Every finding on record at Stonebridge Health & Rehabilitation Center

Based on observations, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 18 residents reviewed (Resident 11). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included COPD (chronic obstructive pulmonary disease- a progressive, inflammatory lung disease that blocks airflow and makes breathing difficult) and anxiety. During an interview with Resident 11 on June 8, 2026, at 10:34 AM, Resident 11 stated that she was missing her left hearing aid. Observation of Resident 11 at that time revealed she did not have a hearing aid in either ear. Review of facility's grievance log revealed a grievance filed by Resident 11, on January 6, 2026, stating that Resident 11 was missing her hearing aid. The grievance did not specify if it was the right or left hearing aid that was missing. The plan was for the facility to replace the hearing aid. Further review of the grievance form revealed that Resident 11 decided she no longer wanted the hearing aid replaced and stated she didn't wear either hearing aid. Resident 11 signed the grievance resolution on February 9, 2026. During an interview with the Nursing Home Administrator (NHA) on June 9, 2026, at 2:07 PM, he stated he believes it was the left hearing aid that went missing. He stated that Resident 11 still has her other hearing aid but that she doesn't wear it. Review of Resident 11's current physician orders revealed an order, dated June 30, 2025, to assist Resident 11 with left hearing aid placement in the AM and removal in the PM. Review of Resident 11's MARs (medication administration record), dated January, February, March, April, May and June 2026, revealed nursing staff were signing off on each day that they were assisting Resident 11 with left hearing aid placement in the AM and removal in the PM, with the exception of the following dates: January 15, 16 and 17 was documented as the placement being held, and January 15 and 16 was documented as the removal being held. June 6 the removal was documented as other, and June 7 the removal was documented as other and that the Resident claimed she lost them. In a follow up interview with Resident 11 on June 10, 2026, at 11:04 AM, Resident 11 again stated that it was the left hearing aid that was missing. Resident 11 was observed not to be wearing any hearing aid at that time. Resident 11 pulled out her right hearing aid that was located in its case in her top nightstand drawer. Resident 11 stated she doesn't wear the right hearing aid because she was able to hear out of that ear. On June 10, 2026, at 11:07 AM, clinical record review revealed that Employee 5 (Licensed Practical Nurse) had signed off on Resident 11's MAR, on June 10, 2026, day shift, that assistance was provided with placement of the left hearing aid. During a staff interview with Employee 5 on June 10, 2026, at 11:11 AM, the surveyor asked Employee 5 about Resident 11's hearing aid, since Resident 11 was just observed to not be wearing any hearing aids and the left one was missing. Employee 5 stated that she didn't know anything about the resident's hearing aids. Review of Resident 11's MAR, dated June 2026, revealed that in addition to Employee 5 signing off on the left hearing aid on June 10, 2026, Employee 5 also signed off that the left hearing aid was in place six other times in June, prior to June 10. On June 10, 2026, at 11:36 AM, the NHA stated that it has been verified that it was Resident 11's left hearing aid that was missing. In a follow up interview with the NHA on June 10, 2026, at 1:00 PM, he confirmed that since January 2026, staff have continued to sign off on Resident 11's left hearing aid, even though it was reported missing in January and was not replaced. The Director of Nursing stated that the order has been discontinued and the care plan has been updated. In a final interview with the NHA on June 11, 2026, at 11:22 AM, he stated that he would expect staff to not sign off on the MAR that the left hearing aid is in place when it is not. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident right to receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 18 residents reviewed (Resident 1). Findings include: Review of facility policy, titled Cardiopulmonary Resuscitation CPR Policy last reviewed March 16, 2026, read, in part, At admission, facility staff should confirm whether the resident has advance directives and identify the resident/legal representative's preferences regarding CPR (Cardiopulmonary Resuscitation, an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating). This review may occur as part of the admission assessment. If physician order(s) differ from the resident's wishes or there are no physician orders present: Promptly contact the provider for an appropriate order. Review of Resident 1's clinical record revealed diagnoses that included unspecified severe protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets) and gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally). Review of Resident 1's physician orders revealed an order for Code Status: Full Code (a medical order indicating that all life-saving interventions should be attempted if a patient's heart stops or they stop breathing, including CPR) with a start date of May 20, 2026. Review of Resident 1's care plan revealed a focus area Resident has chosen to be a full code with an intervention for Resident's code status will be honored daily through next review, with a start date of May 22, 2026. Review of Resident 1's POLST form (Physician Orders for Life Sustaining Treatment- is a medical order that allows seriously ill or frail individuals to specify the types of medical treatment they want during emergencies), revealed under the CPR section it was marked DNR (Do Not Resuscitate- a medical order indicating that a person does not want CPR or other life-saving measures if their heart or breathing stops). During an interview with the Director of Nursing (DON) on June 9, 2026, at 2:19 PM, she acknowledged there was a discrepancy between the physician order and the POLST form, and she was going to get it clarified immediately. Interview with Employee 2 (Licensed Practical Nurse) on June 9, 2026, at 2:21 PM, she revealed if there was a discrepancy between the physician order for a code status and the POLST form, she would go by the physician's order in the electronic health record. Interview with Employee 3 (Licensed Practical Nurse) on June 9, 2026, at 2:23 PM, she revealed if there was a discrepancy between the physician order for a code status and the POLST form, she would go by the physician's order in the electronic health record. During an interview with Resident 1 on June 9, 2026, at 2:29 PM, he revealed in the event he went unresponsive and needed emergency life sustaining treatment, he would want CPR. Review of Resident 1's clinical record on June 9, 2026, at 2:36 PM, revealed his physician order from full code had switched to DNR, and his chart was flagged with DNR rather than full code. Interview with the DON on June 9, 2026, at 2:41 PM, she revealed she changed his code status order to a DNR while it was getting clarified so it would match the POLST form signed by the Resident. Interview with Employee 4 (ADON- Assistant Director of Nursing) on June 9, 2026, at 2:45 PM, she revealed she just spoke with Resident 1 and he confirmed he would like to be a full code, so she was fixing the orders, updating his POLST, and putting a note into the electronic health record. Review of Resident 1's nursing progress notes revealed a note written on June 9, 2026, at 2:37 PM, that read Reviewed POLST with resident. Resident wishes to be a Full Code. This ADON and DON witnessed resident sign updated POLST indicating he wishes to be a full code. Orders / Facesheet / POLST all now reflect Full Code/ CPR. Phone call placed to Responsible Party to notify. During a follow up interview with the DON on June 10, 2026, at 1:06 PM, she revealed she would expect POLST forms, resident wishes, and physician orders for code status to be consistent across records. 28 Pa. Code 201.29 (a) Resident Rights28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement transmission-based precautions to prevent the spread of infection for one of two residents (Resident 36) on transmission-based precautions.Findings Include: Review of facility policy, titled Transmission-Based Precautions and Isolation Policy, revised April 15, 2026, revealed, Contact Precautions - intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. Review of Resident 36's clinical record revealed diagnoses that included giardia (an infection of the small intestine) and urinary tract infection (UTI- is a bacterial infection in the urinary system [kidneys, bladder, or urethra]). Observation of Resident 36 on June 9, 2026, at 8:50 AM, revealed Resident 36 lying in her bed. Hanging on the wall outside of Resident 36's room was a sign indicating that Resident 36 was on contact precautions and that anyone entering the room was required to put on gloves and a gown, and then remove the gloves and gown before exiting the room. Further observation at that time revealed Employee 1 entering the room without applying any of the required PPE (personal protective equipment) to administer Resident 36's medications. Review of Resident 36's care plan revealed a care plan with a problem area that Resident 36 started on antibiotics for giardia with an intervention of transmission-based precautions as ordered, with a start date of May 28, 2026. Interview with the Nursing Home Administrator on June 10, 2026, at 11:10 AM, revealed that he would expect employees to wear the required PPE. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 8).Findings include: Review of facility policy, titled Restorative Nursing Referral Process & Policy last reviewed February 24, 2026, read, in part, Procedure: The referral form is filled out by the referring therapist and given to the Director of Rehab. Residents who could benefit from restorative programs (RNP) include but are not limited to: residents who are ready to finish a program of skilled rehabilitation therapy. Referral to restorative should be generic, not complicated, or should be reconsidered to stay on therapy. Review of Resident 8's clinical record revealed diagnoses that included infection and inflammatory reaction due to internal right hip prosthesis (infection of artificial hip joint that can cause pain and swelling) and generalized osteoarthritis (when protective cartilage that cushions the ends of the bones wears down over time). Review of Resident 8's Physical Therapy Discharge Summary signed on May 28, 2026, read, in part, Discharge Recommendations: Patient is being discharged due to reaching max potential at this time. It is recommended for him to continue working on maintaining progress with RNP for transfers and lower extremity exercises. Review of Resident 8's Restorative Program Referral documents revealed he was recommended to start a program for stand pivot transfers and range of motion on May 28, 2026. During an interview with the Director of Nursing (DON) on June 10, 2026, at 1:39 PM, she revealed the RNP program never got implemented into the medical record to capture documentation related to minutes completed and tolerance to the program, so she does not have any documentation to provide that the RNP program had been implemented. During an interview with Employee 2 (Licensed Practical Nurse) on June 11, 2026, at 9:12 AM, she revealed she typically spends one day a week at the facility updating and integrating restorative programs into the electronic health record once the therapists fill out an order sheet for her, but due to short staffing, she has been responsible for other duties such as being assigned to a medication cart on those days, so she was unable to transcribe Resident 8's RNP program to his chart and care plan. She further revealed she told the Resident to keep track of his RNP exercises, such as what he is doing and how often on his own. During an interview with the DON on June 11, 2026, at 11:39 AM, she revealed she was going to educate the therapy staff that they can come to her to transcribe recommendations for RNP programs into resident health records and care plans, and she would expect RNP programs to be entered into the electronic system and implemented timely. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for two of two residents observed; failed to ensure staff implemented infection control policies to prevent the spread of infection for one of 19 residents reviewed; and failed to maintain an accurate data collection system of infection surveillance from October 2024 through March 2025. Findings Include: Review of facility policy, titled 6.0 General Dose Preparation and Medication Administration, last revised November 15, 2024, revealed it stated, 1.2 Medications should not come in contact with any surface except for the medication cup .2.3 Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package . Review of facility policy, titled Enhanced Barrier Precautions (EBP) Policy, revised May 19, 2025, revealed EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. The policy further stated, in part, that high-risk residents include those with chronic wounds and high contact care activities include wound care. Further review of the policy revealed Staff engaging in high-contact activities will don both gloves and gown before initiating the activity . and that a sign will be placed on the resident's door indicating the appropriate type(s) of precautions. During medication administration observation on July 1, 2025, between approximately 8:54 AM and 9:10 AM, Employee 1 (Licensed Practical Nurse) was observed preparing and administering medications to Residents 18 and 38. During the medication preparation for Resident 18, Employee 1 was observed dispensing a medication from the medication card (tablets packed in individual blisters with paper backs to be punched out during preparation) directly to Employee 1's bare hand and then into the medication cup. During medication preparation for Resident 38, Employee 1 was observed dispensing a medication from the medication card, the medication tablet landed on the fingers of Employee 1's left hand, at which time Employee 1 dropped the medication tablet into the medication cup. During a staff interview on July 2, 2025, at approximately 11:40 AM, Nursing Home Administrator (NHA) confirmed that staff should follow the facility's policy on medication preparation and administration and not touch medications with their bare hands. Review of Resident 44's clinical record revealed diagnoses that included an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to the sacrum (triangular bone at the base of the spine) and hypertension (elevated blood pressure). Observation of Resident 44's room on June 30, 2025, at 9:47 AM, and July 1, 2025, at 9:59 AM, revealed no signage on Resident 44's door indicating that Resident 44 was on EBP. Observation of Resident 44's wound care to her pressure ulcer, on July 1, 2025, at 10:00 AM, revealed Employee 2 wearing gloves, but no gown, while performing Resident 44's wound care. At the conclusion of Resident 44's wound care, Employee 2 was asked if Resident 44 should be on EBP. Employee 2 stated that she thought she should have worn a gown, but there was no sign on Resident 44's door for EBP. Observation of Resident 44's room on July 1, 2025, at 11:06 AM, revealed a sign had been placed on Resident 44's door, indicating she was on EBP. During an interview with the NHA and Director of Nursing (DON) on July 1, 2025, at 1:04 PM, the DON confirmed that Resident 44 should have been on EBP and a gown should have been worn during Resident 44's wound care. Review of facility form, titled Antibiotic Use Tracking Log, revealed data to be collected and documented each month included, in part, resident's name and room number, admission date, infection type, onset date, signs and symptoms, how/where the infection was acquired, labs, imaging, antibiotic information, and any isolation. Review of the facility's Antibiotic Use Tracking Log forms for August 2024 through June 2025, revealed no tracking was completed for October 2024 through March 2025. During an interview with the NHA and DON on July 2, 2025, at 11:36 AM, the DON confirmed that the Antibiotic Use Tracking Log form was not completed for the months of October 2024 through March 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28. Pa Code 211.12(d)(1)(2)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed for mobility (Resident 48). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included stroke and elevated blood pressure. Review of Resident 48's current physician orders revealed an order, with a start date of October 15, 2024, for left hand splint, on at all times, may remove for care and to remove splint every shift to observe and monitor for skin breakdown. Review of Resident 48's current care plan revealed left hand splint on at all times, remove splint every shift and observe and monitor for skin breakdown, dated October 15, 2024. Observations of Resident 48 on June 30, 2025, at 10:14 AM, 12:37 PM, 1:39 PM, and on July 1, 2025, at 11:04 AM and 12:05 PM, revealed Resident 48's left hand splint was not in place. During an interview with Resident 48 on July 1, 2025, at 11:04 AM, Resident 48 stated that she does have a splint but they haven't put it on. At this time, a black splint was observed in a basket on Resident 48's bedside dresser. Review of Resident 48's Medication Administration Record (MAR) dated June 2025, revealed that Resident 48's splint was signed off as being on, on each shift, each day, with the exception of night shift on June 6 and 9, and evening shift on June 24 and 28. It was signed off as being refused by the Resident on those shifts. Review of Resident 48's MAR for July 2025, revealed the splint was signed off as being on on day shift on July 1, 2025. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 2, 2025, at 10:20 AM, the DON stated that on May 1, 2025, there is a progress note stating that the splint was put on hold due to swelling and that therapy discontinued the splint. The DON also stated she was unable to state why staff were documenting placement of the splint, when it was not applied. Review of Resident 48's nursing progress notes revealed a note on May 1, 2025, at 12:02 AM, stating that the Resident's hand splint was on hold due to swelling. Review of Resident 48's nursing progress note on May 1, 2025, at 11:35 AM, revealed that the left hand swelling had decreased, the splint was in place and the Resident was tolerating it well. Review of additional nursing progress notes on May 2, 2025, at 2:30 PM and 6:02 PM, revealed documentation that Resident 48's splint was in place. Review of Resident 48's Occupational Therapy (OT) evaluation and plan of treatment, dated June 3, 2025, revealed to continue with left hand wrist/forearm resting hand splint. Review of Resident 48's facility form titled Rehabilitation Services Screening, dated July 1, 2025, revealed that OT was discontinued on June 30, 2025, and the left hand splint is not needed. Review of a nursing progress note dated July 2, 2025, at 8:51 AM, revealed that, in speaking with the director of rehab, the splint has been discontinued due to swelling and increase in pressure caused by the splint. There is no evidence that the splint was to be discontinued prior to July 1, 2025, and no orders for the splint to be put on hold. In a follow-up interview with the NHA and DON on July 2, 2025, at 11:35 AM, no additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 16 residents reviewed (Resident 47). Findings include: Review of Resident 47's clinical record revealed diagnoses that included chronic kidney disease (a gradual loss of kidney function) and hyperlipidemia (high levels of fat in the blood). Review of Resident 47's clinical record revealed an active physician's order for prevalon boots on at all times every shift, with a start date of October 9, 2024. Observations of Resident 47 on June 30, 2025, at 12:15 PM and 2:16 PM, revealed the Resident was sitting in their wheelchair wearing sneakers instead of prevalon boots. Observation of Resident 47 on July 1, 2025, at 12:03 PM and 2:26 PM, revealed the Resident sitting in their wheelchair wearing sneakers instead of prevalon boots. Review of Resident 47's Medication Administration Record (MAR) for June 30, 2025, revealed that Resident 47 was marked off as having prevalon boots on during day, evening, and night shift. Review of Resident 47's MAR for July 2025, revealed the Resident was marked off as having her prevalon boots on during the day shift. Review of Resident 47's comprehensive care plan revealed a problem area for skin integrity, that the Resident is at risk for impaired skin integrity related to impaired mobility, cognitive deficits, incontinence, depression, and prescribed medications, with a problem start date of August 14, 2024, and an edited date of November 13, 2024. Further review of Resident 47's care plan revealed an approach area to wear prevalon boots at all times, with a start date of August 21, 2024, and an edited date of October 10, 2024. Review of Resident 47's clinical record revealed the Resident had a consult with a foot and ankle doctor on October 9, 2024, who gave the recommendation for the Resident to wear a prevalon boot to right foot daily at all times. Review of Resident 47's clinical record revealed a nursing progress note written on July 2, 2025, at 8:55 AM, with the following text: after reviewing prevalon boot order for the resident, the resident had heel skin alteration when admitted and prevalon boots were in place for this - heels are now completed healed and resolved. Family had provided shoes after heels healed that they wanted the resident to wear. Review of Resident 47's clinical record revealed the Resident had a stage 3 pressure wound to their right heel that has been resolved as of November 13, 2024. Review of Resident 47's clinical record on July 2, 2025, at 11:30 AM, revealed the order for prevalon boots was removed as well as the approach area on their care plan to wear prevalon boots at all times. Review of Resident 47's clinical record failed to indicate that the Resident or family preferred Resident 47 to wear the sneakers that were provided by the family daily instead of the prevalon boots that were ordered and recommended from the physician prior to July 2, 2025. Interview conducted with the Nursing Home Administer on July 2, 2025, at 11:41 AM, revealed he would have expected staff not to be documenting Resident 47 wearing prevalon boots if they were not, Resident 47's physician order to have been updated, and the care plan to have been updated at the time the family requested the Resident to wear shoes they brought in for her instead of prevalon boots. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide routine drugs and biologicals to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three of seven residents reviewed (Residents 1, 2, and 3). Findings include: Review of facility policy, titled Delivery and Receipt of Routine Deliveries subsection Long-Term Care Facilities Receiving Products and Services from Pharmacy last revised August 1, 2024, read, in part, Receipt of Medications and Supplies: A facility nurse should inspect the package(s) for any damage or errors and notify pharmacy as soon as possible but within twenty-four hours of any damage or other discrepancies. If any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy slip explaining the reason a medication or item was not delivered. Facility should contact pharmacy if facility requires an explanation for the missing items or medications and document any delivery discrepancies. Review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included orbital eye cellulitis (a serious bacterial infection that affects the fat and muscle tissue within the eye socket) and other lower back pain. Review of Resident 1's clinical record revealed he had physician orders for cefepime (antibiotic medication) via intravenous infusion (IV infusion- medication and fluid that is administered directly into a vein), three times daily, with a start date of February 12, 2025, and to be completed on February 26, 2025. Review of Resident 1's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored) revealed it was noted he failed to receive four administrations of his IV antibiotic between when he was admitted to the facility and the next day, with corresponding notes that the medication was unavailable. Review of Resident 1's nursing progress notes revealed a note written by Employee 6 (Registered Nurse) on February 13, 2025, at 1:57 PM, that stated, IV medications arrived from pharmacy at this time, provider updated on missed doses from this morning. New order to extend IV antibiotic for additional doses not received this morning. It was not noted that the provider was made aware of the missed doses on February 12, 2025. Further review of Resident 1's physician orders revealed he had an order for MS Contin (morphine pain medication) tablet extended release, 15 mg, twice a day, and Morphine concentrate solution, three times a day, with a start date of February 12, 2025. Further review of Resident 1's MAR revealed the MS Contin was not administered on February 12, 2025, and three doses of the morphine concentrate solution were not administered between his admission and his AM dose on February 13, 2025. Review of Resident 1's nursing progress notes revealed a note written by Employee 6 on February 13, 2025, at 8:07 PM, that states she spoke to the pharmacy who stated MS Contin is unavailable on backorder and that the doctor was notified. The doctor ordered to discontinue the MS Contin and start Oxycodone, but that the Resident declined the Oxycodone, and stated he would just take the liquid morphine and hydrocodone (pain medication) that were available starting on February 13, 2025. Review of Resident 2's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of prostate (malignant tumor involving the prostate gland) and generalized weakness. Review of Resident 2's clinical record revealed he had a physician order for Casodex (an anti-androgen, it works in the body by preventing the actions of androgens or male hormones), with a start date of March 16, 2025. Review of Resident 2's MAR revealed it was noted he failed to receive two administrations of the Casodex with corresponding notes that the medication was unavailable on March 16 and 17, 2025. Review of Resident 3's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors) and multiple sclerosis (an autoimmune disease that affects the central nervous system). Review of Resident 3's clinical record revealed the following physician orders: Lacosamide (a medication used to treat seizures) 200 mg, twice a day, take with 50 mg tab twice a day, with a start date of April 7, 2025. Lacosamide 50 mg, twice a day, take with 200 mg tab twice a day, duration 30 days, with a start date of April 7, 2025. Review of Resident 3's MAR revealed it was noted she failed to receive two administrations of both orders of the Lacosamide, from when she was admitted to the facility and the next day, with corresponding notes that the medication was unavailable. Review of Resident 3's nursing progress notes revealed an admission note written by Employee 1 (Registered Nurse) on April 7, 2025, at 7:27 PM, that read, in part, Resident arrived to facility at 2:24 PM. All medications arrived STAT (without delay or immediately) to facility except Lacosamide. Further review of Resident 3's nursing progress notes revealed a note written by Employee 6 on April 8, 2025, at 9:04 PM, that stated, Spoke with provider and made aware of not receiving 50 mg dose of Lacosamide from pharmacy. Lacosamide 200 mg dose arrived from pharmacy this evening. Per provider, resident to receive Lacosamide 200 mg dose this evening. Spoke with pharmacy, 50 mg dose will be delivered on late pharmacy run. Interview with Employee 1 on April 9, 2025, at 11:43 AM, revealed they sometimes have issues with delayed medication deliveries or order discrepancies, but that it is the responsibility of the nursing staff to address these issues with the pharmacy and/or doctor when they are discovered. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on April 9, 2025, at 2:15 PM, the surveyor revealed the concern with the delay in the medication deliveries and administrations for Residents 1, 2, and 3. In addition, the surveyor requested information as to the delay in contact with the pharmacy and/or doctor when the medications were initially noted to be unavailable, why the medications were unavailable for extended periods, if any delivery discrepancies were documented for review, and to provide information related to the medication delivery schedule from the pharmacy. Review of select facility documentation provided from the pharmacy, revealed scheduled medication delivery for new orders and admissions are as follows: Pharmacy departure on Monday through Friday at 11:30 AM and 12:30 AM overnight; and Saturday, Sunday, and Holidays at 1:00 PM. During a follow-up interview with the NHA and DON on April 10, 2025, at 2:03 PM, the DON revealed that in the case of the IV antibiotic medication, they had the medication onsite, but in a different dose, so they should have reached out to the doctor on the day he was admitted to see if he could utilize that until his proper dose arrived from pharmacy. The NHA and DON revealed they were unable to provide information related to the delay in medications delivered to the facility, as there are various delivery times from pharmacy. They further revealed they would be meeting with the pharmacist to evaluate their in-house medication stock; and revealed their expectation that medications would be available timely to meet the needs of each resident, and the doctor would be notified of discrepancies, delays, or medications unavailable from pharmacy. 28 Pa. Code 211.9(d)(2) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 6). Findings include: Review of facility policy, titled Clean Dressing Change Policy last revised, March 10, 2024, read, in part, Wounds will be dressed using a clean technique which avoids direct contamination of material and supplies. Apply new dressings as ordered. Document procedure and update findings. Review of Resident 6's clinical record revealed diagnoses that included pressure ulcer of right heel (wound that occurs when the skin and tissue are damaged by prolonged pressure) and osteoarthritis (a type of arthritis that affects the joints in your body). Review of Resident 6's physician orders revealed the following pressure wound order: Treatment as follows: Cleanse right heel with soap & water, pat dry. Apply betadine then calcium alginate to base of wound, secure with ABD (abdominal pad), three times a day, with a start date of March 26, 2025. Review of Resident 6's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored), revealed his treatments were documented as not administered during night shift on March 31, 2025; and April 1 and 8, 2025. During an interview with the Director of Nursing (DON) on April 10, 2025, at 2:11 PM, revealed she spoke with Employee 2 (Licensed Practical Nurse) who stated she did not administer the treatments because it was noted on the evening shift on March 31, 2025, that the wound treatment order needs clarified. However, no one reached out to clarify the order throughout the week, so she just continued to not administer. The DON further revealed she would expect wound treatments to be administered as ordered and clarified timely if needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living for two of six residents reviewed (Residents 3 and 4). Findings Include: Review of the facility policy, titled Resident Bath/Showering/Scheduling Policy with a last revised date of September 9, 2022, revealed (A) Each resident will be asked about his/her bathing preferences upon admission (type of bath, preferred days and times), (H) If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report this to the Charge Nurse, and (I) The Charge Nurse will speak with the resident who refuses to ascertain why they are refusing and to determine if alternate arrangement that suit the resident can be made. If the resident continues to refuse the Charge Nurse document the resident's refusal in the medical record. Review of Resident 3's clinical record revealed diagnoses that included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood) and hypertension (high blood pressure). Review of Resident 3's clinical record revealed their shower days are on every Wednesday and Saturday. Review of Resident 3's clinical record failed to reveal their bathing preference. Review of Resident 3's current care plan revealed a problem area that the Resident is unable to effectively communicate related to dementia, hearing loss. Mostly non-verbal, speaks in non-sensical sentences, gibberish, unable to follow commands, unable to answer simple yes/no questions appropriately, created on August 14, 2024. Review of Resident 3's Activities of Daily Living (ADL's) type of bath task from March 1, 2025, through April 2, 2025, revealed that the Resident received a bed bath on their scheduled shower days on March 1, 5, 8, 15, 22, 26, 29, 2025, and on April 2, 2025. Review of Resident 3's progress notes from March 1, 2025, through April 2, 2025, failed to reveal any notes indicating a shower refusal on the dates listed above. Review of Resident 4's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hypertension. Review of Resident 4's Quarterly MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes), dated February 11, 2025, revealed the Resident had a BIMS (brief interview for mental status) of 7, which indicates severe cognitive impairment. Review of Resident 4's clinical record revealed their shower days are on every Tuesday and Friday. Review of Resident 4's clinical record failed to reveal their bathing preference. Review of Resident 4's ADLs type of bath task from March 1, 2025, through April 2, 2025, revealed that the Resident received a bed bath on their scheduled shower days on March 4, 7, 11, 14, 18, 21, 25, and 28, 2025, and April 1, 2025. Review of Resident 4's progress notes from March 1, 2025, through April 2, 2025, failed to reveal any notes indicating a shower refusal on the dates listed above. During an interview with the Assistant Director of Nursing (ADON) on April 2, 2025, at 10:20 AM, revealed that the expectation is for staff to ask the resident every shower day what type of shower the resident prefers. Further, if the residents refuse a shower, the staff are to reapproach the resident and, if they refuse again, the staff are to inform the Licensed practical nurse (LPN). The LPN is then to document the resident's shower refusal and give them a bed bath. During a further interview with the ADON on April 2, 2025, at 12:13 PM, revealed the expectation is for staff to be providing non-verbal residents with showers unless they are giving non-verbal cues of refusing a shower on their shower day, and, if that occurs, they are to inform the LPN and give the resident a bed bath and document the refusal in a progress note. During an interview with the Nursing Home Administrator on April 2, 2025, at 2:02 PM, he revealed he would expect residents to be receiving showers on their shower days and staff to be documenting refusals. 28 Pa Code 211.12(a)(c)(d)(1)(3)(5)Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents reviewed for mobility (Resident 22). Findings Include: Review of Resident 22's clinical record revealed diagnoses that included hypertension (elevated blood pressure), congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview with Resident 22 on June 10, 2024, at 10:38 AM, she stated that she wants to walk at least once a day, but stated that staff don't always assist her in doing so. During the resident group interview on June 11, 2024, at 11:00 AM, Resident 22 again expressed concern with her walking program and not being assisted with walking every day. Review of Resident 22's facility form, titled Restorative Ambulation Program Referral, dated January 23, 2024, revealed goals/objectives for Resident 22 to walk in cooridor with assist of one and to walk 50 feet. Review of Resident 22's restorative nursing order revealed an order dated April 10, 2024, for a walking goal- Resident will ambulate 50 feet per day in hallway with one-person assist and front wheeled walker. Review of Resident 22's current care plan revealed an intervention dated May 16, 2024, that Resident will ambulate 50 feet per day in hallway with one-person assist and front wheeled walker. Review of Resident 22's restorative nursing documentation for walking dated April 2024, revealed that on April 10, 2024, it was documented as not performed. Review of Resident 22's restorative nursing documentation for walking dated May 2024, revealed that on May 8 and 12, 2024, there is no documentation of Resident 22 walking; and on May 25, 2024 it was documented as not performed. Review of Resident 22's restorative nursing documentation for walking dated June 2024, revealed that on June 7 and 8, 2024, there is no documentation of Resident 22 walking. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 12, 2024, at 2:12 PM, they were made aware of Resident 22's statements regarding not being walked every day and asked about the restorative documentation on the aforementioned days. In a follow-up interview with the DON on June 13, 2024, at 9:45 AM, she stated that the facility recently changed providers for their electronic medical records and staff are still getting used to documenting in the new system. She stated that that could be the reason for the missing documentation or being documented as not performed. On June 13, 2024, at 10:15 AM, the NHA was again made aware of Resident 22 stating staff do not assist her to walk every day and the documentation supporting that interview. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary for one of three closed records reviewed (Resident 55). Findings Include: Review of facility policy, titled Discharge Planning Policy, revised September 24, 2020, revealed When a discharge is anticipated, [Facility] will develop a discharge summary/instructions that includes, but is not limited to, the following: .Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter.) Review of Resident 55's clinical record revealed diagnoses that included cerebral infarction (stroke - occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and anxiety (a feeling of fear, dread, and uneasiness). Further review of Resident 55's clinical record revealed that he was discharged from the facility to home on May 31, 2024. Review of Resident 55's discharge summary dated May 31, 2024, failed to reveal a reconciliation of all pre-discharge medications with the Resident's post-discharge medications. During an interview with the Director of Nursing on June 13, 2024, at 9:50 AM, she confirmed that Resident 55's discharge summary did not contain his medication reconciliation. 28 Pa. Code 211.5(f)(x) Medical Records 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on review of facility policy, observations, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 21 residents on transmission-based precautions (Residents 46). Findings include: Review of facility policy, titled Transmission-Based Precautions Isolation Policy, revised April 15, 2024, read, in part, contact precautions also apply where there is urinary incontinence or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (gloves, gown, face mask, face shield) recommended: gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. Gowns whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces. Review of Resident 46's revealed diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking), Methicillin resistant Staphylococcus aureus infection (MRSA-Bacterial infection that is resistant to antibiotics and can be difficult to treat), contractures right and left hands (condition of shortening of muscles, tendons or other tissue leading to deformity and hardening of joints), and urinary tract infection (UTI). Observation of Resident 46's door revealed a contact precaution sign that read, in part: clean hands, including before room entry and when leaving the room; put on gloves and gown before entry and discard before exiting the room. Review of Resident 46's physician orders included contact isolation related to MRSA and proteus mirabilis (a bacterial infection), with a start date of June 10, 2024. Urinalysis dated May 16, 2024, revealed MRSA. Urinalysis dated June 6, 2024, revealed proteus mirabilis. Further clinical record review revealed Resident 46 is incontinent of urine. Observation on June 10, 2024, at 12:12 PM, revealed a contact precaution sign was on the door to Resident 46's room. Employee 1 (Nursing Assistant) entered Resident 46's room to serve lunch; touched the overbed table to position it closer to the Resident, and provided meal set up. Employee 1 failed to don gloves prior to entering Resident 46's room or assisting with meal set up, however, did utilize hand sanitizer upon exiting the room. Observation on June 11, 2024, at 12:20 PM, revealed Employee 2 (Nursing Assistant) entered Resident 46's room to serve lunch; touched the overbed table to position it closer to the Resident and provided meal set up, went into the hallway, retrieved a clothing protector from the linen cart, and then assisted Resident 46 with the clothing protector. Employee 2 failed to don gloves prior to entering Resident 46's room or assisting with meal set up and the clothing protector; and failed to complete hand hygiene both times when exiting the room. Employee 2 then went to C- hall, without completing hand hygiene, opened the food cart, obtained a lunch tray, entered Resident 7's room, served lunch, and assisted with tray set up. Employee 2 exited Resident 7's room without completing hand hygiene, went to the beverage cart, poured hot water, inserted a tea bag, and then served the hot tea to Resident 7. After exiting the room, Employee 2 went to the restroom to wash her hands. During an interview with Employee 3 (Registered Nurse) on June 12, 2024, at 11:30 AM, it was revealed that Resident 46 had tested positive for MRSA in his urine; most recent culture was positive for proteus mirabilis (bacterial infection). It was also revealed that she would expect staff to utilize Personal Protective Equipment (PPE-gloves, gown) and complete hand hygiene after doffing PPE and after serving each resident their meal, regardless if PPE was worn. It was further revealed that serving a meal to a Resident on contact precautions doesn't require full use of gloves and a gown, however, if surfaces are touched or contact is made with the Resident, at least gloves should be worn. Additionally, if there is a potential for staff's clothing to come into contact with the Resident or a surface, a gown should be worn. During an interview with Nursing Home Administrator and Director of Nursing on June 12, 2024, at 2:16 PM, the surveyor informed them of concerns with failure to utilize PPE and complete hand hygiene during meal service for Resident 46. No additional information was provided. During an interview with Director of Nursing on June 13, 2024, at 9:39 AM, it was revealed that if resident care wasn't provided and no resident contact was made, she wouldn't expect hand hygiene to be performed. It was also revealed that, because Resident 46 was assisted with a clothing protector, hand hygiene should've been completed. 28 Pa code 211.10(d) Resident care policies 28 Pa code 211.12(d)(5) Nursing services

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 1). Findings Include: Review of facility form, titled Clean Dressing Competency, undated, revealed 4 .Avoid crossing over clean supplies with soiled items. Review of Resident 1's clinical record revealed diagnoses that included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and Diabetes Mellitus Type 2. Further review of Resident 1's clinical record, including a wound consult dated August 2, 2023, revealed Resident 1 with a stage 4 pressure ulcer to the left buttock (localized damage to the skin and/or underlying soft tissue usually over a bony prominence; stage 4 is full-thickness skin and tissue loss). Review of Resident 1's current physician orders revealed a treatment order to cleanse the left buttock pressure ulcer with normal saline solution, apply magic cream (a mixture of nystatin, hydrocortisone and zinc oxide) to wound bed, cover with optilock (non-adhesive super absorbent wound dressing), and apply zinc oxide ointment to periwound. Observation of Resident 1's wound care on August 9, 2023, at 9:41 AM, revealed Employee 2 (Registered Nurse) cleansed the wound with normal saline solution. Employee 2 removed her gloves, performed hand hygiene, and then reached in her shirt pocket for tape. Employee 2 then opened two packages of the optilock, which had been laying on Resident 1's bedside table and was not cleaned prior to the wound care. With the same gloved hands, Employee 2 was observed dipping her gloved finger in the container of magic cream, placing magic cream on her gloved finger, and then applying the magic cream directly to Resident 1's wound bed using her gloved finger. On August 9, 2023, at 11:20 AM, the Nursing Home Administrator (NHA) was made aware of Resident 1's wound care observations. On August 9, 2023, at 11:22 AM, the Director of Nursing (DON) was made aware that Employee 2 used her gloved finger to apply the magic cream directly to Resident 1's wound. The DON stated she didn't believe use of an applicator was part of the facility's wound care policy. She also questioned if Employee 2's gloves were clean. Surveyor made the DON aware that Employee 2 reached into her shirt pocket with her gloved hands to pull out tape, and that she also opened the optilock with those gloved hands. The optilock had been lying on Resident 1's bedside table, which was not cleansed prior to the start of Resident 1's wound care. On August 9, 2023, at 2:35 PM, the wound care observation was again discussed with the NHA and DON. No additional information was provided. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident the right to formulate an advance directive for three of 17 residents reviewed (Residents 1, 28, and 212). Findings Include: Review of facility policy, titled Advanced Directives Protocol, undated, revealed Upon admission during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have been chosen .Advance directives will be reviewed at minimum annually according to MDS schedule. Review of Resident 1's clinical record revealed Resident 1's most recent admission to the facility was on April 12, 2023, with diagnoses that included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and Diabetes Mellitus Type 2. Further review of Resident 1's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. Review of Resident 28's clinical record revealed Resident 28 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (PVD- a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and heart failure. Further review of Resident 28's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. During an interview with the Nursing Home Administrator (NHA) on August 8, 2023, at 1:20 PM, he stated that advance directives are reviewed with Residents at time of admission. He stated they are also sometimes reviewed during the care plan meetings, but that isn't always consistent. In a follow-up interview with the NHA on August 9, 2023, at 2:35 PM, he confirmed that there is no documentation of an advance directive for Residents 1 or 28, and no evidence that Residents 1 or 28 and/or their Representatives were offered the right to formulate an advance directive. Review of the clinical record for Resident 212 on August 8, 2023, revealed she was admitted to the facility on [DATE], with diagnoses that included Congestive heart failure (CHF - heart can't pump enough oxygen-rich blood to meet the body's needs) and Hypertension (high/elevated blood pressure). Further review of the clinical record for Resident 212 on August 8, 2023, revealed there was no Advance Directives form on record. Further, Resident 212's clinical record revealed Resident 28 had a Pennsylvania - Orders for Life Sustaining Treatment (POLST) form completed on file, which indicates their wishes. Review of Resident 212's comprehensive care plan on August 8, 2023, revealed a care plan with a focus area of: Resident has advance directives. Resident is full code, which was initiated on July 24, 2023. During an interview with the NHA on August 9, 2023, at 10:47 AM, the NHA confirmed that they do not have an advance directive for Resident 212. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to review and revise the resident's plan of care for two of 17 residents reviewed (Residents 1 and 46). Findings include: Review of Resident 1's clinical record revealed diagnoses that included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and Diabetes Mellitus Type 2. Further review of Resident 1's clinical record, including a wound consult dated August 2, 2023, revealed Resident 1 with the following wounds: stage 2 pressure ulcer to the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence; stage 2 is partial-thickness skin loss); stage 4 pressure ulcer to the left buttock (full-thickness skin and tissue loss); and a wound to the right posterior (the back side) upper thigh. Review of Resident 1's current skin care plan, with a revision date of April 13, 2023, revealed no mention of the right posterior thigh wound or the stage 2 sacral pressure ulcer. Further review revealed seven additional wounds that have since been resolved, but remained on the care plan as current wounds. On August 10, 2023, the surveyor received an updated care plan for Resident 1, with a revision date of August 9, 2023. The right posterior thigh wound was added to the care plan as well as the stage 2 sacral pressure ulcer, which was resolved on August 9, 2023, and marked on the care plan as resolved. The seven additional wounds on the care plan were also revised to show they have resolved. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 10, 2023, at 10:40 AM, the DON stated that Resident 1's care plan should have been revised prior to August 9, 2023. Review of Resident 46's clinical record on August 8, 2023, revealed diagnoses including Vascular Dementia (persistent disorder of mental processes marked by memory disorders, personality changes, and impaired reasoning) and Major Depressive Disorder (at least two weeks of low mood that is present across most situations). Further review revealed that Resident 46 was admitted to the facility on [DATE]. Review of Resident 46's clinical record revealed Resident 46 had a diagnosis of contracture of muscle, right hand, and diagnosis of contracture of muscle, left hand, identified on October 19, 2022. Review of Resident 46's Occupational Therapy Discharge Summary completed on November 1, 2022, revealed that Resident 46 received occupational therapy from October 19, 2022, to November 1, 2022. Review of Resident 46's occupational therapy discharge recommendations were indicated as: no adaptive equipment needed for self-feeding; cue for hand stretches when complaining of stiffness. Review of Resident 46's comprehensive plan of care revealed a care plan with the focus of: Resident has Activities of Daily Living (ADL)/self -care deficit related to impaired mobility, cognitive deficits, generalized weakness, and history of falls, which was initiated on March 15, 2022, failed to include hand contractures in the goal or intervention/task area. During an interview on August 10, 2023, at 10:49 A.M., the DON confirmed that, if the Resident has a diagnosis of contractures, they should have been care planned. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for one of 17 residents reviewed (Resident 4). Findings Include: Review of facility policy, titled Transmission-Based Precautions Policy, with a revision date of February 3, 2023, revealed: 1. Contact Precautions- intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment recommended: a. Gloves- whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. b. Gowns- whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the resident Signage indicating the appropriate type(s) of precautions and indicating that visitors should stop at Nurses Station before entering, will be placed on the resident's door. Review of Resident 4's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus, atrial fibrillation(Afib-an irregular heartbeat), and peripheral vascular disease (PVD- a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Further review of Resident 4's clinical record revealed a urine culture was collected on July 29, 2023. Review of the results dated August 3, 2023, revealed >100,000 cfu/ml (colony forming units) Klebsiella pneumoniae ESBL (Extended Spectrum Beta-Lactamase). This isolate has been identified as an ESBL producer. Contact isolation is warranted. The results were signed off on by the provider, dated August 3, 2023, with new orders to start an antibiotic. Observation of Resident 4's room on August 7, 2023, at 12:28 PM, revealed no signage on Resident 4's door indicating it was a contact precautions room, nor a PPE (personal protective equipment) bin located outside of Resident 4's door. Review of Resident 4's clinical record revealed no order for contact precautions. On August 7, 2023, at 1:15 PM, the Director of Nursing (DON) was asked about the results of Resident 4's urine culture and if Resident 4 should be on contact precautions. Observation of Resident 4's room on August 7, 2023, at 1:58 PM, revealed a PPE bin located outside of Resident 4's room as well as a sign on Resident 4's door, stating the room was contact precautions. On August 7, 2023, at 2:33 PM, the DON and Employee 1 (Infection Preventionist) both confirmed that Resident 4 has now been placed on contact precautions based on the urine culture result. Review of Resident 4's physician orders revealed an order, dated August 7, 2023, for contact isolation when in contact with urine per facility policy. In a follow-up interview with Employee 1 on August 10, 2023, at 10:06 AM, Employee 1 stated that she has since educated the staff about reviewing labs and implementing transmission based precautions if warranted. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to act upon a recommendation to reduce a psychotropic medication in a timely manner for one of five residents reviewed for unnecessary medications (Resident 35). Findings Include: Review of Resident 35's clinical record revealed diagnoses that included stroke, depression, and anxiety. Review of Resident 35's psych consult dated July 26, 2023, revealed a recommendation to decrease Resident 35's sertraline (Zoloft- antidepressant medication) from 25 mg (milligrams) daily to 12.5 mg daily. Further review of the consult revealed agree and initials were written on the bottom. Review of Resident 35's nursing progress note dated July 27, 2023, revealed, Resident had psych visit on 7/26/23. New order recommendation to GDR [gradual dose reduction] Zoloft to 12.5 mg daily. [Resident representative] called and educated on risks vs benefits of GDR and in agreement; orders updated. RP [responsible party] notified. Review of additional nursing progress notes on July 31, 2023, and August 1, 2023, both revealed No behaviors noted R/T GDR of Zoloft. Review of Resident 35's current physician orders, on August 8, 2023, revealed an order dated June 23, 2023, for Zoloft, give 25 mg daily. Further review of the orders revealed no Zoloft order for 12.5 mg. On August 10, 2023, at 10:42 AM, the Director of Nursing (DON) provided a statement from Employee 2 (Registered Nurse) stating that on July 26, 2023, Employee 2 input a psych order recommendation for a GDR of Zoloft from 25 mg to 12.5 mg daily and that the provider was in agreement, as well as Resident 35's RP. The statement further stated that Employee 2 failed to update the Zoloft order and the order continued at 25 mg, as previously ordered. At that time, the DON confirmed that the Zoloft order was never changed, per recommendation, and that it was an oversight by the nurse. She stated that the new Zoloft order has been placed, an incident report has been initiated, and that the provider, Resident 35, and Resident 35's RP have all been notified. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for three of 18 resident records reviewed (Residents 23, 34, and 47). Findings include: Review of Resident 23's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress note dated April 26, 2022, revealed that Resident 23 was admitted to the hospital. Review of facility provided documents failed to reveal that notice of transfer was provided by the facility to the Resident, Resident Representative, and/or the Office of the State Long-Term Care Ombudsman. Review of Resident 34's clinical record on August 9, 2022, at approximately 9:15 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 34's clinical record revealed that Resident 34 was transferred to the hospital for evaluation and treatment on February 1, 2022, and subsequently returned to the facility on [DATE]. Review of Resident 34's clinical record revealed no notice of transfer was provided to the Resident, Resident Representative, and/or the Office of the State Long-Term Care Ombudsman. Review of Resident 47's clinical record on August 8, 2022, at approximately 12:30 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 47's clinical record revealed that Resident 47 was transferred to the hospital for evaluation and treatment on March 29, 2022, and subsequently returned to the facility on [DATE]. Review of Resident 47's clinical record revealed no notice of transfer was provided to the Resident, Resident Representative, and/or the Office of the State Long-Term Care Ombudsman. Interview with the Director of Nursing on August 10, 2022, at 11:10 AM, revealed that the facility had not been sending transfer notices to the Resident, Resident Representative, nor the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on employee record review, facility policy review, and staff interview, it was determined that the facility failed to ensure a thorough screening of new hires was completed for five of five staff members reviewed (Employees 1, 2, 3, 4, and 5). Findings include: Review of facility policy (not titled), last reviewed July 2022, revealed section, Procedure subsection 1. Screening, stated, [the] facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The aforementioned subsection continued with, It is the policy the Facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks .The Facility will do the following prior to hiring a new employee .Generally attempt to obtain references from 2 prior employers for an applicant .Check with the applicable nurse assistant registry, and any other nurse assistant registries that the Facility has reason to believe contain information on an individual, prior to using the individual as a nurse assistant .Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job functions and have no disciplinary action as a result of abuse or neglect . Review of personnel records for Employee 1, revealed a hire date of June, 28, 2022. Further review of Employee 1's personnel file revealed there were no prior employment reference checks were performed. Review of personnel records for Employee 2, revealed a hire date of July 12, 2022. Further review of Employee 2's personnel file revealed there were no prior employment reference checks were performed. Review of personnel records for Employee 3 revealed Employee 3 was hired for the position of Licensed Practical Nurse, with a hire date of July 27, 2022. Further review of Employee 3's personnel file revealed there were no prior employment reference checks were performed, and the facility did not have documentation of verification of licensure and/or possible disciplinary action against Employee 3's professional license. Review of personnel records for Employee 4, revealed a hire date of June 14, 2022. Further review of Employee 4's personnel file revealed there were no prior employment reference checks were performed. Review of personnel records for Employee 5 revealed Employee 5 was hired for the position of Registered Nurse, with a hire date of May 10, 2022. Review of Employee 5's personnel file revealed there were no prior employment reference checks were performed, and the facility did not have documentation of verification of licensure and/or possible disciplinary action against Employee 5's professional license. During a staff interview on August 11, 2022, at approximately 11:00 AM, Nursing Home Administrator confirmed that the facility did not have documented prior employment reference checks for Employees 1, 2, 3, 4, and 5; nor documentation that the facility performed professional license verification for Employees 3 and 5. 28 Pa code 201.18(b)(3)(d) Management

Based on clinical record reviews and interviews with the staff, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being with regard to the insertion of a Foley catheter 14 French to replace an 18 French PEG Tube (Percutaneous endoscopic gastrostomy, a tube passed into the stomach through the abdominal wall to profice a means of feeding, and medication administration). The physician's orders indicated to replace the PEG tube with an 18 French Foley catheter. Review of the Progress Notes (documentation about the daily events and care of residents as they occur) revealed that no call was made to the physician to request an order to insert the Foley catheter of a different size and/or get a possible order to replace it with a PEG Tube, (which were not available in the facility at the time) resulting in a resident not having the correct PEG tube for eight days, developing pneumonia and requiring hospitalization because of a concern for aspiration for one of 3 residents reviewed (Resident 1). Findings: Review of the Job Description of the LPN (Licensed Practical Nurse), indicated that, Under Direct Care/Patient Responsibilities, the LPN is to monitor, record and report symptoms and changes in the resident's/patient's conditions and is to report all changes in the resident's/patient's condition to the supervisor timely. Review of the Job Description of the RN (Registered Nurse), indicated that Under Direct Care/Patient Responsibilities, the RN is to maintain accurate, detailed reports and records. The RN is to maintain accurate, detailed reports and records and monitor records and report symptoms and changes in the resident/patient conditions. The RN is to report all changes in the resident's condition to the supervisor timely. Further review of the RN Job Description revealed that the RN is to observe the resident/patients and the surroundings, identify changes in the resident's behavior or condition and record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner. Review of the facility policy titled, Notification of /Patient Change in Condition last updated December 2015, revealed that the facility clinicians will notify the resident/patient's physician and family or legal representative immediately if there is a crucial/significant change in the resident/patient's condition. The policy indicated that the physician and family or legal representative should be notified immediately if there is a significant change in condition regardless of the time of day. Review of the facility policy titled, Physician Notification last updated December 2015, revealed that the attending physician in the facility was ultimately responsible for the supervision and the management of the resident/patient. Licensed Nurses will ensure that the physicians are notified of changes which include events. Under item 3, if there has been no verbal contact within a reasonable time frame, (based on nursing judgment and the acuity of the situation), the Licensed Nurse should notify the Director of Nursing (DON) or designee and notify the Medical Director. Review of the physician's orders dated November 2016, for Resident 1 revealed [DIAGNOSES REDACTED]. Additional review of the MARs (Medication Administration Records- a form used to document when and by whom a medication was given) revealed that Resident 1 was not to take anything by mouth. All intake was to be via the PEG tube (Percutaneous Endoscopic Gastrostomy - a tube passed into the stomach through the abdominal wall to provide a means of feeding and medication administration). The PEG tube size ordered was an 18 French PEG gastrostomy tube. Review of the progress notes (documentation about the daily events and care of residents as they occur) revealed that on November 22, 2016, at 7:00 a.m., Resident 1 pulled his PEG tube out. It was replaced by a RN with a 14 French (a smaller sized tube than the 18 French that was ordered by the physician) Foley catheter (a thin, sterile tube normally inserted into the bladder to drain urine) with a 30 cc (cubic centimeter) balloon (a sterile water filled balloon to hold the catheter in place) with no problem. The placement of the catheter was checked and the tube feeding was continued. Review of the progress notes failed to reveal any indication of notifying the supervisor or the physician at that time to request an order, since the PEG tube was replaced with a Foley catheter and was not the size ordered in the physician's orders (18 French was ordered and the Foley catheter was a 14 French). Later that day, the resident had clear, mucousy, emesis (vomit). The resident was assessed and the tube feeding was turned off to rest the resident's belly (stomach). The progress notes failed to reveal any notification to the physician or the family. On November 23, 2016, at 2:45 p.m. the resident pulled out his Foley catheter and was holding it in his hand. It was again replaced with a 14 French Foley catheter with a 10 cc balloon. There was no further vomiting and the feeding was restarted. On November 26, 2016, at 10:30 p.m. Resident 1 had emesis three times that was foul smelling and the LPN called the physician. On November 27, 2016, at 3:00 a.m. they were still waiting for the physician to call back to the facility. Further review of the progress notes revealed that there was no attempt to call the physician again or to notify the supervisor. The notes revealed that later that same morning at 5:40 a.m., the physician returned the call and ordered a chest X-ray and an abdominal flat plate X-ray. The feeding was held (stopped). The physician was not informed at that time that the 18 French PEG tube was replaced by a 14 French Foley catheter. On November 27, 2016, at 9:30 a.m. results from the chest X-ray showed bilateral pneumonia (at least one lobe in both lungs has a lung infection caused by bacteria, viruses or fungi. Affected patients have fluid in the lung area and have lack of breath) and the flat plate of the abdomen was negative. The results were relayed to the physician who then gave an order to start [MEDICATION NAME] (an antibiotic) via the PEG tube and to restart the feedings. The POA (Power of Attorney - Resident 1's sister) was notified at that time. This was 5 days after the tube was pulled out and neither the physician nor the POA were informed about the Foley catheter replacing the PEG tube. Review of the progress notes on November 28, 2016, revealed that the physician made rounds and wrote new orders. At that time the POA was notified that the physician had been in and wrote new orders for labs, to have the head of bed up to 45 degrees, and antibiotics. Later that night, (no time was documented in the progress note) Resident 1 had vomiting of a large amount of bilious (green liquid secreted by the liver). He was coughing and shaking and the RN called the physician regarding Resident 1 and a concern for aspiration and the need for new PEG tube insertion. A verbal order was received to send the resident to the hospital. At that time, the POA was informed that the resident was going to the hospital and that a new PEG tube had to be inserted (the first that she was told that the PEG tube was pulled out). The Director of Nursing (DON) on December 12, 2016, at 2:45 p.m. was asked if it would be customary to have replacement PEG tubes available in the facility when there are residents in the facility with PEG tube feeding. She indicated that the Foley catheter was placed to keep the site open and PEG tubes were ordered on November 28, 2016 (6 days after the tube was pulled out). The DON revealed in an interview on December 12, 2016 at 4:54 p.m. that a 14 French Foley catheter was used to replace the PEG tube because no PEG tube was available. They were ordered on November 28, 2016 (6 days after the PEG tube was pulled out). The DON indicated that if a 14 French was used, the nurse should have called the physician for an order, although the Foley catheter was used to keep the site open. During the same interview the DON revealed that there was no information provided to the physician that the PEG tube was replaced by a 14 French Foley catheter. The DON indicated that the physician should have been informed by the nurse at that time on November 22, 2016. Additionally an interview with the DON on December 12, 2016 at 5:10 pm, revealed that the POA should have been notified of a significant change in the resident's condition according to the facility policy on November 22, 2016, when the tube was pulled out. The DON confirmed that the POA was not notified of any changes until November 27, 2016. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being with regard to the insertion of a Foley catheter 14 French to replace an 18 French PEG tube. The physician's orders indicated to replace the PEG tube with an 18 French Foley catheter. Review of the progress notes revealed that no call was made to the physician to request an order to insert the Foley catheter of a different size and/or get a possible order to replace it with a PEG Tube, resulting in a resident not having the correct PEG tube for eight days, requiring hospitalization for the tube replacement and developing bilateral pneumonia requiring the administration of antibiotics. 42 CFR 483.24 Provide Care/Services for Highest well Being Previously cited 11/17/16, 4/27/16, 1/22/16 28 Pa. Code 211.5(f) Clinical records Previously cited 11/11/16, 11/17/16, 3/30/16, 1/22/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/17/16, 11/11/16, 4/27/16, 3/30/16, 1/22/16 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/17/16, 3/30/16, 1/22/16

Based on clinical record reviews and interviews with staff, it was determined the facility failed to inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical status regarding the resident pulling out their PEG tube (Percutaneous Endoscopic Gastrostomy - a tube passed into the stomach through the abdominal wall to provide a means of feeding and medication administration). The facility also failed to promptly notify the physician, the resident and the resident's representative of a change in condition related to not having the correct physician ordered replacement PEG tube resulting in the resident pulling out the Foley catheter (which had been inserted as a replacement for the PEG tube), subsquent episodes of vomiting, a chest X-ray that indicated bilateral lung pneumonia, requiring the administration of antibiotics, and a hospitalization related to aspiration concerns by the facility nurse and a delay of eight days to get the proper PEG tube placement at the hospital for one of three residents reviewed (Resident 1). Findings include: Review of the Job Description of the LPN (Licensed Practical Nurse), indicated that, Under Direct Care/Patient Responsibilities, the LPN is to monitor, record and report symptoms and changes in the resident's/patient's conditions and is to report all changes in the resident's/patient's condition to the supervisor timely. Review of the Job Description of the RN (Registered Nurse), indicated that Under Direct Care/Patient Responsibilities, the RN is to maintain accurate, detailed reports and records. The RN is to maintain accurate, detailed reports and records and monitor records and report symptoms and changes in the resident/patient conditions. The RN is to report all changes in the resident's condition to the supervisor timely. Further review of the RN Job Description revealed that the RN is to observe the resident/patients and the surroundings, identify changes in the resident's behavior or condition and record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner. Review of the facility policy titled, Notification of /Patient Change in Condition last updated December 2015, revealed that the facility clinicians will notify the resident/patient's physician and family or legal representative immediately if there is a crucial/significant change in the resident/patient's condition. The policy indicated that the physician and family or legal representative should be notified immediately if there is a significant change in condition regardless of the time of day. Review of the facility policy titled, Physician Notification last updated December 2015, revealed that the attending physician in the facility was ultimately responsible for the supervision and the management of the resident/patient. Licensed Nurses will ensure that the physicians are notified of changes which include events. Under item 3, if there has been no verbal contact within a reasonable time frame, (based on nursing judgment and the acuity of the situation), the Licensed Nurse should notify the Director of Nursing (DON) or designee and notify the Medical Director. Review of the physician's orders dated November 2016, for Resident 1 revealed [DIAGNOSES REDACTED]. Additional review of the MARs (Medication Administration Records- a form used to document when and by whom a medication was given) revealed that Resident 1 was not to take anything by mouth. All intake was to be via the PEG tube (Percutaneous Endoscopic Gastrostomy - a tube passed into the stomach through the abdominal wall to provide a means of feeding and medication administration). The PEG tube size ordered was an 18 French PEG gastrostomy tube. Review of the progress notes (documentation about the daily events and care of residents as they occur) revealed that on November 22, 2016, at 7:00 a.m., Resident 1 pulled his PEG tube out. It was replaced by a RN with a 14 French (a smaller sized tube than the 18 French that was ordered by the physician) Foley catheter (a thin, sterile tube normally inserted into the bladder to drain urine) with a 30 cc (cubic centimeter) balloon (a sterile water filled balloon to hold the catheter in place) with no problem. The placement of the catheter was checked and the tube feeding was continued. Review of the progress notes failed to reveal any indication of notifying the supervisor or the physician at that time to request an order, since the PEG tube was replaced with a Foley catheter and was not the size ordered in the physician's orders (18 French was ordered and the Foley catheter was a 14 French). Later that day, the resident had clear, mucousy, emesis (vomit). The resident was assessed and the tube feeding was turned off to rest the resident's belly (stomach). The progress notes failed to reveal any notification to the physician or the family. On November 23, 2016, at 2:45 p.m. the resident pulled out his Foley catheter and was holding it in his hand. It was again replaced with a 14 French Foley catheter with a 10 cc balloon. There was no further vomiting and the feeding was restarted. On November 26, 2016, at 10:30 p.m. Resident 1 had emesis three times that was foul smelling and the LPN called the physician. On November 27, 2016, at 3:00 a.m. they were still waiting for the physician to call back to the facility. Further review of the progress notes revealed that there was no attempt to call the physician again or to notify the supervisor. The notes revealed that later that same morning at 5:40 a.m., the physician returned the call and ordered a chest X-ray and an abdominal flat plate X-ray. The feeding was held (stopped). The physician was not informed at that time that the 18 French PEG tube was replaced by a 14 French Foley catheter. On November 27, 2016, at 9:30 a.m. results from the chest X-ray showed bilateral pneumonia (at least one lobe in both lungs has a lung infection caused by bacteria, viruses or fungi. Affected patients have fluid in the lung area and have lack of breath) and the flat plate of the abdomen was negative. The results were relayed to the physician who then gave an order to start [MEDICATION NAME] (an antibiotic) via the PEG tube and to restart the feedings. The POA (Power of Attorney - Resident 1's sister) was notified at that time. This was 5 days after the tube was pulled out and neither the physician or the POA were informed about the Foley catheter replacing the PEG tube. Review of the progress notes on November 28, 2016, revealed that the physician made rounds and wrote new orders. At that time the POA was notified that the physician had been in and wrote new orders for labs, to have the head of bed up to 45 degrees, and antibiotics. Later that night, (no time was documented in the progress note) Resident 1 had vomiting of a large amount of bilious (green liquid secreted by the liver). He was coughing and shaking and the RN called the physician regarding Resident 1 and a concern for aspiration and the need for new PEG tube insertion. A verbal order was received to send the resident to the hospital. At that time, the POA was informed that the resident was going to the hospital and that a new PEG tube had to be inserted (the first that she was told that the PEG tube was pulled out). The Director of Nursing (DON) on December 12, 2016, at 2:45 p.m. was asked if it would be customary to have replacement PEG tubes available in the facility when there are residents in the facility with PEG tube feeding. She indicated that the Foley catheter was placed to keep the site open and PEG tubes were ordered on November 28, 2016 (6 days after the tube was pulled out). The DON revealed in an interview on December 12, 2016 at 4:54 p.m. that a 14 French Foley catheter was used to replace the PEG tube because no PEG tube was available. They were ordered on November 28, 2016 (6 days after the PEG tube was pulled out). The DON indicated that if a 14 French was used, the nurse should have called the physician for an order, although the Foley catheter was used to keep the site open. During the same interview the DON revealed that there was no information provided to the physician that the PEG tube was replaced by a 14 French Foley catheter. The DON indicated that the physician should have been informed by the nurse at that time on November 22, 2016. Additionally, an interview with the DON on December 12, 2016 at 5:10 pm, revealed that the POA should have been notified of a significant change in the resident's condition according to the facility policy on November 22, 2016, when the tube was pulled out. The DON confirmed that the POA was not notified of any changes until November 27, 2016. The facility failed to notify the physician and the family of a change of condition for Resident 1 resulting harm to the resident, as evidenced by the resident spending eight days without the correct sized tube for nutrition as ordered by the physician, having to be hospitalized for [REDACTED]. 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/17/16, 3/30/16, 1/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/17/16, 11/11/16, 4/27/16, 3/30/16, 1/22/16

Based on the review of facility policy and staff interview, it was determined that the facility failed to protect residents from abuse for two of 3 resident records reviewed (Resident 1 and Resident 2). Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. The facility acknowledges the following definitions: Physical - includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. It also includes controlling behavior through corporal punishment. Review of Resident 2's clinical record revealed an admission Minimum Data Set assessment (MDS - a resident assessment and care screening tool) dated November 7, 2014, revealed [DIAGNOSES REDACTED]. Review of a Witness Investigation Statement dated November 6, 2014 at 1:30 a.m. to 2:00 a.m., completed by NA 3, revealed that, .NA1 . and I were doing 1st rounds. We went into .Resident 2's . room to check and change her and .Resident 2 . was grabbing at us and .NA 1 . grabbed .Resident 2's . hand and smacked them and told her no, that that is not nice and we turned her over and .Resident 2 . tried to grab me and then .NA1 . grabbed .Resident 2's . hands and shoved them into .Resident 2's . face and told her to grab and claw at herself to see how it feels. Review of a Witness Investigation Statement dated November 7, 2014, completed by NA 1 revealed that, .Resident 2 . was my assigned resident for the shift November 5, 2014.NA 3 . and I went to do rounds and provide care for the resident. Resident was wet, we changed her brief & repositioned her. Resident was scratching & pinching me and I told her that was not nice & I showed .NA 3 . how she was pinching me & .NA 3 . placed her hand over .Resident 2's . hand so I could fasten the brief. Finished her care then left the room after putting her in bed low position. Review of a Witness Investigation Statement dated November 6, 2014 at 6:10 a.m., completed by LPN 2, revealed that, .NA 3 . reported to .LPN 2 . of a witness of abuse by .NA 1 CNA had slapped the top of Res. B/L (bilateral - both) hands during care. Review of a Witness Investigation Statement dated November 6, 2014 at 4:30 a.m., completed by NA 4 revealed, When I was in the shower room showering .Resident 4 ., .NA 3 . came in the room, and proceeded to tell me, that when her & .NA 1 . were doing rounds .Resident 2 . was grabbing at their arms and .NA 1 . slapped her hands & then took her hands towards .Resident 2's . face & said see how it feels. I told .NA 3 . if it bothers you need to report it. Review of Resident 1's Medication Administration Record [REDACTED]. Review of a Witness Investigation Statement dated September 21, 2015, completed by NA (Nurse Aide) 1 revealed, I am writing this statement as, my co-worker accused me of a violation, of slapping a resident. This is not true. My co-worker asked me to help assist care on a resident it was around 12:15 pm. We went in to do care my co-worker washed her with soap and toweled her dry, as usual the resident does not like care, so she rejects care & is combative. The resident scratched my arm & was being combative, I told her that was not nice. My co-worker said she was giving her a good bath as, she was a dirty girl. My co-worker asked me to help hold her leg so she could wash between her legs. The resident was kicking her legs & swinging her arms. The resident was hitting & pulling my clothes. My co-worker was telling her to stop but, she didn't. We got her washed & now we are dressing her in a pretty brown dress & white sweater. We then put the sling under her & hoyered her into her wheel chair. The resident said her knee was hurting & she was sorry for resisting care. I put her leg rest on wheel chair . Review of a Witness Investigation Statement dated September 21, 2015, completed by NA 2 revealed, We rolled .Resident 1 . to her left, .Resident 1 . was combative, .NA 1 . smacked .Resident 1 . back, .Resident 1 . was smacking back & .NA 1 . & .Resident 1 . were smacking each other over & over, I said ok girls that enough. In the mean time I am trying to clean poop from .Resident 1's . butt. After they were done smacking each other, I asked .Resident 1 . to raise her leg so I could clean her up, she was trying to smack .NA 1 ., .NA 1 . grabbed her hands and arms held her down & yanked her right leg up. I heard a pop. At first, I thought maybe the noise was .Resident 1 . ripping at .NA1's . shirt. It wasn't til .Resident 1 . complained of her knee hurting in the dining room that I realized that the pop noise could have been her knee. I reported this to .DM (Dietary Manager)1 . & .LPN (Licensed Practical Nurse)1 . & then .DON (Director of Nursing) ., while .Resident 1 . was still in the dining room. Review of the Risk Management Statement/Interview Documentation dated September 21, 2015, completed by the Risk Manager Registered Nurse (RN) 2, revealed that during an interview with Resident 1 on September 21, 2015 at 1:00 p.m., .Resident 1 . stated that the employee 'hurt me.' She complained of pain in her right knee area. Right knee swollen.Resident 1 . described the employee as, 'tall' with 'glasses'. She stated she 'hurts here' and pointing to her right knee. Shook her head 'yes' when asked if employee had long hair. Review of the progress note dated September 21, 2015 at 12:45 p.m., completed by RN 1 revealed, notified by Director of Nursing (DON) to check on resident due to c/o (complaint of) pain in right knee. Resident seen sitting in wheel chair at dining room. Right knee appears swollen, slightly reddened. Resident screams with pain if knee is even touched. Review of the progress note dated September 21, 2015 at 7:15 p.m., completed by the DON, revealed that EMS (Emergency Medical Services -the ambulance) was notified and responded to the facility at 1:36 p.m., and that Resident 1 was transported to the hospital. Review of the hospital report dated September 21, 2015 at 5:12 p.m., revealed a final [DIAGNOSES REDACTED]. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/29/15, 2/5/15.

Based on closed clinical record review, review of select facility documents and staff interview, it was determined that the facility failed to ensure that one of one residents reviewed was free from a significant medication error (Resident R1). Findings include: The facility policy entitled, "Med Administration," effective July 2010, revealed that the licensed nurse would check the right medication, the right dose, the right dosage form, the right route, the right resident, and the right time prior to administering medications. The policy indicated that the licensed nurse would verify that the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR (Medication Administration Record). Closed clinical record review for Resident R1 revealed physician orders [REDACTED]. Observation of the medication on November 3, 2011, at 12:30 p.m., revealed that the pharmacy sent the facility a 25 milliliter (ml) bottle in a bag with a label that stated "[MEDICATION NAME] 10 milligrams/5 ml solution." Additional Physician orders [REDACTED]. The facility used the supply of the 25 ml bottle on October 31, 2011, at 6:00 p.m. Observation of the medication on November 3, 2011, at 12:30 p.m., revealed that the pharmacy sent a second bottle of [MEDICATION NAME], which contained 30 ml in a bag with a label on both the bottle and the bag that stated "[MEDICATION NAME] 20 mg/1 ml solution" and a sticker on the bag, which read "5 mg = 0.25 ml." On both the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Post Acute/Change of Condition Monitoring Record revealed the following record of vital signs for Resident R1: October 29, 2011, at 3:00 a.m., BP 148/88 (Blood pressure, BP, is the pressure exerted by circulating blood upon the walls of blood vessels), respirations 20 per minute, temperature 99.4 degrees Fahrenheit, oxygen saturation 87 percent (measure of the amount of oxygen in the blood) on 3 liters of oxygen via nasal cannula (nc, a device used to deliver supplemental oxygen); October 30, 2011, at 5:00 a.m. BP 126/72, pulse 82, respirations 24, temperature 95.2 degrees Fahrenheit, oxygen saturation 96 percent on 2 liters of oxygen via nc; October 31, 2011, at 12:00 a.m. BP 90/44, pulse 90 beats per minute, respirations 24 with 2 second periods of apnea (a brief pause in breathing), temperature 97.2 degrees Fahrenheit, oxygen saturation 91 percent on 2 liters of oxygen via nc; October 31, 2011, at 11:00 p.m. BP 82/58, respirations 17 with 2 seconds period of apnea, temperature 100 degrees Fahrenheit. On November 1, 2011, Resident R 1 was found absent of pulse and respirations and was pronounced dead at 12:35 a.m. A review of nursing documentation on the Disposition of Unused Medication record revealed that on October 31, 2011, at 6:00 p.m., LPN 1 (Licensed Practical Nurse) administered [MEDICATION NAME] 2.0 ml (4 mg) to Resident R 1 from the first bottle of [MEDICATION NAME] (which emptied that bottle) and 0.5 ml (10 mg) from the second bottle. This was a total of 2.5 ml (14 mg) of [MEDICATION NAME], which was almost 3 times the physician order. At 8:00 p.m. and 10:00 p.m., LPN 1 administered 2.5 ml (50 mg) of [MEDICATION NAME] to Resident R 1 from the second bottle. The last two [MEDICATION NAME] dosages were each 10 times the dosage that the physician ordered. According to the Medication Error Report, the facility notified the physician of the medication errors on October 31, 2011, at 11:30 p.m. According to the Geriatric Dosage Handbook, 12th Edition 2007, one of the overdose toxicology symptoms for [MEDICATION NAME] ([MEDICATION NAME]) is respiratory depression, which is abnormally slow and shallow breathing. An interview with the Director of Nursing (DON) on November 3, 2011, at 12:30 p.m., verified that LPN 1 administered [MEDICATION NAME] as noted above. The DON indicated that a contributing factor may have been that the second bottle of [MEDICATION NAME] was a different concentration than the first and that the second bottle was mistakenly put into the bag which had contained the first bottle. However, the DON also noted that LPN 1 should have read both the label on the bag and the label on the bottle of [MEDICATION NAME] before administering the medication. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 1/14/11, 7/13/11, 8/8/11 28 Pa. Code 211.10(c) Resident care policies. Previously cited 1/14/11, 7/13/11, 8/8/11 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 1/14/11 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/14/11, 7/13/11, 8/8/11, 9/20/11

Based on observations, review of facility policy and interviews with staff, it was determined that the facility failed to provide timely and necessary care and services for one of two residents (Resident R1) reviewed for compromised skin condition. Findings include: Review of the facility's Wound Prevention and Management policy dated October 2010 included that one form of Skin Grid should be completed for each area of skin impairment. On identification, the wound should be updated weekly, if the condition of the skin impairment changes, or with a dressing change. Skin Grid includes the descriptions of initial identification, date, stage, length, width, depth, color and amount of drainage, odor, peri-wound area, healed status, physician and responsible party notification. Observations on July 28, 2011, around 2:00 p.m., revealed that Resident R1's left buttock had a skin opening on the middle of left buttock approximately 1.5 centimeters (cm) by 1.5 cm (look like L shape). When Licensed Practice Nurse (LPN) 1 removed the 5 inch by 5 inch Allevyn (soft absorbant) wound dressing bordered with adhesive film the tissue that surrounded the skin opening and below area from the opening toward the lower buttock, was dark red (approximately 9.8 cm by 8 cm) when the dressing was removed. Numerous bloody pin point spots were noted at the lower part of left buttock (the area was also covered with Allevyn). Observation on July 29, 2011, around 1:00 p.m., revealed that Resident R1's left lower buttock had pinpoint blood dotted areas dripping with dark red blood when LPN 1 removed the soiled dressing from the previous day. LPN 1 stated that he should've received new order from the physician for the worsening skin condition on lower buttock area. Progress notes dated June 23, 2011, reported that Resident R1 had an open are on his right buttocks and a physician's orders [REDACTED]. On June 24, 2011, the Interdisciplinary Team (IDT) review note reported that he frequently sits in his recliner and is much less mobile and that he was to be screened by therapy to determine if an appropriate cushion can be used on the recliner. Subsequently on July 23, 2011, he was identified to have an open area on his right buttocks. An IDT review note dated July 25, 2011, reported that he had bouts of [DIAGNOSES REDACTED] (antibiotic-associated diarrhea) and is in the recliner most of the day. His Skin Gird regarding the skin opening on left buttock dated July 23, 2011, revealed that there was a 1.0 cm by 1.5 centimeter skin opening with no drainage. There was no further documentation for the progression of worsening skin conditions on the left buttock other than general descriptions like dressing intact or dressing changed until July 29, 2011. His Care delivery guide dated July 5, 2011 and Comprehensive care Plan review Summary dated July 28, 2011, failed to address any Skin/Wound issues. Interview with Registered Nurse (RN) 1 on July 29, 2011, at 10:00 a.m., stated that the facility is not measuring skin rashes or reddened area unless it is open. If the resident has rashes/reddened area, just follow the general skin protocol to apply skin protective cream. Interview with Director of Nursing (DON) on August 8, 1:17 p.m., confirmed that the licensed nurse should have assessed the skin condition and try to find appropriate interventions (update physician and family, receive new order or other nursing measures) when the rash or any change of skin problem was identified. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 7/13/11, 1/14/11 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 7/13/11, 1/14/11 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Previously cited 7/13/11, 1/14/11