paraplegia (a form of paralysis that affects the lower half of an individual's body and their ability to walk), and heart failure (an individual's heart can't supply enough blood to meet the body's needs). The resident also had a diagnosis of deep vein thrombosis (blood clots) and end stage renal disease (the gradual loss of kidney function) that required hemodialysis treatment 3 times a week. During a phone interview with Resident R61's mother/responsible party, on November 5, 2024 at 9:36 a.m., the resident's mother reported that she spoke with the social worker (Employee E13) in July 2024 regarding having the resident transferred closer to where she and the resident are from. The resident's mother reported that she never heard anything back from the social worker at the facility, so when she came up to the facility the Tuesday, Wednesday, and Thursday after Labor Day in September 2024. The resident's mother reported during the interview that on one of the above referenced days that she visited her son, she provided the social worker with a list of 6 facilities and 3 dialysis centers that are in the area of where the resident previously resided prior to his transfer to the facility in July 2024. The resident's mother stated that she was calling up everyday and left voicemail messages for the social worker and the Director of Nursing (DON) to call her back to get an update on the status of Resident R61's discharge, but the resident's mother reported that she did not receive any phone calls back from either individual. Review of the resident's clinical record, including the resident's person-centered plan of care, did not include any evidence of the implementation and documentation of a discharge planning process for Resident R61. During an interview with the social worker on November 7, 2024 at 12:48 p.m. the social worker reported that the discharge plan for the resident was for the resident to be transferred back up to the area where the resident's mother was, and where he originally resided, prior to admission into the facility on [DATE]. The social worker also reported that the resident would also need to be connected to a dialysis center for his treatments The social worker confirmed that there was no documentation in the clinical record, or in the resident's person-centered plan of care related to any discharge plan/planning for the resident that she completed on behalf of the resident. 28 Pa. Code 201.29 (c) Resident rights

Based on review of clinical records, observations, interviews with staff and residents, it was determined that the facility failed to ensure the availability of necessary emergency tool kit for one resident, out of the six residents receiving hemodialysis (R36). Findings include: A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE], with a diagnosis of End Stage Renal Disease. Review of physician order for Resident R36, dated August 26, 2024, indicated an order to receive dialysis on Monday, Wednesday, and Friday. The physician order also indicated for an emergency tool kit (clamp, gauze, and tape) with the Resident R36, at all times during every shift, day shift, and night shift, at bedside. An observation and interview with Resident R36, on November 5, 2024, at 9:44 a.m., revealed there was no emergency tool kit located in the resident's room, or with the resident, or any Emergency Clamp at bedside. Absence of emergency tool kit was confirmed with Resident R36 and a Licensed Nurse, Employee E11, on November 5, 2024, at 9:46 a.m. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required. Findings include: Documentation of notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past six months was requestedon October 1, 2024, at 10:48 a.m. from Employee E2, Director of Nursing (DON). A follow-up telephone call with the Administrator on October 2, 2024, at 11:03 a.m. confirmed that they had received the request, that they were working on this request, and they would send the information electronically by email. A telephone interview with the DON on October 2, 2024, at 1:32 p.m. confirmed that the facility did not have documentation to prove that the facility sent the notification to the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the past six months. She indicated that the facility had been sending this electronically by email though January 2024, and in February 2024, the facility started faxing the information, but did not have the confirmation pages showing the date, time, phone number and number of pages sent. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on January 29, 2024, at 9:55 a.m. with Employee E9, Food Service Director, which revealed the following: Observations in the receiving area revealed piles of cardboard and leaves at the receiving enterance door which allowed pest harborage (conditions or place where pests can obtain water or food, nest, or obtain shelter). Further observation in the receiving area revealed significant amount of cigarette buds (50-100 count), at the door. Interview with the Food Service Director conducted on January 29, 2024, at approximately 10:26 a.m. confirmed the above mentioned findings. Further interview revealed that the food receiving area was also a smoking area for staff and acknowledged that the cigarette buds should have been cleaned up to maintain sanitary conditions in the food receiving area. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on review of clinical records, facility policies and procedures, and facility documentation, it was determined that the facility failed to protect the rights of residents to be free from neglect by not providing the goods and serviced necessary to avoid physical harm and pain related to an improper transfer with a mechanical left device, which resulted in harm, transferred to the hospital and two staples (used to close a wound) to the back of the head for one of 26 residents reviewed (Resident R44) Findings include: Review of the facility's Abuse and Neglect Policy dated (MONTH) 2012, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness and to ensure the prevention of neglect to each resident with a safe and comfortable environment. Review of the facility's Mechanical Lift Policy dated (MONTH) 2014, stated that the mechanical lift is used for moving residents that cannot safely move themselves and are too heavy to be safely lifted by one or two assistants. Two person assist is required. To position a sling correctly, the top of the sling should extend above the resident's shoulders with the bottom of the sling extending to just behind the resident's knees. Guide the resident away from the bed with one staff member supporting the resident and one manipulating the lift. Review of the information dated, (MONTH) 26, (YEAR), submitted by the facility, revealed Resident R44 sustained a fall from the Hoyer (a type of mechanical lift) because two nursing assistants (NA), Employees E11, and E12, did not properly secure the Hoyer sling onto the mechanical lift. Review of the documentation revealed, NA, Employee E11 transferred the resident from her bed to her chair and noticed one side of the Hoyer sling was not connected properly and the resident fell from the Hoyer. Review of the same documentation, revealed, NA Employee E12 indicated she did not secure a sling through a hook and the resident slid from the Hoyer sling onto the floor, where she started to bleed from her head. The nursing note, completed after the fall, revealed the resident complained of head pain and copious amount of blood was observed in the back of the resident's head. The resident was sent out 911 to the emergency room for evaluation and returned to the facility with two staples to the back of her head. An interview on (MONTH) 28, (YEAR), at 5:00 p.m. with Nursing Home Administrator, Employee E1 and Registered Nurse, Employee E10, confirmed that all nursing assistants receive training and education regarding Hoyer lifts and safe transfers during the Orientation process and annually. Each nursing assistant must demonstrate their competency with transferring a resident using a mechanical lift. A review of the skills check for mechanical lifts revealed that step one of the competency was to identify the correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. NA Employee E11 was hired on (MONTH) 20, (YEAR), and completed her mechanical lift competency on (MONTH) 25, (YEAR). Employee E11 also completed her annual competency on (MONTH) 24, (YEAR). NA Employee E12, an orientee, was hired on (MONTH) 10, (YEAR), and completed her mechanical lift competency on (MONTH) 11, (YEAR). The facility failed to protect the rights of the resident from neglect by not providing the goods and services necessary to avoid physical harm, and pain, and failed to ensure the safety and well-being for one resident during care. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/14/17, 03/17/16 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 03/02/17, 02/23/17, 03/17/16 28 Pa. Code 201.18(b)(2) Management Previously cited 04/14/17 28 Pa. Code 201.18(b)(3) Management Previously cited 04/14/17, 03/02/17 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/14/17 28 Pa. Code 211.12(c) Nursing services Previously cited 04/14/17

Based on observations, clinical record reviews, and interviews with facility staff, it was determined that the facility failed to accurately assess, monitor and provide the necessary care and services to prevent the development and to promote the healing of a pressure ulcer for one of nine residents reviewed with pressure sores, causing actual harm to the resident. (Resident R29). Findings include: A review of Resident R29's clinical record revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (endocrine disorder results in an over production of steroids, a hormonal substance in the body which can cause fragile skin that is easily injured) and diabetes (failure of the body to make insulin to enable sugar to pass from the bloodstream to the cells for nourishment). A change of condition Minimum Data Set assessment (MDS-an assessment of resident care needs) dated February 1, 2016, revealed that the resident was cognitively intact, required extensive assisstance of two plus staff members for bed mobility and transfers, required extensive assisstance of one staff member for hygiene and total assisstance of two staff members for bathing and was incontinent of bowels. Review of weekly skin assessment dated [DATE], revealed that the resident had redness and scarring to the left and right lower buttock areas. Interventions for wound prevention included the use of a moisture barrier cream to the sacrum (lower back) and buttocks, and to offload (keep pressure off) the heels. A verbal physician's telephone order for November 27, 2015, directed the staff to cleanse the buttocks with normal saline (a mixture of salt and sterile water), pat dry and cover with a dry dressing. There was no record available for review, at the time of the survey, that documented the size or description of the area being treated. There was no evidence available, at the time of the survey, that preventative measures such as a pressure reducing mattress or wound tracking had been put in place at that time. Review of the Treatment Administration Record (TAR) for November 27, 2015 through January 16, 2016, revealed that the prescribed treatment had been completed 23 times in the fifty day time period. A review of the weekly skin assessments dated December 2, 22 and 29, 2015, indicated that no new areas of impairment had been noted. No weekly skin checks were recorded for the weeks of December 8, 2015, and January 5, 2016. Skin checks completed on January 13 and 15, 2016, recorded no new areas of impairment. Review of a, Skin Grid (a skin alteration identification and tracking tool) dated January 16, 2016, revealed that Resident R29 had a Stage III pressure ulcer (involves full thickness skin loss exposing the tissue) located on the left buttock that measured 3 centimeters (cm) by 4.5 centimeters by 2 centimeters with slough (dead tissue). Facility documentation dated January 16, 2016, revealed that the nursing staff had identified a new area of skin impairment on November 27, 2015, however, had not notified the resident's responsible party or the physician regarding the presence of the skin impairment at that time, had not updated the resident's plan of care, had not documented the wound description or size or had not informed other members of the interdisciplinary team. physician's orders [REDACTED]. A wound consultation dated January 21, 2016, noted that the left buttock pressure wound was now an Unstageable wound (full thickness tissue loss with unknown depth), measured 9 centimeters (cm) by 8.0 centimeters by 2.0 centimeters and the resident was sent to the hospital for surgical debridement (removal of dead tissue). The resident was admitted to the hospital and seen on January 22, 2016, for consultation by an infectious disease physician who noted that Resident R29 had a necrotic (dead tissue) pressure wound to the left gluteal (muscle of the buttocks) with presumed associated ischial (hip bone) osteo[DIAGNOSES REDACTED] (bone infection) and was being treated with two intravenous antibiotics. Nursing documentation indicated that the resident returned to the facility on [DATE]. Resident R29 stated in an interview on March 17, 2016 at 10:00 a.m., that a special mattress (pressure reducing air mattress) had been placed on the resident's bed on January 16, 2016. Resident R29 further indicated that the resident had no feeling or sensation below the waist and that the resident was unaware of the severity of the wound. The facility failed to accurately prevent, identify, assess and monitor a new pressure ulcer for a resident identified at high risk for impaired skin causing actual harm to the resident. 28 Pa Code 211.12(d)(1)(5) Nursing Services. Previously cited 2/29/16, 8/20/15, and 4/3/15. 28 Pa Code 201.18(e)(1) Management. Previously cited 2/29/16. 28 Pa Code 211.5(f)(g) Clinical Records.

Based on observations, review of clinical records, review of facility policy and facility documentation, and staff interviews, it was determined that the facility failed to follow and/or clarify physician's orders [REDACTED]. Findings include: Review of Resident R6's clinical record revealed admitting [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. Observation of Resident R6 on March 16, 2016 at 9:00 a.m., revealed an intravenous catheter (IV), a peripherally (outside, going in) intravenous catheter (PICC line - a PICC line is an extra long catheter inserted into a vein and threaded into a main vein close to the heart, used for long term IV medication use.) Review of Resident R6's transfer records from another facility revealed insertion of this PICC line occurred on February 16, 2016. Review of the facility's undated protocol for use of PICC lines titled,Central Venous Catheter-Physician/Licensed Independent Practitioner Order Sheet, for the proper use of the PICC line, revealed preprinted orders to measure the external catheter length on admission, with each dressing change, and when necessary. The protocol directed staff to notify the physician if the external catheter length had changed since the last measurement. The protocol is followed to ensure proper placement of the catheter prior to medication administration. Review of the clinical record, the Treatment Administration Record (TAR) and the Medication Administration Record [REDACTED]. An interview with Employee E5, licensed nurse, on March 16, 2016 at 1:00 p.m., confirmed these findings. The facility did not follow their protocol, and did not follow the physician's preprinted orders which directed staff to measure the external length of the PICC line on admission and with each dressing change to ensure the proper location of the external IV catheter. Review of the clinical record for Resident R48 revealed that the resident had been readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility documents, Wound Status Reports, (weekly wound measurement and status report) dated January 7, 2016 through March 10, 2016, revealed that Resident R48 was being seen weekly by a Wound Care Practitioner (a CRNP-Certified Registered Nurse Practitioner) for an arterial wound (a wound caused by a lack of blood flow) located on the third toe of the right foot. The Wound Status Report dated January 7, 2016, indicated that the resident's wound to the right third toe measured 1.8 centimeters (cm) long by 1.0 cm wide by 0.0 cm deep. Further review of the, Wound Status Reports revealed that on February 18, 2016, the wound care practitioner had requested that an arterial Doppler (studies which check blood flow) be completed on the resident's lower extremity (foot and leg). A review of the Doppler Arterial Ultrasound report of the right lower extremity completed on February 21, 2016, indicated that, . a possible occlusion (blockage) of the posterior tibial artery (vessel which supplies circulation to the lower leg and foot). Review of the physician's progress notes dated February 27, 2016, revealed a physician's plan for Resident R48 to see a vascular specialist (physician who specializes in circulatory disorders). Further review of Resident R48's clinical record revealed a wound care note dated March 3, 2016, which recommended that the resident have a, . vascular follow-up ASAP (as soon as possible): (due to a) possible occlusion of the tibial artery with a history of a L (left) BKA. Additional wound care documentation on March 10, 2016, revealed that the wound care consultant again noted, *Vascular f/u (follow up) ASAP* possible occlusion per Doppler. Continued review of the Wound Status Reports, dated March 10, 2016, revealed that the resident's wound had increased in size to 2.0 cm long by 2.0 cm wide to 0.2 cm deep. The physician's progress notes dated March 14, 2016, indicated that Resident R48, still needs appointment with vascular. Further review of the clinical documentation for Resident R48 dated February 21, 2016 through March 16, 2016, revealed no documentation that the resident had the vascular consultation completed as requested. A review of the nursing progress notes dated February 21, 2016 through March 16, 2016, revealed no documentation that the staff had been monitoring the status of the circulation to the resident's right lower leg. A review of Resident R48's individualized care plan dated January 11, 2016, and dated as last reviewed March 2016, revealed that the staff had not developed any specific interventions for monitoring the status of the circulation to the resident's right lower leg. An interview with Employee E11, a Licensed Nurse, on March 16, 2016 at approximately 1:30 p.m., revealed that the employee works at the facility full time and that Resident R48 was well known to the employee. Further interview with Employee E11 revealed that the employee was unsure if the resident still had a posterior tibial (back of the knee area) pulse present. Interviews with the Director of Nursing on March 16, 2016 at approximately 10:30 a.m. and at 1:30 p.m., confirmed that the facility staff had not secured an appointment with a vascular specialist for Resident R48 (24 days after the original Arterial Ultrasound) as recommended by the wound care specialist and the resident's attending physician. Further interview with the Director of Nursing confirmed that the staff had not developed or documented any specific interventions for the ongoing monitoring of the impaired circulation to Resident R48's right lower leg. The facility failed to secure a consultation with a vascular specialist in a timely manner resulting in an twenty-four day delay in the evaluation and treatment for [REDACTED]. 483.25 Provide Care/Services for Highest Well Being. Previously cited 8/20/15, 4/3/15, and 4/10/14. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited 4/3/15. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 2/29/16, 4/3/15, and 4/10/14.

Based on a review of clinical documentation, facility policy and procedure and interview with staff, it was determined that the facility failed to adequately assess and monitor the development of a pressure ulcer resulting in harm for one resident (Resident C1). Finding include: A review of Resident C1's admission MDS (Minimum Data Set - assessment of needs) dated October 10, 2011 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also indicated that the resident was alert and oriented (Brief Interview for Mental Status 15/15) and required extensive assistance for transfers, ambulation and hygiene. A nursing skin assessment completed on October 3, 2011 indicated that the resident was admitted with a Stage II (a partial thickness skin loss) sacral pressure ulcer that measured 2 cm. by 1 cm. A review of physician's orders dated October 3, 2011 indicated that the physician ordered that the wound be cleansed and a dressing be applied to absorb the drainage (Allevyn). A Braden Scale (a tool used to determine risk factors for pressure ulcer development) dated October 3, 2011 indicated that the resident was at a high risk to develop a pressure ulcer. Review of a care plan dated October 3, 2011 indicated that staff was to complete a PUSH Tool (a tool to monitor change in pressure ulcer status over time) weekly and complete the Braden scale weekly for four weeks. There was no evidence that either of these assessments had been completed as scheduled. A review of the facility weekly pressure/stasis ulcer wound report, dated October 13, 2011, indicated that the wound on the resident's sacrum measured 4.5 cm. by 4.0 cm. and had drainage. A review of the facility weekly pressure/stasis ulcer report, dated October 19, 2011, indicated that the resident's wound on the sacrum now measured 9.0 cm. by 5.0 cm. with drainage. Review of the facility's weekly pressure wound report dated November 2, 2011, indicated that the resident's sacral wound measured 9 cm. by 6 cm. by 7 cm .deep and had been debrided (a surgical procedure to remove dead skin). There was no evidence between October 19, 2011 and November 2, 2011, that indicated the facility was adequately monitoring and thoroughly assessing the change in the status of the wound which increased in size over that period of 20 days. There was no indication in either the physician's progress notes or nurse's progress notes regarding who had debrided the wound or when the wound had been debrided. There was no documentation that indicated that the family had been notified of the change in the resident's wound. The first entry of the facility's skin grid, dated November 28, 2011, indicated that the resident's sacral wound measured 8 cm. by 9 cm. by 4 cm. deep and had a foul odor. There was no evidence that the physician had been notified that the wound was identified with a foul odor. There was no evidence that the weekly skin grid had been completed prior to November 28, 2011. Review of Nursing documentation, dated November 29, 2011 at 5:00 p.m., revealed that per the family's request, the physician ordered a CBC (complete blood count test). The written result, dated November 30, 2011, indicated that the resident's white blood count was high (an indicator of an infection). Nursing documentation dated December 4, 2011 revealed that family members expressed concern regarding the smell of the resident's wound. Nursing documentation dated December 5, 2011 at 7:00 p.m. revealed that the resident was transferred to the hospital and was admitted related to the sacral wound. Review of the facility policy and procedure Weekly Skin Assessments indicated that the staff was to monitor areas of skin impairment using the Skin Grid and to document significant changes in the nursing progress notes and to notify the responsible party and to document the notification. There was no evidence that the facility was adequately assessing or monitoring the residents sacral wound on a consistent basis or that the responsible party had been notified of the deteriorating condition of the resident's wound. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 3/11/11