Every finding on record at Stroudsburg Post Acute Nursing & Rehabilitationllc

Based on observation and staff interviews, it was determined the facility failed to ensure that qualified personnel directed and provided oversight of the food and nutrition services department following the departure of the facility's qualified food service director.Findings include: Federal requirements for food and nutrition services require a facility to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services department. When the facility does not employ a qualified dietitian to serve as the director of food and nutrition services, the facility must designate a director who meets the applicable federal qualification requirements and receives the required consultation from a qualified dietitian or other clinically qualified nutrition professional. Observation on August 10, 2026, at 9:00 AM during a tour of the food and nutrition services department revealed that a qualified food service director was not present. During an interview at that time, Employee 1, cook, stated the facility had been without a qualified dietary manager for approximately two weeks after the previous dietary manager left employment. Employee 1 stated the facility employed a dietitian but indicated that Employee 1 was unaware whether the dietitian provided oversight of the kitchen. During an interview on August 10, 2026, at 10:00 AM, the registered dietitian (RD, a licensed or credentialed professional who assesses and manages nutritional needs) stated the facility hired her on July 14, 2026, as the full-time dietitian. The RD stated that since her hire, her responsibilities had focused on addressing residents' clinical nutritional needs. The RD stated that, as of the date of the survey, she had not provided oversight of kitchen sanitation or food production. During an interview on August 10, 2026, the Nursing Home Administrator (NHA) stated that the qualified food service director's last day of employment was July 31, 2026. The NHA stated that the facility was in the process of hiring a full-time qualified food service director. The facility did not provide evidence that, following the qualified food service director's departure on July 31, 2026, it had designated another qualified individual to direct and oversee the food and nutrition services department, including food production and sanitation, through the time of the survey on August 10, 2026. Refer to F812.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Based on observation, review of facility documentation, and staff interviews, it was determined the facility failed to store food at safe temperatures and failed to ensure that equipment and utensils were effectively cleaned and sanitized in the food and nutrition services department to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). According to the 2022 Food and Drug Administration (FDA) Food Code and federal regulatory guidance, Time/Temperature Control for Safety (TCS) food, formerly referred to as Potentially Hazardous Food (PHF), is food that requires control of time and temperature to limit the growth of disease-causing microorganisms or the formation of toxins. TCS food that requires cold holding is generally maintained at 41 degrees Fahrenheit ( F) or below. The temperature range above 41 F and below 135 F is commonly referred to as the danger zone because temperatures within this range can support the growth of pathogenic microorganisms (microorganisms capable of causing disease) that may cause foodborne illness. Time and temperature are important factors in controlling this growth. TCS foods maintained within the danger zone for extended periods may become unsafe for consumption. Food safety guidance establishes specific time limits for TCS foods exposed to temperatures within this range, including up to four hours under certain circumstances when food is prepared from ingredients at ambient (room) temperature and up to six hours under specified conditions for food that has been properly cooked and cooled. Review of the facility's Food Storage Policy, last reviewed November 22, 2025, revealed that the facility was to provide sufficient storage facilities to keep food safe, wholesome, and appetizing. The policy directed staff to store, prepare, and transport food at appropriate temperatures and by methods designed to prevent contamination. The policy further directed staff to refrigerate perishable foods such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products immediately and maintain refrigeration temperatures at or below 40 F. Staff were to check refrigerator and freezer temperatures twice daily and document the temperatures on the Freezer and Refrigerator Temperature Form. Observation of the food and nutrition services department on August 10, 2026, at 9:00 AM revealed that the thermometer inside the walk-in cooler identified as Refrigerator Number 2 displayed a temperature of 45 F, which exceeded the facility's policy requirement of 40 F or below. Review of the August 2026 Freezer and Refrigerator Temperature Form revealed that Refrigerator Number 2 had also exceeded the facility's required temperature on three consecutive evenings:August 7, 2026: 44 FAugust 8, 2026: 45 FAugust 9, 2026: 48 F Despite the documented elevated temperatures, there was no documented evidence that staff had notified maintenance or otherwise initiated corrective action to ensure that Refrigerator Number 2 consistently maintained the temperature required by facility policy. During an interview on August 10, 2026, Employee 1, cook, confirmed that Refrigerator Number 2 had been intermittently running warm and cold. Employee 1 stated that staff limited the amount of food stored in the refrigerator and moved items to other available refrigerators as needed. As a result of the August 10, 2026, observation, staff removed a case of pasteurized shell eggs, three pitchers of sweet tea, and two pitchers of fruit punch from Refrigerator Number 2 and transferred the items to another refrigerator. There was no documented evidence that maintenance had been notified that Refrigerator #2 was not maintaining the required temperature of 40 degrees or less for food storage. Observation of the three-compartment sink on August 10, 2026, revealed that staff used a quaternary ammonium compound (Quat, a chemical sanitizer used to reduce microorganisms on food-contact surfaces, in the sanitizing compartment). Posted instructions above the three-compartment sink directed staff to maintain the water in the wash and rinse compartments between 110 F and 130 F and the sanitizing compartment between 75 F and 110 F. Review of the August 2026 Three Pot Sanitizer Form revealed that staff documented the Quat sanitizer concentration three times daily, with an identified acceptable concentration range of 150 to 400 parts per million (ppm, a measurement used to determine the concentration or strength of a chemical sanitizer in water). The form contained no documentation that staff measured the water temperatures in the three-compartment sink to verify that the temperatures met the posted requirements. During an interview on August 10, 2026, Employee 2, dietary aide, confirmed that staff used test strips each time they filled the three-compartment sink to determine the concentration of the sanitizer. Employee 2 stated that staff used their hands to determine whether the wash and rinse water felt hot and whether the sanitizing water felt lukewarm. Employee 2 confirmed that staff did not use a thermometer to measure the water temperatures and did not document the temperatures on the Three Pot Sanitizer Form. Observation of the dishwashing machine on August 10, 2026, revealed that the machine's final rinse temperature was 119 F. The machine did not achieve the 180 F final rinse temperature required when using high-temperature heat sanitization. During an interview at the time of the observation, Employee 2 confirmed the observed final rinse temperature and stated that staff had notified maintenance on August 6, 2026, that the machine was not reaching a final rinse temperature of 180 F. Employee 2 stated that maintenance was working to have the machine repaired and that the facility had switched the machine to operate as a low-temperature dishwashing machine. Observation revealed that detergent and low-temperature rinse aid were connected to the dishwashing machine; however, a chemical sanitizer was not connected to the machine. During an interview on August 10, 2026, at 10:00 AM, the Nursing Home Administrator confirmed the observation and stated that the dishes would be rewashed and that the dishwashing machine would not be used until the required chlorine-based sanitizer was obtained from a sister facility. Chlorine sanitizer test strips were available in the food and nutrition services department. During an interview on August 10, 2026, at 12:45 PM, the facility's contracted chemical supplier representative confirmed that when the dishwashing machine operated as a low-temperature machine, it required the designated chlorine-based sanitizer and chlorine test strips to verify a sanitizer concentration of 50 to 100 ppm. During a follow-up interview on August 10, 2026, at 2:00 PM, the Nursing Home Administrator confirmed the findings regarding Refrigerator Number 2 and the dishwashing machine. The Nursing Home Administrator acknowledged that refrigerator temperatures were to be monitored and maintained in accordance with facility policy and confirmed that the required sanitizer was not connected to the dishwashing machine when it was being operated as a low-temperature machine. Refer F80128 Pa Code 201.18 (e) (2.1) Management.28 Pa Code 211.6(f) Dietary services.28 Pa Code 211.10 (a)(d) Resident care policies.

Based on review of select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents had reasonable and safe access to operate their over-the-bed lighting for four residents out of 29 residents reviewed (Residents 63, 134, 10, and 90).Findings include: The facility policy titled Environment last reviewed by the facility on April 3, 2026, indicated the facility is committed to maintaining an environment that promotes resident comfort, safety, privacy, dignity, and emotional well-being. The physical environment shall support quality of life through cleanliness, appropriate maintenance, infection prevention, and resident-centered atmosphere. The policy further indicated the facility would conduct routine environmental rounds to monitor cleanliness, safety, odors, lighting, temperature, equipment condition, and overall resident comfort. Identified concerns would be addressed promptly. During observations conducted on May 19 and May 20, 2026, Residents 63, 134, 90, and 10 were observed to have over-the-bed lighting fixtures with pull cords measuring two inches in length. The pull cords were not within reach of the residents, preventing independent operation of the lights. During an interview on May 19, 2026, at 11:56 AM, Resident 63 stated she was hard of hearing and requested communication through written language. After information was written on a notepad, the resident indicated she had difficulty seeing due to impaired vision. The surveyor observed that the resident's over-the-bed light was turned off and that the resident was unable to access the light because the pull cord was only two inches long and out of reach. Resident 63 stated she would like access to the light but could not reach the cord independently. During an interview on May 19, 2026, at 1:30 PM, Resident 134 stated she was admitted 3 weeks ago and reported, Never has there been a cord for me to reach the light. I don't know why they can't just make it longer. During an interview on May 20, 2026, at 9:10 AM, Resident 10 stated she was unable to reach the over-the-bed light and reported that she frequently stood up and stretched in an attempt to turn on the light, placing herself at risk for falling. Resident 10 stated, It would be nice to be able reach it without having to get out of bed or stand and reach for it. I'm starting to read a book and this way I could read it at night too. During an interview on May 20, 2026, at 9:25 AM, Resident 90 stated she previously had a longer cord to activate her over-the-bed light; however, it broke several weeks ago and had not been replaced. Resident 90 stated she used the light frequently and would like to have independent access to it again. During an interview on May 20, 2026, at 12:30 PM the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure residents had accessible over-the-bed lighting, limiting residents' ability to independently operate the lights according to their individual needs and preferences. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on resident and staff interviews and meal test tray results, it was determined the facility failed to serve meals that are palatable and attractive for four out of 29 residents reviewed (Residents 4, 6, 37 and 55), including experiences reported by five residents during a resident group interview (Residents 48, 68, 73, 131, and 132).Findings include: A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time) and hyperlipidemia (high fats in the blood). A review of Resident 4's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 23, 2026, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). During an interview on May 19, 2026, at 1:30 PM, Resident 4 indicated he was dissatisfied with the food and stated most of the meals served are tasteless and described the food as lousy. Resident 4 stated he felt like most of the foods, especially the meats, are overcooked and hard to eat. Resident 4 stated that the pork is the toughest food that is cooked on the menu and considers it inedible. Resident 4 stated he has brought up food concerns in the past; however, nothing gets done about it. Resident 4 stated he would like to be served over easy eggs for breakfast but stated he is only allowed to have scrambled and stated the scrambled eggs have no taste. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and neurogenic bowel (loss of bowel control due to brain or spinal cord damage). A review of Resident 6's quarterly MDS, dated [DATE], revealed that Resident 6 was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates cognition is intact). During an interview on May 19, 2026, at 11:45 AM, Resident 6 indicated that he was very dissatisfied with multiple meals at the facility. He explained that he is upset because the vegetables are consistently mushy, the kielbasa (a traditional Polish sausage) tastes like a hot dog, the hot ham and cheese sandwiches are often cold, the meat is often overcooked and dry, the food does not have any seasoning, and the pork is too hard to eat. He explained in general the food is not flavorful. Resident 6 indicated that he has brought this issue up in the past, but he has given up discussing it because the facility does nothing to fix the problem. He explained that he often only eats cheeseburgers and peanut butter because the food sucks. A clinical record review revealed Resident 37 was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident 37's admission MDS, dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates cognition is intact). During an interview on May 19, 2026, at 1:40 PM, Resident 37 indicated she was dissatisfied with the food that is served at the facility and stated she felt like it had no taste and no nutritional value. She stated she felt like they were served a lot of the same white foods, such as white rice, pasta, and chicken, and they were often overcooked. Resident 37 also was displeased with the French toast that is served at the facility, citing she feels like it is just a piece of bread on a plate. Resident 37 stated most of the food that is served stinks. A clinical record review revealed Resident 55 was admitted to the facility on [DATE], with diagnoses to include hypertension and rheumatoid arthritis (a chronic inflammatory disorder usually affects small joints in the hands and feet). A review of Resident 55's quarterly MDS, dated [DATE], revealed the resident had moderately impaired cognition with a BIMS score of 12 (a score of 8 through 12 indicates moderate cognitive impairment). During an interview on May 21, 2026, at 1:30 PM, Resident 55 indicated she was dissatisfied with the food and stated most of the meals served are overcooked and tasteless. She described the potatoes as powdered leftovers and had no taste. The brown gravy sometimes comes on the tray, and it is not fully mixed all the way and has powder on top. Resident 55 described the vegetables as being hard and unable to be eaten, including the vegetables in the soup. Resident 55 stated she felt like the soup was mostly flavored water mixed with hard vegetables. She stated she has not eaten a full meal in a long time because the meals served are not one hundred percent edible. She stated she often relies on the food her daughter brings her and has frozen meals in her personal bedside refrigerator. Resident 55 described the meat patties as looking the same, such as chicken, beef and veal patties. Resident 55 stated she is unable to eat the pork because it is so tough and inedible. She requests that she does not get pork due to this concern, yet often she states she will still receive pork for her meals. Resident 55 stated she has been complaining so long about the food and feels like no one listens anymore, and therefore nothing gets done about the food. Resident 55 stated she also loves hot dogs but would like sauerkraut served with her hot dogs, as this was a staple in her lunches prior to coming to the facility; however, she states she does not have the option of ordering sauerkraut with her hot dogs. During a resident council interview on May 20, 2026, at 10:00 AM, five alert and oriented residents in attendance indicated they are dissatisfied with the quality, taste, and palpability of the meals they receive at the facility. During the resident council interview, Resident 48 indicated the appearance of the meals makes her not want to eat. She explained that the meat is dry and there is no flavor. Resident 48 indicated that they bring up issues during resident council meetings and food committee meetings, but there are no changes to the quality of the meals. During the resident council interview, Resident 131 indicated the food does not have any flavor and is not seasoned well. He explained that he has brought this up in the past, and the facility indicated that they have to prepare the meals like that for residents. Resident 131 indicated that he becomes frustrated when the meal is unappetizing and he requests an alternate meal option, but no one from the kitchen responds or assists. He explained that he doesn't bring up the issues with the food because nothing improves when residents complain. During the resident council interview, Resident 73 indicated she is not satisfied with the quality of the food or the food's taste. She said the food is not seasoned. Resident 73 indicated that the meat is tough and often dry. During the resident council interview, Resident 68 indicated that food is not flavored or seasoned well. She explained that the way it is prepared makes you not want to eat the meal. Resident 68 indicated that often the meals have an unappetizing presentation. She explained that residents have brought this issue up in the past, but nothing has been done to improve the quality, taste, and appearance of the food. In particular, she indicated that the meat is dry, hard, and not flavored in an appealing manner. During the resident council interview, Resident 132 indicated the facility serves meat that is tough She explained that many times she was unable to chew the meat that was served. Resident 132 indicated that the pork is the worst. She explained that the meals do not have flavor, the vegetables have a terrible consistency, and she has not been satisfied with the meals. Resident 132 indicated that residents bring up their issues with the food, but there has not been a change to improve the meal quality. She expressed her frustration that there is nothing that can be done and no one is helping improve the meal quality. A test tray for the A-1 Hall nursing unit on May 21, 2026, at 12:22 PM revealed a serving of off-white mashed potatoes, collard greens, and chicken. A sample of the mashed potatoes revealed the texture was gritty, bland, and not appetizing. The collard greens were soft and had a bland flavor. A portion of the chicken coated in a reddish-brown glaze was sampled with no issues noted. During an interview on May 21, 2026, at 1:15 PM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The NHA and DON were unable to explain why residents were presenting with frustration and dissatisfaction with the food that is served at the facility. The facility failed to serve food that is palatable, attractive, and satisfying for Residents 4, 6, 37, 48, 55, 68, 73, 131, and 132. Refer F692 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.12(d)(3) Nursing services.

Based on observation, review of the Facility Assessment (a comprehensive evaluation conducted by the facility to determine the resources necessary to care for its resident population), and staff interviews, it was determined the facility failed to conduct and update a facility-wide assessment, using evidence-based methods to identify the specific resources necessary to care for its resident population. Findings include: Review of the facility's current floor plan revealed the B-Wing residential section was outlined in red. During an interview on May 21, 2026, at 9:30 AM, the Nursing Home Administrator (NHA) stated the B-Wing was outlined in red to indicate it was a locked unit. The NHA reported the facility created and opened a locked memory care unit for residents with dementia (a progressive cognitive disorder affecting memory and functioning) or wandering tendencies. The NHA further reported the unit was opened on November 4, 2025. Review of the facility's matrix (a document used to identify current residents and note pertinent care categories such as Alzheimer's disease/dementia, antipsychotic medication use, pressure wounds, tube feedings, intravenous therapies, and other care needs) revealed there were 34 residents residing on the B-Wing. Observation of the B-Wing conducted daily from May 19, 2026, through May 21, 2026, revealed the unit doors were locked and required a security code for entry and exit. An audible alarm sounded once the door was opened after the security code was entered. Review of the Facility Assessment, last reviewed by the facility on March 3, 2026, failed to identify the locked memory care unit and the specific services, staffing, and resources required to meet the individual and collective needs of the resident population residing on the unit. There was no evidence the facility updated its facility-wide assessment after implementation of the secured memory care unit to address how available resources were being utilized to support staffing and operational decisions in a manner that ensured compliance with regulatory requirements. The assessment lacked comprehensive data regarding the current resident population and resources necessary to provide safe and appropriate care. Further review of the Facility Assessment revealed the facility failed to accurately identify resident population subsets and characteristics, including types of diseases, conditions, physical and behavioral health needs, cognitive impairments, and overall acuity (the severity of a resident's illness and their daily dependency on caregivers). The Facility Assessment failed to identify how increased resident acuity affected staffing needs, workload, supervision and the time required to provide basic care. Additionally, the Facility Assessment failed to include the resources necessary to care for the resident population, including an evaluation of the overall number of facility staff and the competencies and skill sets required to ensure a sufficient number of qualified staff were available to meet each resident's needs. During an interview on May 21, 2026, at 11:35 AM, the Nursing Home Administrator confirmed that the Facility Assessment did not contain all of the required information related to the facility's current resident population, services and staffing resources. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management.

Based on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's representative was informed of treatment options, as well as the risks and benefits for psychotropic medications for one of 29 residents reviewed (Resident 65).Findings include: A review of a facility policy titled Psychotropic Medication Use, last reviewed by the facility on April 3, 2026, revealed it is the facility's policy to ensure psychotropic medications are used safely, appropriately, and only when clinically necessary in accordance with physician orders and that informed consent for psychoactive/psychotropic medications shall be obtained from the resident or responsible party. (Psychotropic medications affect the mind and emotions by altering chemicals in the brain.) A clinical record review revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and age-related debility (gradual loss of overall functional independence as a person gets older). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 28, 2025, revealed that Resident 65 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of Resident 65's quarterly MDS, dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 04 (a score of 0 through 7 indicates severe cognitive impairment). A review of a physician's order dated July 22, 2025, at 9:32 PM, revealed an order for Seroquel 25 milligrams (mg) (an antipsychotic medication used to treat mood disorders) daily at bedtime for impulsivity. A review of a nurse's progress note dated July 22, 2025, at 11:24 PM, revealed the resident was educated on psychotropic medication therapy and potential side effects, and consent was obtained from the resident. A review of a form titled Consent for Psychoactive Medication Therapy, dated July 22, 2025, revealed consent for use of psychotropic medication to include antipsychotic medication with consent signed at the bottom of the form by Resident 65 and their physician. It was also marked that the resident is agreeable to any additional changes for psychotropic medication, including additional or discontinued, as the psychiatrist or primary physician sees fit. There was no indication that Resident 65's resident representative was made aware of this consent for the antipsychotic medication. A review of Medication Administration Records (MARs) from July 2025 to May 2026 for Resident 65 revealed the resident received Seroquel 25 mg as ordered by the physician. Review of the clinical record at the time of the survey revealed that Resident 65 was their own representative. Following surveyor inquiry, the facility updated the clinical record to reflect that Resident 65 had a designated power of attorney who served as the resident's representative. An interview with the Director of Nursing on May 22, 2026, at 12:00 PM confirmed there was no documentation available for review at the time of the survey to indicate that informed consent was obtained prior to the start of psychotropic medication for Resident 65 by their representative, that the risks and benefits were explained, or that they were offered alternative treatment options. 28 Pa Code 201.29(a) Resident rights. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on observation, a review of clinical records, and select facility policy and staff interviews, it was determined the facility failed to ensure the self-administration of medications was clinically appropriate for one of 29 residents reviewed (Resident 131).Findings include: A review of the facility policy titled Medication Storage Policy, last reviewed by the facility on April 3, 2026, revealed that it is the facility policy to ensure all medications are stored safely, securely, and in compliance with federal, state, and facility regulations to maintain medication integrity and resident safety. A clinical record review revealed that Resident 131 was admitted to the facility on [DATE], with diagnoses that include multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment). A review of Resident 131's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 9, 2026, revealed that Resident 131 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A physician's order for muscle rub cream 10 -15% (menthol -methyl salicylate, topical analgesics that create a cooling/warming sensation, which helps numb the area and desensitize nerve endings and causes blood vessels to widen) with directions to apply to the back topically two times a day for back pain initiated on August 21, 2025. During an observation on May 19, 2026, at 11:02 AM, three clear plastic medication cups filled with an unknown white cream substance were observed on Resident 131's bedside table. At the time of the observation, there were no residents in the room. During an interview on May 19, 2026, at 12:05 PM, Employee 3, Registered Nurse Supervisor (RNS), identified the white cream found in Resident 131's room as muscle rub cream 10-15% (menthol -methyl salicylate) cream. She confirmed that the white plastic cups were not marked or labeled to identify what substance was contained inside the medication cups. Employee 3, RNS, confirmed that all medications should be marked and labeled to prevent accidents and ensure safe use of the medication.Prior to inquiries made during the survey, a clinical record review revealed no evidence the facility assessed Resident 131 in order to ensure he was capable, safe, and clinically appropriate to administer and properly secure the 10-15% muscle rub cream (menthol-methyl salicylate) in his room. During an interview on May 21, 2026, at 1:30 PM, the above information was reviewed with the director of nursing (DON) and nursing home administrator (NHA). The DON and NHA were unable to provide documented evidence that prior to inquiries made by surveyors, Resident 131 was assessed and determined to be clinically appropriate to self-administer his medication. The facility failed to ensure the self-administration of medication was clinically appropriate for Resident 131. 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, resident interview, and staff interview, it was determined that the facility failed to implement its weight management policy and failed to timely assess and re-evaluate significant weight loss for one of 29 sampled residents reviewed (Resident 81).Findings include: Review of the facility's Weight Protocol policy, reviewed April 3, 2026, revealed that all residents will be weighed by the 7th of each month. A registered dietitian will review weights and request re-weights on any weight loss or gain of 5 pounds from the prior month. Re-weights will be completed by the 15th of each month. A weight meeting will be held by the Interdisciplinary Care Plan Team after the 15th of each month to assure nutritional adequacy. Clinical record review revealed that Resident 81 had a diagnosis of diabetes (elevated levels of sugar in the blood). A review of Resident 81's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 3, 2026, revealed that Resident 81 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). An interview with Resident 81 on May 19, 2026, at 11:00 AM and again on May 21, 2026, at 10:30 AM revealed the resident was dissatisfied with the quality and taste of the food served at the facility. The resident stated the food was horrible and reported losing a significant amount of weight because she was unable to eat the meals provided. The resident stated she wanted to lose weight but did not want to lose weight because she could not eat the food. The resident further stated that no one had discussed the significant weight loss with her and that family members would bring meals when able. Review of the weight record revealed that on December 6, 2025, the resident's weight was recorded as 190 pounds using a mechanical lift scale. Review of the January 6, 2026, weight record revealed the resident's weight was 175.8 pounds using a mechanical lift scale, representing a weight loss of 14.2 pounds, or 7.4 percent, in one month. Clinical record review revealed that despite the significant weight loss, the next documented weight was not obtained until January 25, 2026. The January 25, 2026, weight was not obtained in accordance with facility policy requiring a re-weigh following a weight change greater than 5 pounds in one month and completion of the re-weigh by the 15th of the month. Review of the February 8, 2026, weight record revealed the resident's weight was documented as 176 pounds using a using a mechanical lift scale. Review of the clinical record revealed that the first dietary note addressing the resident's weight loss was not entered until February 12, 2026, more than one month after the January 6, 2026, weight identified a significant weight loss. Although the dietary note indicated the weight loss was desired, there was no evidence the facility completed the required re-weigh in accordance with facility policy. Additionally, there was no evidence the registered dietitian or interdisciplinary team completed a timely assessment or re-evaluation to determine the cause of the significant weight loss, evaluate the resident's nutritional status, assess the resident's reported concerns regarding food intake, or ensure nutritional goals continued to be met. During an interview on May 21, 2026, at 12:30 PM, the Nursing Home Administrator was unable to provide evidence that the facility implemented its weight management policy following the resident's significant weight loss or that a timely assessment and re-evaluation were completed to ensure the resident's nutritional adequacy and ongoing nutritional needs were addressed. Refer to F-804.28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services.

Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident with a prosthetic device received the necessary care and services to attain or maintain the highest practicable physical well-being, consistent with professional standards of practice, for 1 of 29 residents reviewed (Resident 10). Findings include: Review of the facility policy titled Prosthetic Device Policy, last reviewed by the facility on April 3, 2026, indicated residents requiring prosthetic devices (an artificial replacement for a missing body part) were to receive appropriate assistance, monitoring, and care in accordance with physician orders, care plans, and resident preferences. The policy further indicated prosthetic devices were to be maintained in clean and safe conditions and nursing staff were to routinely assess the prosthetic device and resident's skin integrity for redness, irritation, pain, swelling, breakdown, or improper fit. The policy also required staff to assist residents with application, removal, cleaning, and storage of prosthetic devices as needed to promote resident safety, comfort, mobility, and quality of care. The policy procedures included:1. Verify physician orders and care plan related to prosthetic use. 2. Assess the prosthetic device routinely for cleanliness, fit, and function. 3. Assess skin integrity before and after prosthetic use. 4. Assist the resident with applying and removing the prosthetic device as needed. 5. Ensure prosthetic devices are labeled and stored appropriately when not in use. 6. Encourage safe use during transfers, ambulation, and activities. 7. Report changes in condition, pain, skin issues, or equipment concerns promptly. 8. Document assessments, assistance provided, and abnormalities in the medical record. Clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses including below-the-knee amputation of the right leg (loss of the lower portion of the right leg due to a surgical procedure), Type 2 diabetes (a chronic condition in which the body resists or does not produce enough insulin, causing elevated blood sugar levels) with a left foot ulcer (an open sore on the foot related to diabetes-associated poor circulation and nerve damage), and Alzheimer's disease (a progressive irreversible brain disorder affecting memory, thinking, and daily functioning). Review of the annual Minimum Data Set (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 17, 2026, revealed the resident was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a screening tool used to assess cognition; a score of 8-12 indicates moderate cognitive impairment). Nursing documentation dated April 14, 2026, at 2:36 PM revealed that upon return from therapy, the resident removed the prosthetic device and blisters were observed on the right residual limb (the remaining portion of the leg following amputation). Documentation indicated the nurse practitioner and wound nurse were notified and new orders were received to apply skin prep (a protective barrier film) and an ABD dressing (a highly absorbent multilayer dressing) daily. Documentation further indicated the resident was to be scheduled for evaluation by the prosthetist (a healthcare professional who designs, fits, and maintains prosthetic devices) regarding prosthetic fit concerns. Review of a physical therapy treatment note dated April 14, 2026, revealed the resident arrived at therapy with the right prosthetic leg donned (properly put on and worn). The therapist observed the prosthetic device had not been applied properly. Upon removal of the prosthesis, the therapist identified the inner gel liner (a soft cushioning sleeve worn over the residual limb) had not been applied prior to placement of the prosthesis. The therapist documented a blister to the right lateral knee (outer knee), a blister to the anterior medial thigh (front inner thigh), and redness to the patella (kneecap). Review of facility documentation titled Skilled Charting dated April 16, 2026, indicated the resident had treatable wounds of the left heel and right prothesis site from wearing prothesis. However, no specific wound location to the residual limb was identified and no wound measurements, characteristics (type, depth, and healing stage of wound), staging (extent of tissue damage), or detailed assessment findings were documented. Further review revealed no documented wound assessments addressing the blisters and redness identified on April 14, 2026, including wound location, description, measurements, drainage, or treatment effectiveness. Review of the resident's comprehensive care plan dated April 2, 2026, revealed the resident had a right below-the-knee amputation related to diabetes and infection. The goal indicated the resident's mobility would be restored through use of a prosthetic device and adaptive equipment such as a walker, crutches or wheelchair, by July 22, 2026. Interventions included encouraging participation in rehabilitation and administering pain medication as ordered. However, the facility failed to develop and implement individualized interventions to ensure safe prosthetic use and prevent complications. Specifically, the care plan lacked interventions addressing: staff assistance to ensure proper application of the prosthetic device and prescribed wear schedule; monitoring of the residual limb for redness, irritation, swelling, or skin breakdown before and after prosthetic use; parameters for safe prosthetic wear time and gradual increase in usage; prosthetic hygiene instructions for cleaning and drying the liner, socks, and prosthetic device; and resident and staff education regarding proper prosthetic management and skin monitoring. Review of current physician orders revealed no orders addressing monitoring of the residual limb, prosthetic wear schedule, prosthetic hygiene, or skin assessment related to prosthetic use. Observation on May 21, 2026, at 1:00 PM of Resident 10's right residual limb in the presence of Employee 3 (Registered Nurse Supervisor) revealed the skin had healed with no blisters, redness or open areas present. During an interview conducted on May 21, 2026, at 1:25 PM, the Nursing Home Administrator, Director of Nursing, and Director of Therapy were unable to provide documented evidence the facility had developed or implemented a prosthetic care assessment process, prosthetic wearing schedule, residual limb skin monitoring protocol, staff education, resident education, or comprehensive wound assessments related to the resident's prosthetic use. 28 Pa. Code:201.18 (b)(1) Management. 28 Pa. Code:211.10 (c) Resident care policies. 28 Pa. Code:211.12(d)(1)(3)(5) Nursing services.

Based on observation, a review of select facility policy, and staff interview, it was determined the facility failed to ensure that medications and pharmaceutical products were stored in accordance with expiration date guidelines in one of three medication storage areas (first floor A Unit medication storage room).Findings include: A review of the facility policy titled Medication Storage Policy last reviewed by the facility on April 3, 2026, indicated all medications, including prescription medications, controlled substances, and over-the-counter (OTC) medications, shall be stored in designated secure areas under proper storage conditions according to manufacturer recommendations and facility procedures. Observation of the first floor A Unit medication storage room on May 21, 2026, at 8:53 AM revealed a multi-dose vial of Tuberculin (solution used for tuberculosis screening) stored in the medication refrigerator that had been opened, was available for use, and was not dated when opened. Review of the manufacturer dosage and administration for Tuberculin revealed that multidose vials opened and in use for more than 30 days should be discarded. Continued observation of the medication storage room revealed seven expired medications and supplements available for use, including:2 bottles of Oyster Shell Calcium 500 mg (calcium supplement) with an expiration date of July 20251 bottle of Zinc 50 mg ( zinc supplement) with an expiration date of January 20262 bottles of Vitamin B-6 100 mg with an expiration date of January 20262 bottles of Melatonin 1 mg (dietary supplement to aid in sleep) with an expiration date of February 2026 During an interview on May 21, 2026, at 9:15 AM, Employee 3 (Registered Nurse Supervisor) confirmed the Tuberculin vial had been opened and was not dated and confirmed the presence of the expired medications and supplements in the first floor A Unit medication storage room. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs on a daily basis for one out of 29 residents reviewed (Resident 119).Findings include: A clinical record review revealed that Resident 119 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). Resident 119 was admitted to hospice services (care and support provided to a resident with a terminal illness that focuses on comfort and symptom management) on April 22, 2026, related to dementia and suspected osteomyelitis (bone infection). A clinical record review revealed Resident 119's plan of care was not integrated with hospice services or measures planned to assure that nursing facility staffing coordinates and monitors the delivery of resident care in conjunction with the hospice provider's services to meet the resident's needs. A review of the comprehensive plan of care revealed the facility failed to integrate hospice services care and interventions in the following areas for Resident 119: (1) Potential for pain-related behavioral health symptoms related to end-stage renal disease, (2) risk for adverse effects related to antipsychotic medication use, (3) risk for respiratory impairment related to chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), (4) actual skin breakdown related to impaired mobility, moisture, and refusals for care, (5) neurological deficiencies related to metabolic encephalopathy (inflammation of the brain), (6) sleep cycle issues related to medications and sleeplessness, (7) altered cognition and impairment related to dementia, or (8) activities of daily life deficiencies related to dementia and physical limitations. During an observation on May 21, 2026, at 11:00 AM, Resident 119's hospice communication tool was reviewed in the facility nursing station. The communication tool did not contain or account for the abovementioned care areas or corresponding interventions hospice staff perform when providing care to Resident 119. During an interview on May 21, 2026, at 1:15 PM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The NHA and DON were unable to provide documented evidence the facility integrated hospice care services into a comprehensive care plan for Resident 119. The facility failed to ensure the coordination of hospice services with facility services to meet the resident's needs. 28 Pa Code 211.12(d) (3) Nursing services.

Based on a review of the facility's Abuse Prohibition and Neglect Prevention policy, clinical records, physician orders, care plans, medication administration records, facility investigative documentation, and resident and staff interviews, it was determined the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one of nine residents reviewed (Resident 3), resulting in a Stage III pressure injury constituting actual harm due to neglect. Findings include: A review of the facility policy titled Resident Abuse & Neglect Prevention Program, last reviewed by the facility on May 30, 2025, revealed it is the facility policy that the facility has a plan in place to assure appropriate steps are taken to protect each resident from neglect. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated neglect is the deprivation by a caretaker of goods or services (failure to provide goods and services) necessary to maintain physical or mental health and avoid physical harm, mental anguish, or mental illness. The policy further indicated neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment, and care. A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnoses including incomplete quadriplegia (severe weakness or paralysis affecting all four limbs) and neurogenic bowel (loss of normal bowel control caused by damage to the nervous system). A review of Resident 3's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 19, 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 3's quarterly MDS assessment section GG Functional Abilities revealed the resident was dependent (helper does all of the effort and resident does none of the effort to complete the activity) on staff for bed mobility (the ability to roll from lying on the back to the left and right side and return to lying on the back while on the bed). A review of Resident 3's care plan initiated December 8, 2015, revealed the resident was at risk for impaired skin integrity related to decreased mobility. Interventions initiated on September 13, 2023, directed staff to promptly remove the bedpan (a shallow device used as a portable toilet by individuals confined to a bed, allowing them to urinate or defecate while lying or sitting down) after administration of an enema and discourage the resident from remaining on the bedpan longer than 30 minutes. Additional interventions initiated February 4, 2024, directed nurse aides on the 3:00 PM to 11:00 PM shift to report when the resident was removed from the bedpan. A review of Resident 3's care plan revealed an activities of daily life self-care performance deficit related to limited range of motion, limited mobility, and quadriplegia initiated on December 8, 2015. Interventions initiated on April 7, 2025, directed staff on the 11:00 PM to 7:00 AM shift to check the resident at the beginning of the shift and ensure he was removed from the bedpan. The care plan also directed assistance from two staff members for bed mobility due to the resident's physical limitations. A review of physician orders revealed an order initiated June 27, 2025, directing the nurse to validate that care was completed by the 11:00 PM to 7:00 AM shift nurse aides, including confirmation the resident was removed from the bedpan, peri-care (cleaning of the genital and buttock area to maintain hygiene and protect the skin) was provided, and bed linens were changed. A review of physician orders further revealed an order initiated April 11, 2025, for Fleet Bisacodyl rectal enema 10 milligrams/30 milliliters (a medication that involves injecting liquid into the rectum to stimulate a bowel movement) at bedtime for constipation (difficulty passing stool). A review of the April 2026 medication administration record revealed Employee 3, Licensed Practical Nurse (LPN), administered Resident 3 a bisacodyl rectal enema on April 24, 2026, at 10:00 PM. A review of the April 2026 medication administration record revealed Employee 3, LPN, documented on April 25, 2026, at 6:00 AM that the resident was off the bedpan and peri-care (cleaning of the genital and buttock area to maintain hygiene and protect the skin) had been provided by the 11:00 PM to 7:00 AM nurse aides. This documentation was completed more than seven hours after the resident had been placed on the bedpan. A review of the facility investigation and documentation provided during survey revealed no documented evidence staff completed the required intervention to verify Resident 3 had been removed from the bedpan during the overnight shift on April 24 through April 25, 2026. A review of a written witness statement from Employee 1, Nurse Aide (NA), revealed she assisted Employee 2, NA, in placing Resident 3 on the bedpan at approximately 10:50 PM on April 24, 2026. Employee 1 NA stated she was informed the resident was alert and oriented and would ring his call bell when he wanted off the bedpan. Employee 1 NA further stated she answered the resident's call bell at approximately 6:30 AM on April 25, 2026, and discovered the bedpan covered by a disposable pad. A review of a written witness statement from Employee 2, NA, dated April 27, 2026, revealed Employee 2 NA provided care to Resident 3 multiple times throughout the night but indicated the resident did not ask to be removed from the bedpan. Employee 2 NA stated Employee 1 NA requested assistance around 6:45 AM on April 25, 2026, to provide care to the resident. A review of facility provided investigative documentation dated April 25, 2026, revealed the on-call nurse responded to Resident 3's concern regarding overnight care. Resident 3 reported he fell asleep on the bedpan overnight and believed staff failed to reposition and remove him from the bedpan. Documentation revealed a full body skin assessment identified a new blister on the resident's coccyx (tailbone, located at the bottom of the spine). Documentation further revealed preventative and protective skin interventions were initiated and the resident was referred to external wound care services. A review of an external wound care progress note dated April 28, 2026, revealed Resident 3 developed a new wound to the coccyx after reportedly being left on a bedpan overnight at the facility on April 24, 2026. The wound was described as beefy red with necrotic tissue (dead tissue caused by loss of blood supply or pressure injury) and yellow discoloration. The wound was identified as a Stage III pressure injury (a full thickness skin wound extending into fatty tissue below the skin) measuring 5.1 centimeters by 11.4 centimeters by 0.3 centimeters with moderate serosanguineous drainage (fluid containing both blood and clear drainage). During an interview on May 5, 2026, at 10:31 AM, Resident 3 explained that staff put him on the bedpan nightly after he is given an enema to help him have a bowel movement. He indicated that he is unable to feel the bedpan because of his condition (quadriplegia affects sensation in the lower body, including the legs, feet, and torso, resulting in numbness, tingling, or a total loss of feeling). Resident 3 explained that about two weeks ago, (April 24, 2025), staff put him on the bedpan sometime after 10:00 PM, and he fell asleep. When he woke in the morning, he didn't realize he was still on the pan until staff provided care in the morning. He indicated that he was upset because he developed a new wound after being left on the bedpan all night. During an interview conducted on May 5, 2026, at 2:30 PM, the above findings were reviewed with the Nursing Home Administrator and Regional Consultant. Facility representatives acknowledged Resident 3 developed a pressure injury after staff failed to remove him from the bedpan overnight on April 24 through April 25, 2026. The facility neglected to provide the necessary care and services to protect Resident 3 from physical harm by failing to implement the resident's plan of care, follow physician orders, and ensure required staff monitoring and repositioning occurred after placement on the bedpan. This neglect resulted in actual harm when Resident 3 developed a Stage III pressure injury to the coccyx measuring 5.1 centimeters by 11.4 centimeters by 0.3 centimeters. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observations, a review of facility policy, and interviews with staff, it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of insects and pests for one floor out of two floors observed (First Floor). Findings include: A review of the facility policy titled Rodents and Pests, last reviewed by the facility on May 30, 2025, revealed that an exterminator is under contract by the nursing facility and available upon request. During an observation on May 5, 2026, at 11:01 AM, small black flies were observed in multiple areas of the kitchen. Five small black flying insects were observed flying near and on a floor drain to the right of the entrance from the facility hallway. Over 50 small black flying insects were observed flying near and landing on brown cardboard boxes and a clear plastic flour container in the dry storage area. Three small black flying insects were observed opposite the kitchen entrance on a stainless steel table. Additionally, multiple small black flying insects were observed flying throughout the kitchen during a walkthrough between 10:58 AM and 11:10 AM. During an interview on May 5, 2026, at 11:10 AM, Employee 5, dietary director, confirmed the presence of the small flying black insects in the kitchen. Employee 5, the dietary director, explained that the facility is waiting on the pest management company to treat the kitchen. She explained that she was not sure when the small black flies appeared in the kitchen but indicated that they were present for at least two weeks. During an interview on May 5, 2026, at 2:30 PM, the above information was reviewed with the nursing home administrator (NHA) and regional consultant (RC). The RC indicated that the last external pest control company visit was in September 2025. He explained that the facility's maintenance director was replaced and there was a lapse in pest management services. The facility failed to maintain an effective pest control program by allowing a lapse in pest prevention services, resulting in an infestation of small flying black insects in the facility's first-floor kitchen. 28 Pa. Code 201.18 (e)(2.1) Management.

Based on a review of clinical records, air mattress manufacturer guidance, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement pressure injury prevention interventions by failing to ensure specialty air mattresses were properly configured and operated according to manufacturer guidance and resident-specific weight parameters for two of nine residents reviewed (Residents 2 and 4).Findings include: A review of facility policy titled Pressure Injury Prevention, last reviewed by the facility on May 30, 2025, revealed it is the facility policy to provide evidence-based preventive skin care and wound treatment to prevent skin complications. The facility will provide pressure redistribution and relief devices (bed support surface) according to interdisciplinary assessment and recommendation. All standard mattresses are pressure-relieving and will be used for all residents unless the provider orders a higher level of pressure reduction or specialty mattress. Air mattress settings will be checked daily. A review of the facility's alternating air mattress manufacturer instruction manual revealed the mattress should first be inflated using the static setting (a temporary setting that keeps the mattress fully inflated during setup) and then changed to alternating mode for operation. Alternating mode continuously changes air pressure within the mattress to help reduce prolonged pressure on the skin and underlying tissue and assist in preventing pressure injuries (damage to the skin or underlying tissue caused by prolonged pressure). When properly indicated and configured, these systems support compliance with evidence-based pressure injury prevention protocols, particularly for high-risk populations, including immobile, bariatric, diabetic, neurologically impaired, and critically ill patients. The manufacturer's instructions further indicated mattress pressure settings should be adjusted according to the resident's weight to ensure appropriate pressure redistribution and support. The manufacturer guidance indicated the following settings based on resident weight:Residents weighing 85 to 140 pounds should be set between levels 1 and 2.Residents weighing 120 to 165 pounds should be set between levels 1 and 3.Residents weighing 150 to 193 pounds should be set between levels 1 and 4.Residents weighing 175 to 205 pounds should be set between levels 2 and 4.Residents weighing 200 to 250 pounds should be set between levels 3 and 5.Residents weighing 245 to 300 pounds should be set between levels 4 and 6.Residents weighing 300 to 350 pounds should be set at level 7. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function). A review of the care plan initiated on January 20, 2026, revealed Resident 2 had actual skin breakdown related to impaired mobility. Interventions included promote healing without complication include the use of an alternating pressure mattress and administration of treatments as ordered by the physician. A physician's order dated April 23, 2026, directed the use of an alternating pressure mattress (a motorized support surface designed to redistribute pressure through cycles of air inflation and deflation to help prevent and treat pressure injuries). A physician's order dated April 23, 2026, directed staff to check the function and settings of the alternating air mattress daily. A clinical record review revealed Resident 2 weighed 138.2 pounds on May 4, 2026. An observation on May 5, 2026, at 11:22 AM revealed Resident 2 was lying in bed on an alternating pressure mattress. The mattress soft-firm setting was positioned between levels 6 and 7 while the mattress remained on static mode. According to manufacturer guidance, a setting between levels 6 and 7 is intended for residents weighing approximately 245 to 350 pounds. Manufacturer guidance further indicated the static setting should be turned off and the alternating pressure setting activated during operation to ensure pressure redistribution. A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD). A physician's order for a low air loss concave mattress (a medical device that continuously circulates air to reduce moisture and heat to prevent skin breakdown) was initiated on January 4, 2026, for Resident 4. A review of the care plan initiated on September 7, 2022, revealed Resident 4 had actual or potential impaired skin integrity related to decreased mobility, fragile skin, and incontinence. Interventions included use of a low air loss mattress and administration of treatments as ordered by the physician. A clinical record review revealed Resident 4 weighed 114.8 pounds on April 27, 2026. An observation on May 5, 2026, at 11:30 AM revealed Resident 4 was lying in bed on an alternating pressure mattress. The mattress soft-firm setting was positioned at level 5. According to manufacturer guidance, level 5 is intended for residents weighing approximately 200 to 300 pounds. During an interview on May 5, 2026, at 11:32 AM, Employee 4, Registered Nurse (RN), confirmed Residents 2 and Resident 4's alternating air mattresses were not properly adjusted according to the residents' weights and manufacturer operational guidance. Employee 4 further confirmed Resident 2's mattress remained in static mode rather than alternating pressure mode. During an interview on May 5, 2026, at 2:30 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) and Regional Consultant (RC). The facility failed to ensure Resident 2 and Resident 4's alternating air mattresses were set per manufacturer's operational guidance and resident weight to prevent the development or worsening of pressure injuries. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, resident financial account documentation, billing records, and staff interview, it was determined the facility failed to provide a final accounting of personal funds for one discharged resident (Resident CR1) within 30 days of discharge, in accordance with regulatory requirements, for one of seven residents reviewed for resident funds.Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and was discharged on September 12, 2025. Review of financial documentation provided by the facility revealed that the resident's responsible party had paid the facility for the month of September 2025 in advance. Documentation provided by the facility included an email dated November 12, 2025, from the Nursing Home Administrator to the resident's responsible party indicating the resident's account had not yet been reconciled because the facility was awaiting payments from other sources and remained pending. Additional documentation revealed that on December 31, 2025, the responsible party received an account statement reflecting a credit balance on the resident's account. However, the facility was unable to provide evidence that this statement represented a final accounting of the resident's funds or that the full status of the account, including all charges, credits, and remaining balance, had been reconciled and clearly conveyed within 30 days following discharge. Review of the billing documentation provided by the facility included account statements covering the period from April 2025 through February 2026. However, the facility was unable to provide documentation demonstrating that a final accounting of the resident's personal funds, including the status of the account balance following discharge, had been provided or was clearly explained to the resident's responsible party within 30 days of the resident's discharge. Interview with the resident's responsible party on March 11, 2026, at 1:00 PM revealed that she had contacted the facility on several occasions to inquire about the status of the resident's account and reported that she did not receive clear information regarding the final status of the account following discharge. The responsible party reported that the last communication received from the facility was the account statement dated December 31, 2025. The responsible party indicated that the information was needed in order to complete financial matters related to the resident's estate. During an interview on March 11, 2026, at 1:45 PM, the Nursing Home Administrator was unable to provide documentation demonstrating that a final accounting of Resident CR1's personal funds, including the status of all charges, credits, and remaining balance, had been completed and conveyed within 30 days following discharge from the facility. The facility's responsibility to complete and convey a final accounting of the resident's personal funds within 30 days of discharge is separate from any requirement related to the disbursement of funds. The facility failed to demonstrate that it reconciled the account and provided a clear and final accounting of Resident CR1's personal funds within the required timeframe. As of the time of the survey in March 2026, the facility had not provided evidence that the final accounting and status of Resident CR1's personal funds had been completed and conveyed within 30 days following discharge. 28 Pa. Code: 201.18 (b)(2)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of clinical records, facility policy, resident interviews, and staff interviews, it was determined the facility failed to develop and implement an individualized discharge planning process that addressed residents' discharge goals and incorporated those goals into the resident's comprehensive care plan for two of seven residents reviewed (Residents 3 and 4). Findings include: A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves and may involve hallucinations, delusions, and disorganized thinking). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 2 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the cognitive section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates cognition is intact). The assessment documented in Section Q (the portion of the MDS used to record resident discharge goals and preferences) that the resident's overall discharge plan was unknown and indicated that no active discharge planning process was occurring for a potential return to the community. A review of Resident 3's comprehensive care plan, initiated September 16, 2025, and reviewed March 11, 2026, revealed the care plan did not include interventions, goals, or planning related to discharge preferences, discharge planning activities, or barriers to discharge. Review of the clinical record and resident information revealed Resident 3 expressed a desire to return to the community and live with his sister. During an interview, the Director of Nursing on March 11, 2026 at 1:30 PM she stated the resident's sister did not want the resident to live with her and the resident had a complex history that made discharge to the community difficult; however, documentation reflecting these discharge considerations, planning activities, or barriers was not incorporated into the resident's care plan. A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (a condition characterized by the progressive loss of cognitive functioning, including memory, reasoning, and the ability to perform everyday activities). A review of a quarterly MDS dated [DATE], revealed that Resident 4 was moderately cognitively impaired with a BIMS score of 12 (a score of 8 through 12 indicates moderate cognitive impairment). The MDS indicated in Section Q that the resident's overall discharge plan was unknown and documented that no active discharge planning process was occurring for the resident to return to the community. A review of Resident 4's comprehensive care plan, initiated August 19, 2025, and reviewed March 11, 2026, revealed the care plan did not include discharge planning goals, interventions, or evaluation of discharge options. The clinical record revealed Resident 4 was previously discharged from the facility on June 21, 2025, but returned to the facility on August 19, 2025, following an unsuccessful discharge. Documentation in the record indicated the resident continued to express a desire to return to her home. During an interview on March 11, 2026, at 9:40 A.M., the Social Services Director stated Resident 4 occasionally expressed a desire to return home but the discharge was considered unsafe due to the resident's inability to care for herself and the condition of the home environment, which was described as uninhabitable. The Social Services Director confirmed a discharge care plan addressing the resident's stated preference, barriers to discharge, or alternative discharge options had not been developed. During an interview on March 11, 2026, at 2:15 P.M., the Nursing Home Administrator and Director of Nursing were unable to provide documentation demonstrating individualized discharge care plans had been developed for Residents 3 and 4. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.18(e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to provide person-centered care as prescribed to meet the resident's current clinical needs and failed to follow physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for one of 7 sampled residents (Resident 2).Findings include: A review of the facility policy entitled PICC Dressing Change Policy, (PICC, a long, thin tube inserted into a vein and advanced to larger veins near the heart to deliver medications such as antibiotics directly into the bloodstream) last reviewed May 30, 2025, indicated staff are to change the transparent semi-permeable barrier dressing (a covering that allows gases such as oxygen to pass through while preventing bacteria and fluids from entering) every seven days and immediately if the dressing becomes loose, wet, soiled, or non-occlusive (not sealed and allowing fluid or air to pass through), or if bleeding or drainage is present. A review of the facility policy entitled PICC Tubing (IV Administration Set) Change Policy, last reviewed May 30, 2025, revealed staff are to change intermittent administration sets (IV tubing used for medications that are not infused continuously) every twenty-four hours, change needleless connectors every 96 hours or with tubing changes, and maintain a closed system (a system designed to prevent exposure of the IV line to air or contaminants). A review of the clinical record revealed Resident 2 was admitted on [DATE], with diagnoses including a fracture (a break in a bone) of the left leg and active methicillin-susceptible Staphylococcus aureus (MSSA, a type of bacteria that can cause serious infections but is treatable with certain antibiotics). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 19, 2026, revealed that Resident 2 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of hospital documentation revealed Resident 2 had a PICC line inserted on February 12, 2026, for long-term intravenous antibiotic therapy. A review of Resident 2's comprehensive care plan, initiated February 16, 2026, and most recently revised February 20, 2026, identified the resident had a PICC line for antibiotic therapy however, the care plan failed to include measurable goals, specific interventions, or monitoring related to PICC line care and intravenous antibiotic administration. Physician orders dated February 18, 2026, directed staff to change the PICC dressing weekly on Tuesdays and as needed. A physician order dated February 18, 2026, directed staff to administer vancomycin (an antibiotic medication used to treat serious bacterial infections) 1000 milligrams (mg) intravenously (IV, within the vein) two times a day until March 25, 2026. A review of a nurse progress note dated February 22, 2026, at 4:04 PM, revealed the PICC line was not patent (not open or allowing fluid to pass through), would not allow infusion of vancomycin, and had been pulled out of the insertion site 5 centimeters (cm, a unit of measurement equal to 0.39 inches). The resident was sent to the emergency room for evaluation.A review of hospital documentation dated February 23, 2026, revealed Resident 2 presented with a PICC line malfunction and required replacement of the catheter. The PICC line was replaced and documented as inserted to 42 cm with 0 cm external at the skin. A review of the clinical record revealed no documented evidence that staff monitored arm circumference (measurement around the arm used to detect swelling that may indicate infection or thrombosis/clot) or measured and documented the external catheter length (the portion of the catheter visible outside the body used to identify movement or displacement), despite known complications with the PICC line. On March 11, 2026, at 10:20 AM, observation of Resident 2 revealed a PICC line in the right arm with a dressing in place (a sterile covering applied to protect the insertion site from contamination). The dressing was peeling at the bottom, contained yellow drainage throughout most of the surface, and was dated February 28, 2026. The date was difficult to read due to the condition of the dressing. Resident 2 stated it had been a long time since the dressing was changed. Employee 1, Registered Nurse Unit Manager, confirmed these observations and acknowledged the dressing should have been changed in accordance with the seven-day requirement and due to visible drainage.At the same time, observation of the IV pole revealed an empty antibiotic bag connected to IV tubing that was not labeled with a date, time, or initials. The tubing was hanging freely without a sterile end cap (a protective sterile cover placed on the end of IV tubing to prevent contamination). Employee 1 Registered Nurse Unit Manager confirmed these observations. Observation revealed no emergency PICC supplies were present in the resident's room. An emergency PICC kit (a set of sterile supplies including a clamp and dressing materials used to quickly secure the catheter if it becomes dislodged, leaks, or breaks) was not available. Clinical record review revealed no physician order or documentation requiring or monitoring the presence of an emergency kit at the bedside. The absence of this equipment increased the risk of delayed response to catheter complications, which may result in bleeding, infection, air entering the bloodstream, or loss of IV access. Employee 1, Registered Nurse Unit Manager, confirmed these observations.A review of the March 2026 Treatment Administration Record (TAR, a record used to document treatments provided to a resident) revealed the dressing change scheduled for March 10, 2026, was documented as completed, however, this documentation was inconsistent with the observed condition of the dressing on March 11, 2026, which remained dated February 28, 2026, and visibly compromised. During an interview on March 11, 2026, at 12:00 PM, the Director of Nursing reviewed and confirmed the above findings, including the failure to maintain the PICC dressing, failure to ensure proper tubing management, lack of monitoring of the catheter, absence of emergency supplies, and inaccurate documentation. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement necessary safety interventions for one of 21 residents reviewed (Resident 90), who had been identified as at risk for falls which resulted in actual harm, bilateral periprosthetic knee fractures.Findings include:A review of the facility policy titled Falls and Fall Risk Management, last reviewed by the facility May 2025, revealed it is the facility's policy that based on previous evaluations and current data, staff will identify interventions related to the resident's specific fall risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. Also, the policy indicated that the interdisciplinary team, with the input of the attending physician as appropriate, will identify appropriate intervention to reduce the risk of falls.A clinical record review revealed Resident 90 was admitted to the facility on [DATE], with diagnoses that included paraplegia (a condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body). An admission falls risk assessment dated [DATE], identified the resident was at high risk for falls, due to being bedbound and dependent on staff for assistance with elimination.A physician's order for oxycodone HCI oral tablet (an opioid analgesic medication) with directions to give 1 tablet by mouth every 8 hours for pain was initiated on June 23, 2025.An Occupational Therapy (OT) evaluation dated June 23, 2025, documented that Resident 90 had serious physical limitations, including weakness in both arms, poor balance, and low activity tolerance. The evaluation concluded that Resident 90 was at risk of falling and required full assistance from staff for bed mobility and lower body dressing. The therapist recommended that two staff members be present to safely move the resident in bed due to her physical condition and care needs.This recommendation was confirmed during an interview conducted on July 24, 2025, at 12:05 PM, with the Director of Therapy, who explained the recommendation for two staff was based on the resident's physical size and functional limitations. The Director stated that after therapy staff evaluate a resident's needs, it is the responsibility of the nursing department to review those recommendations and make sure they are included in the resident's care plan, so that direct care staff know what assistance is required.However, a review of the Resident 90's care plan showed no documented evidence the recommendation for two staff to assist with in-bed care was ever added. The care plan did not include this information, even though both the therapy and nursing evaluations identified the resident as needing more help to safely receive care in bed, specifically that two staff members were needed for bed mobility. As a result, staff were not given clear instructions on how many people were needed to safely care for the resident in bed or to help reduce the chance of a fall.Progress notes dated June 26, 2025, at 8:40 PM, documented that Resident 90 sustained a fall during the shift. According to the note, while Employee 1, a Nurse Aide (NA), was changing the resident following a bowel movement, the resident's legs slid off the side of the bed. The aide lowered the resident to the floor, and staff used a mechanical lift to return the resident to bed. The resident complained of pain in the left knee, rated as 10 out of 10 on the pain scale (0 indicating no pain and 10 indicating the most severe pain). The note indicated the resident's skin was intact, with no redness or bruising noted at the time. The physician and family were notified, and the resident was sent to the emergency department for evaluation.A review of the Medication Administration Record (MAR) for June 2025 confirmed that on June 26, 2025, at 9:38 PM, Resident 90 was administered oxycodone HCl 5 mg (a narcotic pain medication) in response to the reported pain level of 10 out of 10.During an interview on July 24, 2025, at 11:55 AM, Employee 2, a Licensed Practical Nurse (LPN), recalled he was working the 3:00 PM to 11:00 PM shift on June 26, 2025. Employee 2, LPN, explained he was alerted by a female nurse aide (unable to recall name) that Resident 90 was falling from the bed. Employee 2, LPN, recalled Resident 90 on the floor when he responded to the room. He indicated he did not see the resident fall. Resident 90 was on the floor when Employee 2, LPN, entered the room. He instructed the nurse aides to obtain a mechanical lift to transfer the resident back to bed. He did not recall if the resident was in pain following the fall.During an interview on July 24, 2025, at 1:30 PM, Employee 1, NA, explained that on June 26, 2025, at approximately 3:30 PM, Resident 90 needed to be cleaned and changed after having a bowel movement. Employee 1, NA, recalled the care plan on that day indicated that Resident 90 only needed the assistance of one staff for bed mobility and hygiene. Employee 1, NA, explained that it was difficult to change and clean Resident 90 because she was not able to hold a position. She needed to reposition the resident a few times to get a good angle to clean her. While providing care, Resident 90's legs began to slide off the side of the bed, legs first. Employee 1, NA, recalled needing to call for other staff to respond. Employee 1, NA, lowered Resident 90 to the floor. After the resident was on the floor, Employee 1, NA, and other staff assisted the resident back to bed with the mechanical lift. Employee 1, NA, recalled resident 90 complained of pain following the event.Additional facility documentation dated June 26, 2025, described the incident, similarly, stating that Resident 90 slid out of bed while being changed after a bowel movement. The resident was lowered to the ground by staff, pain medication was administered, and range of motion was assessed. The document confirmed the mechanical lift was used by two staff to return the resident to bed. It also noted the resident had left knee pain, limited range of motion, and was sent to the emergency department for further evaluation.A review of hospital discharge documentation dated July 3, 2025, revealed that Resident 90 was admitted to the emergency department on June 26, 2025, following a reported fall from bed while being changed by facility staff. The emergency department records indicated the resident was noted to have significant tenderness in the lower extremities, including both knees and the right hip, with visible swelling of the right knee upon examination.Although the hospital documented the possibility of a head strike, particularly relevant given the resident's use of anticoagulation therapy (a medication that reduces the blood's ability to clot), there was no supporting documentation or interview evidence from the facility indicating that the resident struck her head during the fall. A trauma workup, including imaging studies, found no acute intracranial (within the skull) injuries.However, x-rays confirmed multiple serious injuries, including bilateral periprosthetic knee fractures (fractures occurring around previously implanted knee prostheses), and a displaced fracture of the left distal femur (the lower part of the thigh bone). The right femur was also found to have acute fractures involving both the medial and lateral femoral condyles which are the rounded projections at the end of the thigh bone that form part of the knee joint.An orthopedic consultation recommended the use of posterior leg splints, removable supports placed behind the legs, to immobilize the limbs during any movement, as the resident was already non-weight bearing. The hospital also recommended ongoing pain management and outpatient follow-up with orthopedic specialists after discharge.Further clinical record review revealed Resident 90 was not readmitted to the facility after being hospitalized on [DATE]. Resident 90 was not available for interview.During an interview on July 25, 2025, at approximately 10:45 AM, the Director of Nursing (DON) and Nursing Home Director (NHA) were not able to provide documented evidence that Resident 90's assessed risk for falls or interventions required to prevent falls were developed or implemented. The DON and NHA confirmed that following therapy and nursing evaluations, residents' interventions should be implemented to ensure residents' risk for falls is prevented and that adequate safety interventions are implemented for residents identified as at risk for falls.Refer F65528 Pa Code 201.18(b)(1) Management.28 Pa Code 211.10 (d) Resident care policies.28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the food and nutrition services department on July 22, 2025, at 10:45 AM revealed a tray of seven (7) thawed 4-ounce nutritional shakes on a shelf in the walk-in refrigerator. The defrost date on the shakes was June 5, 2025. The manufacturer's label specified the product must be used within 14 days of thawing. As of the date of observation, the shakes had been thawed for over six (6) weeks, well beyond the recommended use period, posing a risk for microbial growth and potential foodborne illness. Continued observation of the walk-in refrigerator revealed a one-gallon container of salad dressing, which was opened but with no date of opening, and a one-gallon container of BBQ sauce, which was opened but with no date of opening. During an interview with the Food Service Director (FSD) at the time of the observation, it was stated that both products are considered safe for up to three (3) months after opening if kept refrigerated. However, the absence of opening dates prevents the ability to determine product viability, representing a failure in proper food labeling and tracking procedures. Further observation of the walk-in refrigerator revealed a 32-ounce carton of liquid eggs, which was opened but not dated. Manufacturer's instruction indicated the product must be used within three (3) days after opening. The absence of opening dates prevents the ability to determine product viability. During an interview conducted on July 22, 2025, at 11:00 AM the FSD confirmed that food and beverages are expected to be labeled, dated, stored, and thawed in accordance with food safety standards. The facility failed to ensure that food was labeled, stored, and used within safe timeframes, in accordance with federal food safety standards and the manufacturer's guidelines. 28 Pa. Code 201.18 (e)(2.1) Management.

Based on review of select facility policy, observations and staff interview, it was determined the facility failed to provide meal service in a manner that maintained the resident's dignity by allowing extended delays in meal delivery at shared tables for seven residents out of 21 sampled (Residents 33, 15, 67, 35, 2, 23, and 37)Findings include:Review of the facility policy titled Resident Rights last reviewed by the facility on May 30, 2025, revealed the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. An observation conducted on July 22, 2025, at 12:10 PM, revealed Residents 33, 15, 67, and 35 were seated together at Dining Table #5 in the main dining room. At 12:20 PM, Resident 35 was served her lunch meal and began eating. The other residents seated at the same table remained without meals. Staff continued serving lunch to other residents in the dining room. At 12:35 PM 15 minutes after Resident 35 received her meal Resident 67 was served. At 12:40 PM 20 minutes after Resident 35 was served Residents 15 and 33 were provided with their meals.Additional observation on July 22, 2025, at 12:33 PM, revealed Residents 2, 23, and 37 were seated together at Dining Table #4. Resident 2 was served her lunch at 12:33 PM. Resident 23 received her meal at 12:43 PM, and Resident 37 at 12:46 PM 13 minutes after the first resident at that table was served.During an interview conducted on July 22, 2025, at 12:50 PM, Employee 5 (nurse aide) reported that there were not enough staff members assigned to the dining room to ensure timely delivery of meals and assistance. Employee 5 further stated the meal trays are not organized by table but are randomly placed on the meal cart, which delays service to some residents at shared tables.During an interview conducted on July 23, 2025, at 12:20 PM the observations were reviewed with the Nursing Home Administrator and Director of Nursing, and they confirmed the lunch meal service in the main dining room was not conducted in a timely or coordinated manner.The facility failed to ensure that residents were provided meals in a dignified manner by allowing extended delays in meal service for residents seated at the same dining table.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of the facility's abuse prohibition policy, select investigative reports, and clinical records, and resident and staff interviews, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for two residents out of the seven sampled (Residents 30 and 42) resulting in serious injuries including a fractured femur, scalp laceration, and multiple pressure injuries. Findings include: A review of the facility policy titled Resident Abuse & Neglect Prevention Program dated as last revised by the facility in November 2022, revealed that management and staff are jointly and individually responsible to ensure each resident shall be free from abuse, neglect and misappropriation of property. Further policy review revealed that the facilities define neglect as the deprivation by a caretaker of goods or services (failure to provide goods and services) necessary to maintain physical or mental health and avoid physical harm, mental anguish, or mental illness. A clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses to include atrial fibrillation (a type of irregular heart rhythm), osteoarthritis (degeneration of the joint) in both knees, and chronic obstructive pulmonary disease (a disease that damages the lungs in ways that make it hard to breathe). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 10, 2023, indicated that Resident 30 was dependent on facility staff and required the assistance of two staff members for transfers (how the resident moves between surfaces, including to or from a bed, chair, or wheelchair). Resident 30's plan of care dated October 11, 2019, for activities of daily living (ADLs) self-care performance deficit due to fatigue, impaired balance, limited mobility, limited range of motion, and pain revealed planned interventions that Resident 30 required the use of a mechanical full-body lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with the assistance of two staff. A physician's order dated February 17, 2021, was also noted for staff to utilize a full-body Hoyer Lift (a powerful mechanical lift and mobility tool utilized for transferring residents) when transferring Resident 30. A nursing progress note dated March 1, 2023, at 1:00 p.m. indicated that Resident 30 was lying on the floor on the side of the bed. The note indicated that the resident fell off the mechanical lift while being transferred from an electric wheelchair to a bed. The resident reported falling off the lift and denied a head injury; however, facility staff stated that blood was present on the floor. A nursing progress note dated March 1, 2023, at 12:25 p.m. indicated that Resident 30 was to be transported to the the emergency room for evaluation and possible treatment after sustaining an injury. The hospital history and physical dated March 2, 2023, at 9:47 a.m., noted that Resident 30 sustained a hematoma (collection of blood outside of the blood vessels) on the back of the head, a 4 cm laceration on the scalp requiring sutures, a right femur (thigh bone) closed fracture requiring surgery, and ecchymosis (bruising) on the right leg. The hospital documentation indicated that while receiving treatment in the hospital, the resident became tachycardic (accelerated heart rate), was administered a blood transfusion, and was then admitted to the intensive care unit. The hospital operative report, dated March 2, 2023, at 9:17 a.m., noted that Resident 30's femur was surgically repaired, and a drain was inserted in the resident's right calf to reduce extreme swelling and serous blisters (blisters filled with clear liquid). Nursing notes March 9, 2023, at 12:26 p.m. indicated that the resident returned to the skilled nursing facility. Admission nursing skin observation dated March 9, 2023, indicted that Resident 30 was assessed with the following injuries: Jawline bruising measuring 9.0 cm x 3.0 cm Laceration on the back of the scalp measuring 4.0 cm x 3.0 cm Right hip sutures measuring 3.0 cm x 2.0 cm Left antecubital (area of the arm opposite the elbow) bruising measuring 2.0 cm x 1.0 cm Right antecubital (area of the arm opposite the elbow) bruising measuring 7.0 cm x 4.0 cm Left lower leg bruise measuring 15.0 cm x 13.0 cm A second left lower leg bruise measuring 13.0 cm x 13.0 cm Nursing progress notes and the resident's March 2023 Medication and Treatment Records for March 2023 revealed that Resident 30 reported experiencing intermittent pain ranging from mild to severe from March 9, 2023, through March 19, 2023. A review of the facility's investigation report revealed that Resident 30 fell and sustained injuries when Employee 1, nurse aide, failed to follow the resident's plan of care and attempted to transfer the resident with the mechanical lift without the assistance of a second staff member present. The facility's investigation also determined that Employee 1 provided false statements during their investigation regarding the number of staff that were utilized to transfer Resident 30 at the time of the incident. A witness statement provided by Employee 2, nurse aide, dated March 2, 2023, indicated that {Resident 30} was laying on the ground by (the) bed, with the Hoyer pad still attached to the machine. {Employee 1} was the only staff person in the room. Employee 2 also indicated that Employee 1 attempted to have Employee 2 provide a false statement about the incident. In the same statement, Employee 2 reported that {Employee 1} kept coming up to me and saying, stick to what I told you that you were in the room, and you don't know anything else. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 25, 2023, at approximately 2:30 p.m., confirmed that Employee 1 transferred Resident 30 without the assistance of a second person as the resident required resulting in serious physical injury to the resident. Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses to include incomplete quadriplegia (severe or complete loss of motor function in all four limbs) and neurogenic bowel (loss of bowel control due to brain or spinal cord damage). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 20, 2023, indicated that Resident 42 was dependent on facility staff and required the assistance of two staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and toilet use (how resident uses the toilet room, commode, bedpan, or urinal and transfers on or off toilet) and was cognitively intact with Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score was 15. Resident 42's plan of care in place for activities of daily living (ADLs) dated April 13, 2023, revealed a self-care performance deficit due to quadriplegia, limited physical mobility, and limited range of motion with planned interventions that Resident 42 would continue with the bowel program nightly and continue to use a bedpan. Resident 42's plan of care, dated April 13, 2023, also indicated that the resident was at risk of developing impaired skin integrity due to decreased mobility with planned interventions for staff to turn and reposition the resident every 2 hours while in bed. During an interview on July 25, 2023, at 10:30 a.m., Resident 42 stated that the planned bowel program begins at 10:00 p.m. Staff administer the resident's first enema at 10:00 p.m. and a second enema at 11:00 p.m. After receiving the enema, the resident sits on the bed pan until he has a bowel movement and staff provide care. The resident further explained that on May 21, 2023, after being administered the second enema, no staff came to remove the bed pan. I don't have much sensation below my waist, so I remember being uncomfortable, but I didn't feel the bed pan. I fell asleep, and it wasn't until the morning that staff noticed that I was still on the pan. Staff did not turn me throughout the night. The resident's clinical record failed to reveal evidence that staff turned and repositioned every two hours on May 21, 2023 11:00 p.m. through May 22nd, 2023 8:00 a.m., as indicated in the resident's plan of care. The facility investigation dated May 22, 2023, included a witness statement from Employee 6, nurse aide, indicating the Employee 6 rolled Resident 42 in the morning of May 22, 2023, the bedpan was stuck to the resident's buttocks, and feces were observed everywhere. Employee 6 indicated that the resident's skin had huge indentations from the bed pan and the resident was covered with blood, feces, and urine. A nursing progress note dated May 22, 2024, at 9:00 a.m. indicated that Resident 42 was found on the bedpan while in bed. The resident's skin was observed to have bilateral buttocks wounds, bilateral posterior thighs wounds, and a sacrum wound. A skin observation tool dated May 22, 2023, indicated that the resident had the following skin injuries: Sacrum pressure injury measuring 1.3 cm x 11.0 cm x 0.1 cm (Stage II Pressure Injury- Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters. Stage 2 pressure ulcers are shallow with a reddish base) Left buttock pressure injury measuring 9.3 cm x 1.2 cm x 0.2 cm (Stage II Pressure Injury) Right buttock pressure injury measuring 9.3 cm x 1.0 cm x 0.2 cm (Stage II Pressure Injury) Left gluteal fold pressure injury measuring 3.0 cm x 0.6 cm x 0.2 cm (Stage II Pressure Injury) Right gluteal fold pressure injury measuring 3.0 cm x 0.8 cm x 0.2 cm (Stage II Pressure Injury) Left rear thigh pressure injury measuring 8.5 cm x 0.8 cm x 0.2 cm (Stage II Pressure Injury) Right rear thigh pressure injury measuring 19 cm x 0.7 cm x 0.2 cm (Stage II Pressure Injury) A witness statement provided by Employee 3, licensed practical nurse, dated May 22, 2023, at 12:50 p.m. indicated that she went to Resident 42's room around midnight (May 21, 2023 into May 22, 2023). Employee 3 stated that the resident did not report being on a bedpan. Employee 3 stated that everyone knows the 11 PM to 7 AM shift takes the resident off the bedpan. Employee 3 stated that Employee 4, nurse aide, should have taken him off the bedpan. A witness statement provided by Employee 4, nurse aide, dated May 22, 2023 p.m. revealed that she denied placing a bedpan under the resident. Employee 4 stated, No one informed me that a bedpan was placed under him. I did my last rounds around 4:00 a.m. (May 22, 2023) Employee 4 indicated that the resident was last turned and checked at 4:00 a.m. (May 22, 2023) An employee witness statement dated May 22, 2023, by Employee 5, licensed practical nurse, indicated that Resident 42 was administered a first enema at 11:00 p.m. (on May 21, 2023) and a second enema at 12:00 a.m. (on May 22, 2023) Also, Employee 5 stated that a verbal report was provided to Employee 3 with the time Resident 42 was administered the last enema and instructions that the resident was still on the bedpan and needed to be cleaned up. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 25, 2023, at approximately 2:30 p.m., that staff neglected to provide Resident 42 the care planned for the resident's bowel program and turning and repositioning to prevent multiple skin injuries. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on observations, a review of clinical records, select facility policy, current CDC (Centers for Disease Control and Prevention) and PAHAN (Pennsylvania Health Alert Network) infection control guidance and staff interview, it was determined that the facility failed to consistently implement infection control precautions necessary to deter the spread of the COVID-19 virus in the facility, which placed residents in immediate jeopardy due to the increased risk of likely spread of COVID-19 that may potentially cause serious illness, hospitalization and/or death. Findings include: A review of the Pennsylvania Department of Health 2022 - PAHAN - 663 - 10-04-UPD dated October 4, 2022, subject: UPDATE: Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic. This HAN Update provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by CDC on September 23, 2022. Key definitions referenced in the PAHAN included a close contact: someone who is within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, during their infectious period. The infectious period begins from 2 days before illness onset or for asymptomatic (without symptoms) patients, 2 days prior to specimen collection date of the positive test. Source control definition: Use of well- fitting cloth masks, well-fitting facemasks, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when breathing, talking, sneezing, or coughing. Up to date: In general, being up to date on COVID-19 vaccination includes receiving all vaccines according to the recommendations provided by CDC. This includes a primary series of vaccine, booster doses, and any recommended third doses for immunocompromised people. For specifics, refer to CDC guidance. Isolation for residents: The term isolations refer to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, health care professionals, or visitors. Isolation in long term care facility residents includes the use of standard and transmission- based precautions for COVID-19 and a private room with a private bathroom or another resident with laboratory confirmed COVID-19, preferably in a COVID Care Unit and restrict the resident to their room with the door closed. (In some circumstances keeping the door closed may pose resident safety risks and the door might need to remain open. If the door remains open, work with facility engineers to implement strategies to minimize airflow into the hallway). An outbreak is considered one or more COVID-19 cases in a facility. If residents develop signs and symptoms of COVID-19 perform [CONDITION(S)] testing, implement isolation while tests are pending and place unvaccinated roommate(s) under quarantine immediately. Do not place a person with suspected COVID-19 into a COVID care unit prior to confirmation of infection by positive test result. Managing residents with exposure: to include use of standard and transmission- based precautions for COVID-19 and always maintain source control while around others; and be placed in a single room. If limited single rooms are available or if numerous residents are simultaneously identified to have known to have [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter- in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2; and restrict the resident to their room; and Quarantine for residents should extend 10 days from the date of the last exposure, regardless of the results of testing, unless the resident should become symptomatic or positive for [CONDITION(S)]-CoV-2 during that period. Limited circumstances where units or facilities might be considered zones. For COVID-care units (RED zone), for admission units designated for unvaccinated residents (YELLOW zone)- a unit based or facility-wide approach to outbreak response where all residents are undergoing quarantine (YELLOW zone) because none are fully vaccinated, or the facility has been advised to do so to respond to an outbreak with ongoing transmission. The facility has a licensed and certified bed capacity of 174 beds. On October 18, 2022, the facility census was 82. At the time the survey began on October 18, 2022, there were 16 residents positive for COVID-19. Observations during a tour of the facility on October 18, 2022, revealed that two of these residents resided on the A units in private rooms. The additional 14 residents resided on the B wing. There were two hallways in the B wing, 4 residents on one hallway and 10 on the second hallway. The unit had a separate entrance and exits, which were clearly marked as such. A review of the facility's policy entitled, COVID-19 protocols and procedures; outbreak protocol revised October 2021, revealed that As per the facility infectious disease policy and procedure, traditional standards for care may need to be altered to maximize health care flexibility to adjust to the COVID-19 pandemic. The facility will continue to use CMS, CDC and DOH for surveillance guidelines and recommendations. Confirmed [CONDITION(S)]-CoV 2 (COVID-19) positive residents who triggers positive on a Rapid Antigen [CONDITION(S)] test will be transferred to the B wing, (Red) isolation zone. Droplet precautions will be initiated when either a suspected or confirmed infectious or communicable disease is identified. Please follow CDC recommendations for COVID-19 (droplet precautions). Droplet precautions to included the following: PPE: -Staff, providers and visitors must wear gown, gloves, mask and eye goggles at all times while in the room; goggles and masks as needed for splashes; Remove PPE before leaving the room; do not wear PPE outside the room unless absolutely necessary. The facility's COVID-19 Infection Control policy had not been reviewed and revised since October 2021 to reflect the most current guidance recommended by the CDC. An observation of the B unit COVID, isolation unit, October 18, 2022, at approximately 10 A.M., revealed Employee 12 (agency nurse aide) and Employee 13 (housekeeping) in the 1 hallway with their N-95 masks below their noses. These two employees were not correctly wearing PPE. An additional observation on October 18, 2022, at approximately 11:45 AM revealed Employee 12 was again observed on the 1 hallway, with her N-95 mask below her nose. The observation was confirmed by the facility Infection control nurse at the time of the observation. She verbally educated Employee 12 to adjust her mask to cover her nose. At 1:30 P.M. Employee 12 was again observed on the B, COVID isolation unit for the third time with her N-95 mask under her nose despite prior reeducation by the facility's infection control nurse earlier that shift. At that time Employee 20 (agency nurse aide) was also observed wearing her N95 mask under her nose. An observation October 19, 2022 at 10 A.M., 12 PM and again at 2 PM, Employee 21 (agency LPN) was observed on the COVID isolation unit (B unit) wearing his N95 mask under his nose with the bottom strap hanging under his chin. An observation October 19, 2022, at approximately 11 AM revealed Employee 15 (agency nurse aide) exited the B unit (COVID isolation unit) into the outside hallway (neutral areas of nursing offices, activities and business office) with her coat on over her isolation gown. She also had taken off her N95 face mask upon entering the neutral area. Employee 15 did not doff her contaminated isolation gown prior to entering the neutral area. During an interview at the time of the observation, Employee 15 stated that she was on her way outside of the facility for her break. Employee 15 stated that this was the first shift she had worked at the facility. Employee 15 said she had not received any education or inservicing on facility policy's and procedures including infection control and COVID procedures. She stated that she did not know that she was to doff the isolation gown before leaving the B unit. An observation October 20, 2022 at 11:20 A.M., revealed Employee 14 (agency nurse aide) walked into the Covid isolation B unit without PPE. Once in the COVID unit, she donned PPE. The resident room doors were open to the hallway. Employee 14 then left the B unit through the entrance doors to the green area, picked up resident supplies and returned to the Covid isolation unit, without doffing contaminated PPE and donning new PPE. A review of the facility policy for food transport cart cleaning for COVID-19 isolation, reviewed October 2020 revealed The facility strives to give all residents meals at an acceptable temperature, even those residents who reside in the COVID19 yellow isolation (quarantine). EPA approved ECO-lab smart power (cleaning solution) will be used to disinfect food transport carts prior to exiting COVID-19 isolation units. The cleaning procedure was as follows: 1. Food transport cart will be disinfected with ECO labs Smart Power solution. a. Smart Power will be stored in the janitors closets located in the isolation zone. b. After completed meals, trays are collected and placed in the food transport cart. The nurse aide or designated staff member will obtain Smart Power ans spray each tray in the cart. c. The cart will then be closed and the nurse aide or designee will spray the outside of the cart focusing on high touch areas such as handles. d. The cart will sit in the yellow zone for at least 60 seconds after it is sprayed. 2. The food transport cart will be removed from the isolation zone and placed outside of the isolation zone. a. The dietary staff will re-spray the outside of the food transport cart and the cart will sit for at least 60 seconds. b. The food cart will then be transported via the biohazard service elevator (red elevator) and taken to the dietary department. This policy was last updated in October 2020 and did not reflect the facility's current COVID-19 outbreak, including use of the current B unit covid isolation unit (Red zone), not yellow zone as noted in the policy. Observation on October 18, 2022, at approximately 10 AM on the B unit outside the closed doors to the COVID isolation unit revealed two partially eaten resident meals from the prior night's dinner remaining were on a food cart. The eating utensils and dinnerware were on top of the trays. Additional observation at 3 PM that afternoon revealed that the same two residents trays had not been removed from the cart. An observation October 18, 2022 at approximately 12 P.M., revealed that dietary staff pushed the meal delivery cart through the closed doors of the B unit, hallway 1, (COVID-19 positive) isolation unit. The two nurse aides assigned to the unit, distributed the 10 resident trays to the residents on that hall. The nurse aides then, without cleaning the food cart or changing their PPE, left the red hallway through the doors marked entrance and brought the food delivery cart through the area marked green (indicating a COVID free zone) wearing their contaminated PPE. The aides then entered hallway 2 and passed the remaining lunch meal trays. At approximately 12:45 P.M., the nurse aides picked up the resident trays, placed the trays back onto the meal delivery cart on hallway 2. The aides brought the meal cart through the green zone and reentered the 1 hallway on the red unit, placed the resident trays onto the meal cart and took meal cart through the door marked entrance to the COVID unit. The meal delivery cart was not disinfected by nursing staff or dietary staff before entering the green unit. The two nurse aides did not change PPE prior to leaving the COVID 1 hallway, entering a non-covid green zone and then entering the 2 hallway of the COVID unit. An observation October 19, 2022 at approximately 12 PM. revealed that the both the dietary and nursing staff used the same practice for meal delivery. Dietary staff brought the meal cart to the B wing isolation doors. The nurse aides then brought the truck into the 1 hallway and proceeded to pass the resident lunch trays. Again, the nurse aides transported the meal cart from the 1 hallway to the 2 hallway by going thru the green zone. The nurse aides did not doff their PPE prior to leaving the 1 hallway and don clean PPE prior to entering the 2 hallway. The meal cart was not cleaned and disinfected prior to leaving the red zone for dietary pick up and transport back to the kitchen. An observation of the housekeeping closet on the B unit on October 18, 2022 at approximately 12:25 P.M., revealed that the closet was located outside COVID unit red isolation hallways. There were no bottles of the Smart Power cleaning solution on the covid B unit hallways. An interview October 18, 2022 at approximately 1 PM Employee 12 (agency na) stated that all the chemicals were located in the housekeeping closet, outside the isolation zone. She stated that staff on the COVID-19 unit would have to come out of the isolation zone, into the neutral/green zone to retrieve the spray bottles of cleaner. An observation October 18, 2022 at approximately 10:15 A.M., Employee 13 (housekeeping) took into the B isolation, hallway 1 on the covid unit. Observation revealed that she cleaned several resident rooms then brought the housekeeping cart back through the closed door of the isolation, covid unit, through the neutral/green zone and placed back into the housekeeping closet without disinfecting the cart. During an interview October 18, 2022, at approximately 2 PM the Director of Housekeeping stated that each housekeeper has their own designated cart. She attempts to keep her staff assignments consistent but at times she has to assign staff to different areas, including the COVID, isolation unit. She stated that the housekeeping carts are returned to the basement via the elevator at the end of staff shifts. She stated that the cart assigned to the COVID isolation unit is to be cleaned at the end of the shift, prior to returning to the basement. An interview on October 18, 2022 at approximately 11 AM, Employee 13 (housekeeping) stated that on the B unit, the Smart Power cleaner is kept in the housekeeping closet on the clean side outside of the Red isolation hallways. She stated that nursing takes the bottles of disinfectant out of the closet when needed for use on the tray trucks. An observation of the B unit, October 18, 2022 at approximately 11 AM revealed that the two medication carts designated for the 1 and 2 hallways (COVID areas) were both stored in the green area outside the COVID quarantine resident hallways. An observation October 18, 2022 a t 11:45 A.M. Employee 22 (LPN) pushed the 1 hallway medication cart onto the quarantine unit. At approximately 12:30 PM, Employee 2 (LPN)moved the medication cart through the closed doors from the red quarantine unit into a green zone. This nurse did not clean the medication cart before entering the green area (COVID free area). An observation of the B unit, October 19, 2022, at approximately 9:30 AM, Employee 21 (agency LPN) was administering residents medications on the 1 hallway (COVID). She finished administering medications and moved the medication cart out of the isolation hallway to the green area. She then took the second medication cart from the green area, through the closed doors back into the COVID unit, hallway 2. After finishing the medication pass, she then returned the medication cart to the green area outside the isolation unit. The nurse did not clean the cart prior to placing it in the green area. A review of facility transportation schedule dated October 20, 2022, and an interview with Employee 20 (van driver) revealed that Resident 41, a COVID positive resident, was transported in the facility van to a [CONDITION(S)] at 12 PM. After this resident was dropped off at [CONDITION(S)], the van driver picked up two other residents who had been dropped off earlier at physicians' offices. An additional resident was then picked up at the facility and dropped off at a physicians office. Resident 41 was then picked up from [CONDITION(S)] and returned to the facility. Employee 20 (van driver) stated that the van transport schedule for the day was so full that he did not have the time to clean the van after the transport of the COVID positive resident to and from her appointment and prior to other residents utilizing the van. Due to the facility's COVID outbreak status during the survey ending October 21, 2022, all employees (unless COVID positive within the past 30 days) were to be tested twice weekly for COVID-19. The testing was to occur prior to working a shift at the facility. On October 19, 2022, Employee 23 (agency LPN) reported for work at 7 AM. Observation revealed that Employee 23 was COVID tested in the lobby of the facility. However, Employee 23 immediately walked through the first floor, green unit to enter the B unit (COVID positive isolation unit) entrance potentially exposing residents and staff on the first floor A unit to COVID 19 infection. Approximately 15 minutes later, Employee 23's COVID test was noted to be positive and nursing staff advised her to leave work at the facility. During an interview October 19, 2022, at approximately 11 A.M., the DON confirmed the possible exposure in the facility as the result of the testing practice of not requiring employees to wait for their results prior to reporting to the residents units. Interview with the Infection Preventionist on October 20, 2022, at 1:00 PM confirmed that the facility presently utilized the services of a large amount of agency nursing staff. She stated that it was difficult to ensure all staff, including agency staff, consistently follow infection control practices, including properly wearing PPE, such as masks. The IP was unable to provide documented evidence that agency staff were educated on the facility's infection control policies and procedures to mitigate the spread of COVID-19 and were trained on the specific tasks and duties for working on the COVID-19 unit to maintain necessary precautions. Immediate Jeopardy was called on October 20, 2022, at 10:30 AM due to the facility's failure to ensure that staff working on the COVID isolation unit located on the B-first floor unit consistently followed isolation protocols to prevent the spread of the COVID 19 virus. There was no evidence at the time of the survey that the staff working on the COVID isolation unit consistently followed isolation procedures. It was verified that agency nursing staff working in the facility were not provided with the necessary training regarding the facility's infection control policy and procedures to mitigate the spread of COVID 19. Additional breaks in infection control practices were observed related to the staff conducting van transport, meal delivery and housekeeping services. These staff members also did not adhere to infection control practices, by failing to perform cleaning procedures of applicable equipment after exposure to COVID-19. The IJ template was provided to the facility on [DATE], to the facility at 12 PM. An immediate plan of correction was requested and received on October 20, 2022 at 4:18 P.M. The plan included: All staff will be re-educated on the COVID Isolation Procedures. Education will be given to each employee coming on shift beginning with 3-11 shift October 20, 2022 and each shift thereafter Agency Staff will do on-boarding education on their first shift at PVM, which will include the COVID Isolation Procedures. Starting with 3-11 shift October 20, 2022. All staff will be COVID swabbed prior to starting on their assigned unit beginning with 11-7 on October 20, 2022. Staff will not report to their unit/department prior to obtaining results. This procedure will be ongoing. Transport van will be disinfected prior to the next transport at 9AM on October 21,2022 Signage will be increased on the COVID unit to alert staff where to find PPE and disinfectant and how to DON/DOFF PPE by October 20, 2022. Medication Carts will be cleaned per procedure and remain on red unit by October 20, 2022 Dietary carts and/or trays will be cleaned per procedure prior to leaving the unit by October 20,2022 The Immediate Jeopardy was lifted on October 21, 2022, at 5 PM when implementation of the plan of correction was verified. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(a)(c)(d) Resident care policies

Based on review of clinical records and select incident reports and staff interview it was determined that the facility failed to utilize safe technique and/or sufficient staff assistance with bed mobility and effectively secure safety devices to prevent a fall from bed resulting in serious injury, a fracture, for one resident out of 20 sampled residents (Resident 6). Findings include: A review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbances [Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia that include symptoms such as depression, anxiety [CONDITION(S)], agitation, aggression, disinhibition, and sleep disturbances.] and history of falls. The resident had current physician's orders, initially dated August 21, 2019, for the placement of bed bolsters on the resident's bed for positioning. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated April 26, 2022, indicated that Resident 6 had severe cognitive impairment and required extensive assistance of two plus staff for bed mobility, transfers, toileting, dressing, and with personal hygiene. Resident 6's care plan initiated on September 13, 2019, revealed that the resident was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor comprehension/communication, and unawareness of safety needs. The resident's goal was not to sustain serious injury through the review date related to falls. Planned interventions were the use of bilateral fall mats with low bed, and bed alarms. The resident's care plan also included the approach of using lift sheets and assist of two staff when turning the resident in bed every two hours. The resident' bedside Kardex (a summary of the care needs and level of staff assistance required for the care of the resident) in effect on May 30, 2022, revealed that Resident 6 required a lift sheet and assist of two staff when turning resident in bed. A facility investigation report dated May 30, 2022, at 10:00 AM, revealed that Employee 1, a RN, was notified that Resident 6 had a witnessed fall from bed while Employee 2, an agency nurse aide, was providing care to the resident. The investigation indicated that while Employee 2 was changing Resident 6 the resident rolled out of bed onto floor. Employee 2 was yelling for help and when Employee 1 entered the resident's room, the resident was found face down on the floor with blood present, and with her right arm underneath her body, and liquid stool being eliminated from the resident. The resident was rolled onto her back as to get her face off the floor. Further review of the investigation report revealed that the resident was assessed for injury and was found to have had a hematoma to right forehead that measured 9.0 cm x 8.0 cm with bleeding and a small laceration to right elbow that measured 2.0 cm x 0.5 cm. Resident 6's right collar bone was protruding and bulging. Wound care was given, her forehead cleaned with absorbent dressing applied, attending physician was notified with orders given to transfer Resident 6 to the emergency department for treatment and evaluation. Review of a nursing progress dated May 30, 2022, at 9:28 PM, revealed that Resident 6 returned to facility at approximately 4:00 PM, with a fractured clavicle and a laceration to right side of head that was actively bleeding upon LPN/RN assessment of return. Additionally, there was evidence of increased pain due to Resident 6 noted to have been wincing with facial grimacing upon movement with new orders given by the attending physician for stronger pain medication. A review of a Fall Investigation Statement completed by Employee 2 and dated May 29, 2022, (fall was documented to have occurred on May 30, 2022, and no time indicated) revealed that Employee 2 stated that I was giving care and when turned, the bed bumper fell to the ground, and she fell along with it. Employee 2's statement indicated that the fall could have been prevented if the bed bumper was secured. A fall investigation statement that was completed by Employee 3, a LPN, dated May 30, 2022 (no time specified), revealed that found the resident in the prone position (lying on your stomach, face down), upon assessment a hematoma to the right forehead, ice pack applied, abrasion (scrape) to the right elbow. Employee 3 noted that the fall could have been prevented if two staff members were used with positioning. Review of an undated facility policy entitled Positioning, Bed indicated to place any positioning devises per order, monitor for proper use and placement. During an interview October 20, 2022, at 10:25 AM, the Director of Nursing (DON) stated that if the resident required two people for care that she (Resident 6) would have had an order for two people for care at all times, and that it would have been care planned. The DON stated that because the resident weighed less than 100 pounds, the resident could be safely turned with one person, despite the MDS assessment, care plan and Kardex indicating that the resident required the assistance of two people for bed mobility. The DON also stated that the bed bolster became disconnected from the bed frame and that the weight of the resident against the bolster caused the to fall from bed. The facility failed to ensure that planned safety devices were securely applied and sufficient staff assistance were used to prevent a fall with serious injury to this resident. The facility failed to ensure two staff were utilized for bed mobility and while receiving care in bed and that these staff members used safe technique to prevent a resident's fall from bed that resulted in a fracture. Employee 2 rolled Resident 6 away from her without another staff member on the opposite side of the bed. Interview with the DON on October 20, 2022, at 10:45 AM, confirmed that the facility failed to safely provide care and verified that the facility had not identified or addressed the failure to provide two-person assistance with the resident's bed mobility as assessed and care planned to prevent the fall from bed. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 211.11 (d)(e) Resident care plan

Based on observations, clinical record review, and staff interview it was determined that the facility failed to consistently provide an enteral feeding as ordered to meet a resident's nutrition and hydration needs to prevent significant weight loss, signs of dehydration and promote satiety and to ensure the resident receives sufficient fluid and feeding formula to maintain proper hydration and health for one resident out of two sampled receiving assisted nutrition and hydration (Resident 10). Findings include: Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 3, 2022 revealed that the resident was severely cognitively impaired with a BIMS score of 5 (Brief Interview for Mental Status - a tool to assess cognitive function) and required maximum assistance of staff with activities of daily living. The resident received enteral feedings to meet the resident's nutrition and hydration needs. The resident had a PEG tube (Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube [PEG tube] is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal [GI] tract to deliver part or all of a person's caloric requirements]. A review of the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nutriton/dietary note dated August 8, 2022, at 12:11 PM. revealed weight that the resident's weight trend noted no significant weight change in 30/90/180 days. The resident's current weight on August 2, 2022, was 123.6 lbs. The resident was NPO (nothing by mouth) with pleasure feedings (at the request of a patient or family member, a doctor will order pleasure feeds to indulge a person's special request, even if NPO for the purpose of food as enjoyment, not proper nutrition) of puree food via teaspoon only with Speech language therapist & daughter. The entry noted that the resident was receiving enteral support, [MEDICATION(S)] 1.5 60 cc/hr x 6 hours for total 360 cc every shift plus 100 cc water flush before & after feedings to deliver 1620 kcal/69 gms pro/1420 cc free water q day. A reassessment of the resident's estimated needs were as follows: 1404-1683 kcal (25-30 kcal/kg) 56-62 gms protein (1-1.1 gms/kg) 1404-1683 cc (1 cc/kcal). The entry indicated that the resident was able to meet 100% of estimated needs for weight maintenance & hydration with current enteral support. The plan was Will continue with current plan of care. Observation of the resident and the resident's feeding delivery in the resident's room on October 18, 2022, at 10:15 AM revealed the label on the resident's 1500 ml [MEDICATION(S)] 1.5 enteral feeding container was dated as opened and connected on October 17, 2022, with no time indicated. The feeding was disconnected and the tubing draped over the tube feeding pole. The tube feeding pump was noted to be in the off position and the feeding container was observed to be empty at that time. The resident was not receiving any enteral nutrition or assisted hydration at that time. Continued observation revealed Resident 10 was in bed. Her lips were very dry and chapped. There was a white film coating on her lips and around her mouth. Her teeth appeared coated with a dried brown film. A second observation October 18, 2022 at approximately 2 P.M., revealed that the resident's tube feeding was unchanged from the previous observation and the resident was still not receiving and enteral feeding delivery. An observation October 19, 2022 at approximately 10 A.M., Resident 10 was lying in bed. Her lips were very dry with chapped peeling skin. Her teeth were coated with a brown film. The resident's feeding was again disconnected and the tubing draped over the tube feeding pole, as observed on October 18, 2022 at 10:15 AM and 2 P.M. The tube feeding pump was again observed in the off position. The feeding container was empty at that time. At the time of the observation, Resident 10 was stating to the surveyor I'm hungry, I'm hungry. During an interview October 19, 2022 at approximately 2:15 P.M., the Speech Therapist confirmed that Resident 10 was receiving Speech Therapy (ST) services at the time to try to increase her by mouth food intakes. She confirmed that her nutritional needs were provided solely by the enteral tube feeding at the present time. An observation October 20, 2022 at approximately 10 A.M. of Resident 10's tube feeding, revealed a 1500 cc bottle of [MEDICATION(S)] 1.5 was infusing at 60 cc per hour via the pump. The date and time on the bottle (indicating the date and time the bottle was hung and started infusing) was noted to be October 19, 2022 at 2:30 PM. There was 1100 ccs in the bottle and the pump was infusing at 60 cc per hour. The October 19, 2022, 2:30 PM bottle of enteral feeding should have infused 360 ccs for the 3 PM to 11 PM shift and October 20, 2022, 360 ccs for the 11PM. to 7 A.M. shift. An additional 180 ccs for the day shift (7 A.M. to 3 P.M.) at the time of the observation. The total amount to be infused was noted to be 900 ccs. However, the amount of enteral feeding in the bottle at the time of the observation October 20, 2022 at 10 A.M. was 1100 ccs, indicating that only 400 ccs had infused, not 900 ccs as when calculating the delivery rate. Based on observations during the survey it could not be determined that Resident 10 had received the physician ordered enteral feedings for October 18, 19 and 20, 2022. A review of Resident 10's weight record revealed the following: 10/20/2022 11:26 118.2 Lbs Mechanical Lift Hoyer 10/18/2022 11:18 127.2 Lbs Mechanical Lift Hoyer 10/7/2022 12:47 126.0 Lbs Mechanical Lift Hoyer 10/6/2022 07:20 126.0 Lbs Mechanical Lift Hoyer The weight taken on October 18, and 20, 2022 were noted to have been taken on the B unit (COVID isolation unit) by the same mechanical hoyer lift. An observation on October 20, 2022 at approximately 11:30 A.M., revealed that Employees 12 (agency nurse aide) and 17 (agency nurse aide) weighed Resident 10 via the mechanical lift scale. Resident 10 weighed 118.2 pounds. Her previous weight on October 18, 2022 was noted to be 127.2 pounds, a 9 pound weight loss or 7.08% weight loss in 2 days. During an interview conducted on October 21, 2022, at approximately 11:30 AM the director of nursing was unable to verify that the resident's enteral feeding had been administered as ordered and was unable to demonstrate that the resident received the necessary assisted nutrition and hydration to prevent weight loss and maintain adequate hydration status. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.

Based on observations, a review of clinical records, select facility policy, resident incident/accident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision and effective safety measures to prevent elopement by one resident (Resident CR1) and failed to consistently provide safety interventions planned for one resident (Resident 3) at risk for elopement out of 11 reviewed (Resident CR1 and Resident 3). The facility further failed to identify staff's reliance on the facility's alarm system to prevent elopements and the deficiencies of this system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits from the facility and the potential for serious bodily injury or death. Findings included: A review of facility policy titled Elopement Policy revised September 2019, indicated ensuring the welfare and safety of the residents was the facility core mission. Wandering and elopement behaviors are closely assessed and monitored. Constant wandering behavior can may progress into an attempt to elope. Residents identified as an elopement risk will have an accucheck elopement band device. This device will trigger an alarm station whenever the resident attempts to leave a safe area. A review of the clinical record of Resident CR1 revealed admission to the facility on [DATE], with diagnoses, which included subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain) with [CONDITION(S)] (complete paralysis of half of the body) and [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of the resident's quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 30, 2019, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status - section of MDS that assesses cognition) of 6 (a score of 0 -7 indicates severely impaired cognition) Further review of the resident's clinical record revealed nursing documentation dated October 20, 2019, noting that the resident was acting extremely dangerous verbally and physically abusive with staff. The resident took a chair and was slamming it off the glass of the courtyard door attempting to break it while screaming. The chair was removed from the resident to ensure safety and the resident became enraged shattering the glass protector of the fire alarm. The resident then continued to wander around the facility yelling and screaming. On November 22, 2019, nursing described the resident as being agitated and strolling around the facility. A review of interdisciplinary progress notes dated November 30, 2019, revealed that Resident CR1 was roaming around the facility in her wheelchair. A review of interdisciplinary progress notes revealed that on December 1, 2019, the resident was wandering through the facility, unable to be redirected. The resident was verbally and physically abusive to staff. Resident refused to remain on the unit. She was found wandering in the activity room attempting to open the back door. On December 2, 2019, the resident was described in progress notes as confused, loud at times, and hard to redirect. The resident was observed self-propelling around the unit. At 10:15 PM the resident was out of bed, roaming the halls, while 15-minute observations of the resident continued according to progress note documentation. Nursing progress notes dated December 3, 2019, revealed that the resident was able to make her needs known, with confusion and 15-minute observations continue. The resident was out of bed and roaming the halls in the wheelchair per documentation. According to nursing documentation dated on December 4, 2019, the resident was roaming around in her wheelchair and 15-minute checks were in progress. Nursing noted on December 6, 2019, the resident continued to roam the halls in her wheelchair. On December 7, 2019, at 10:03 PM nursing documented that the resident was in the wheelchair roaming the halls with extreme behaviors noted. The resident was yelling out of control with staff unable to reason with her. The resident was stripping her clothes, sitting half-naked and refusing to get dressed. A review of the resident's clinical record revealed that on December 8, 2019, at 5:45 PM and December 9, 2019, at 12:36 AM the resident was in her wheelchair roaming the halls while 15-minute observations continued. According to a nursing progress note dated December 9, 2019, at 10:44 PM the resident was observed screaming, agitated and pacing the unit. The resident was refusing to go to bed or to follow basic instruction. A review of progress notes dated December 11, 2019, revealed that the resident can make needs known, with confusion. The resident was observed out of bed roaming the halls while 15-minute checks continued according to documentation. On December 15, 2019, nursing noted that the resident was alert with confusion. The resident was noted to be roaming around in her wheelchair. The resident's 15-minute checks continued. A review of nursing progress notes dated December 15, 2019, indicated that staff saw the resident sitting in the front lobby. Staff noted they witnessed the resident pull the fire alarm activating the alarms. The resident stated I'm not going to jail for this. On December 18, 2019, nursing noted that the resident continued to roam the hall in her wheelchair. The resident was described as confused, but able to make her needs known. According to nursing progress notes dated December 20, 2019, at 2:06 AM the resident was alert with confusion and that the resident was very aggressive for a time period of three hours. The resident threw hot coffee at staff while screaming and yelling. The resident was wandering the facility looking for her mother. On December 21, 2019, the resident was noted to be alert with confusion and roaming around in her wheelchair while 15-minute checks continued. Further review of the progress notes indicated that the resident continued to display similar behavior on December 22, 2019 and December 23, 2019. Nursing noted on December 23, 2019, at 10:07 PM that the resident was out of bed in her wheelchair roaming the halls. The resident had increased behaviors, becoming combative and yelling out. The resident pushed open the door to the court yard, exiting the building, yelling. Nursing noted on December 24, 2019, at 2:09 AM that every 15 minute checks of the resident continued. A review of clinical record documentation dated December 25, 2019, at 6:37 AM by the registered nurse, Employee 1, indicated that Employee 2, the nurse aide assigned to Resident CR1, had notified Employee 1, that this employee had just returned from her break and was looking for the resident for the resident's 15-minute check. Employee 2 and Employee 3, nurse aides, searched through the building and did not find the resident. Employee 2 and Employee 3 noticed that the front door looked like it had been kicked open. The employees went outside and heard the resident yelling out, help me, help me. Employees 2 and 3 stated that they found the resident in her Broda chair (is a wheelchair company that traditionally offers tilt-in-space positioning chairs with the Comfort Tension Seating® system) on the street, behind the activity (side of) building and brought her inside. Prior to the incident the resident was observed on the unit hallway stating, I need to get to Washington DC. Please help me get to the bus. A review of the incident report dated December 25, 2019, revealed that nursing obtained the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) upon the resident's return to the building. The resident's temperature was documented as 94.4° F (degrees Fahrenheit - normal body temperature is approximately 98.6° F). The resident's blood pressure was 131/72 (blood pressure reading has a top number {systolic} and bottom number {diastolic}; Normal blood pressure is less than 120 over 80 [120/80]); pulse 72 (normal resting heart rate for adults ranges from 60 to 100 beats per minute) and respirations 18 (the normal respiration rate for an adult at rest is 12 to 20 breaths per minute). No injuries to the resident were noted. A review of a time line of the event that the facility provided to the surveyors and the local weather for that date revealed that the resident was outside for approximately 12 minutes and the temperature outside was 21 degrees Farenheit. A review of nursing progress notes, conducted at the time of the survey ending January 24, 2020, revealed no documented evidence in the resident's clinical record that the facility's licensed and professional nursing staff had fully assessed the resident for signs of hypothermia when the resident returned to the facility following the elopement on December 25, 2019, in subfreezing temperatures. The resident's vital signs were not documented in the clinical record, but solely on the incident report. A review of information dated December 26, 2019, submitted by the facility revealed that Employee 2 had just returned from break at 4:00 AM on December 25, 2019. The employee went to check on Resident CR1. The employee searched the resident's usual places on the unit and did not see her. As Employee 2 was walking by the front entrance (of the facility) the employee noticed that the left glass door was unhinged. Employee 2 called for Employee 3 thinking the resident might have gotten out of the building. Employee 2 and Employee 3 went through the front entrance and observed an alarm box in the facility driveway. They began calling the resident's name and the resident responded to their calls. The resident was found past the right driveway, on the side of street in front of the activities (side of) the building. The facility description of follow-up action to this event was noted as Employee 2 and Employee 3 brought the resident back into the facility. Employee 1 assessed the resident for injuries. The DON (director of nursing) and NHA (nursing home administrator) were notified. The resident will continue 15-minute checks. The Elopement sensor alarm was checked and functioning properly. The facility checked all residents with elopement sensor alarms, and they all functioned properly. The facility determined that the front door was locked at the time of the resident's elopement and remained locked, but the light on the alarm system was observed just blinking. The alarm did not sound in the facility to alert staff that the resident was exiting the building. According to information submitted by the facility dated December 26, 2019, the facility's follow up to Resident CR1's elopement was noted and included that all alarms were rechecked and functioning properly. Administrator and Maintenance Director to facility to evaluate entrance way. Facility CCTV system indicated Resident CR1 approaching front entrance way, pushed entrance doors frontward but was unsuccessful. She then backed into doors with Broda chair and exited building ~3:55 am. First nursing assistant exited building~4:07 am followed by second nursing assistant one minute later. Elopement alarm functioned properly. Facility checked residents with elopement alarms and they functioned properly also. Alarm company will be notified to recheck door system with alarms. Resident CR1 was transferred to the second floor to decrease exiting occurrence from front door. Resident CR1's alarms were checked post event and were functioning properly. Investigation with staff indicated the alarms did not sound within the facility when Resident CR1 was attempting to exit the building. The doors were locked at that time and remained locked, but light on the alarm console was observed blinking via video system. Resident CR1's accutech alarm was checked on 12/24/19 and was functioning properly. A review of a statement written by Employee 2 dated December 25, 2019, revealed that employee came back from her 3:30 AM break at 4:00 AM, and was about to start her incontinence checks, when the employee decided to go and check on the resident. The employee stated she did not find the resident in her usual hiding spots. The employee went towards the front door and saw it was opened. The employee then went and got Employee 3 to help look outside for her. The employee further stated that is when they found the resident outside the building. A review of a statement written by Employee 3 dated December 25, 2019, revealed that at 4:00 AM Employee 2 came to her asking if she had seen the resident. Employee 3 indicated that the last time she saw the resident was at the nursing station. Employee 2 told Employee 3 that she saw the (front) door opened and went outside to look for the resident. The employee saw the resident's alarm box in the walk way. Employee 3 called the resident's name and the resident answered. Employee 3 stated that the resident was found, in her Broda chair outside the activities building. A review of a statement written by Employee 4 LPN (license practical nurse) dated December 25, 2019, indicated that the resident was on 15-minute checks when Employee 2, who was assigned to the resident, went to check on her and the resident could not be found. The employee stated the resident was self-propelling in her wheelchair on the unit prior to the incident. The employee stated that when checking the front entrance door, it was widely open. She further stated that staff proceeded to look for the resident and found her outside the building. A review of a time line of the event that the facility provided to the surveyors, from the CCTV system (TV system in which signals are not publicly distributed but are monitored, primarily for surveillance and security purposes) revealed the following sequence of events on December 25, 2019: 3:42 AM: Resident CR1 was is in the main lobby approaching the front doors in the Broda Chair. 3:43 AM: The resident pushes on the front doors facing forward, but they do not open. 3:44 AM to 3:49 AM: The resident tried to open the Admission office door and it does not open. The resident then went to the Rehabilitation closet door and opens it, but does not enter. 3:51 AM: The resident backs up into the front doors pushing them open into the alcove. 3:55 AM: The resident exits the building and rolls down the entrance driveway on the flag pole side. 4:07 AM: Employee 2 exits the building towards the resident. 4:08 AM: Employee 3 exits the building and assists with bringing the resident inside. No time is documented when the resident was back in the building. A review of the weather report for December 25, 2019, revealed at the time the resident eloped from the facility the temperature was 21 degrees Fahrenheit. An observation of the front entrance on January 23, 2020, at 9:20 AM revealed that the entrance to the facility had two sets of doors. The first set of doors were sliding glass doors that enter the alcove, which contained a phone to call the facility if the doors were locked. The alcove was not heated. The second set of doors were also sliding glass doors that entered into the facility. These doors were alarmed with a key pad to unlock them. Cameras were seen pointing at the front door and going down the hallway to the B Unit. There was a small receptionist desk to the right of the front door when you walk into the facility. Observation of the outside grounds of the facility on January 23, 2020, 9:22 AM revealed a drive way to the left and the right of the entrance leading to the street. The distance from the front door to the front of the activity side of the building where the resident was found measured at approximately 165 feet. Interview with the DON on January 23, 2020, at 9:30 AM revealed that the first set of doors to enter the building are never locked, but the second set of doors are locked. The DON further stated that the second set of doors can be pushed open and swing outward in case of an emergency. A review of Resident 3's most recent MDS dated [DATE], revealed that the resident was severely cognitively impaired (BIMS score of 3). According to review of the resident's clinical record, the facility last assessed the resident on August 28, 2019, for wandering or exit seeking behaviors and the potential for elopement from the facility. The resident was determined to be at low risk (score 7.0) for wandering (0-8 low risk), based on the assessment tool utilized by the facility. Subsequently, the resident displayed the behavior of packing her clothing daily and verbalizing her intent to go home and was identified at risk for elopement. Nursing progress notes dated November 18, 2019, revealed that the resident also had a history of removing her safety alarm box. A review of the resident's most recent comprehensive plan of care, which was reviewed and revised on November 12, 2019, revealed that the resident remained at risk for elopement. Interventions planned were to distract the resident from wandering, provide structured activities and to utilize an accutech sensor alarm to the wrist (an alarm which audibly sounds and locks the doors when the wearer attempts to pass through a sensor equipped door). At approximately 9:40 AM on January 23, 2020, observations were conducted of the accutech sensor alarms in place for residents identified at risk for elopement. Observation revealed that Resident 3 was not wearing the accucheck sensor alarm planned to prevent the resident from exiting the building undetected. Employee 5 LPN confirmed at that time the observation that Resident 3 was not wearing an elopement sensor alarm. An interview was conducted on January 23, 2020, at 10:20 AM with Employee 6, LPN. The employee stated that she had never witnessed an accutech sensor alarm not working. The employee further stated that the alarm system should sound at the front door. When asked if she knew how often alarms are checked for proper function, Employee 6 stated that she thinks the alarms are checked monthly. The employee further stated that night shift staff are the only ones who check to make sure the alarm is correctly placed on the resident. Employee 7, nurse aide, was interviewed on January 23, 2020, at 10:25 AM. The employee stated that the alarm system functions by locking the doors. She stated that the alarm system is tested weekly, but doesn't know if residents are checked to make sure the accucheck sensor is on the resident. Interview with Employee 8, the front lobby receptionist, on January 23, 2020, at 10:27 AM revealed the employee sits at the desk and monitors the door during the day. She stated when the alarm is activated the light on the key pad will turn yellow, the doors will lock, and an alarm will sound in the building. She further stated that when it is deemed safe, she would then deactivate the alarm system by entering a code on the key pad. The light would then turn green, indicating that it was deactivated and then the system would reset. Observation on January 23, 2020, at 10:30 AM revealed that Resident 6 was wearing an accutech sensor and Employee 9, nurse aide, wheeled the resident to the front door to test the alarm system. When Resident 6 approached the door, the doors locked, but the alarm system did not sound. Employee 8 reset the alarm and Employee 9 tested the system again with Resident 6. The doors locked, but the alarm again did not sound. Employee 9 took the resident back to the nursing unit. Observation on January 23, 2020, at 10:34 AM revealed that Employee 9 brought an empty wheelchair with an accutech alarm attached to it from the A wing. The sensor on the wheelchair activated the alarm system. The doors locked and the alarms sounded. During an observation on January 23, 2020, at 10:35 AM Employee 7 brought Resident 7 to the front doors to test his accutech sensor. The resident's sensor locked the front doors. The light on the key pad was yellow, but the alarm did not sound. Employee 8 entered the key pad code to reset the system. The light was green on the key pad. The employee again tried to test the alarm system with Resident 7 and was able to push the resident right out the front door due to a delay from the time when the system is deactivated until it resets. Resident 7 was brought back to the B unit. Observation on January 23, 2020, at 10:40 AM Employee 7 brought an empty wheelchair with an accutech alarm attached to it from the B wing. The sensor on the wheelchair activated the alarm system. The doors locked, but the alarm system did not sound to alert staff a resident at risk for elopement was trying leave the building. During an observation on January 23, 2020, at 10:47 AM Employee 7 brought Resident 8 to the front doors to test her accutech sensor. The resident's sensor locked the front doors and the light on the key pad was yellow, but the alarm did not sound. Employee 7 tried to test the alarm system again and it again did not function properly. A phone interview was conducted with Employee 1, RN, on January 23, 2020, at 3:05 PM. The employee stated that Resident CR1 always exhibited wandering and exit seeking behaviors during the night shift (11:00 PM to 7:00 AM). The employee was unable to state when the last time she saw the resident prior to the resident's elopement on December 25, 2019, but stated that she did see the resident by the nursing station. The employee further stated she had work to do and became busy and did not see the resident until she was brought back inside. The employee was unable to recall what the resident was wearing that night when she was found outside. A phone interview was conducted with Employee 4, LPN, on January 23, 2020, at 3:10 PM. The employee stated she saw the resident 20 to 30 minutes prior to when the resident was found outside. The employee further stated that the resident was supposed to be on 15-minute checks. She stated that the resident always has wandering and exit seeking behavior and the staff let her roam around the facility. Employee 4 stated that the alarm never sounded that night that a resident eloped from the building. Employee 4 stated that she did not look at the CCTV monitor at the nurses station because she didn't hear an alarm. Observation of the A wing nurses station on January 23, 2020, at 9:40 AM revealed that the (CCTV) monitor is in place behind the nursing desk, facing the backs of the staff who are seated at the desk. Staff would have to turn around to view the monitor when sitting at the desk. An interview on January 23, 2020, at 3:30 PM with Employee 3, Nurse Aide, revealed that the last time she saw the resident, prior to the elopement on December 25, 2019, the resident was at the nurses station, but was unable to recall what time. The employee stated that the resident is always rolling around the facility calling out for her family. The employee was unable to recall what the resident was wearing that night, but did remember that it was very cold outside. The alarm system never sounded in the building when the resident exited that night. She further stated she helped Employee 2, nurse aide, look for the resident outside. Employee 3 stated that she was yelling out the resident's name and the resident responded back to her. Employee 3 stated that she found the resident on the main road in front of the activities (side of) building. Employee 2 was contacted by telephone on January 24, 2020, for an interview, but the employee did not return the surveyor's message. The facility had indicated that they had evaluated the functionality of its alarm system following Resident CR1's elopement on December 25, 2019, however observations on Janaury 23, 2020, revealed that the system did not function properly to prevent resident elopements. As a result of the facility's failure to promptly identify and act upon the issues, which allowed to Resident CR1 to successfully elope from the facility, which included inaudible alarms and the failure of staff to meet the resident's individualized needs for supervision of exit seeking behaviors, at the time of survey, Immediate Jeopardy to the health and safety of the residents at the facility was identified to the Nursing Home Administrator on January 23, 2020, at 10:15 AM. The facility's immediate action plan included: 1. Effective immediately the main lobby entrance will be directly supervised at all times 24 hours a day, 7 days a week, 365 days a year to identify and immediately respond to any resident seeking to elope 2. The facility will provide coverage at the main lobby reception desk which is located just inside the double set of entry doors. Coverage will be provided by a facility staff member. 3. A coverage schedule has been established to provide 24 hours a day 7 days a week coverage on a week to week basis. 4. A sign in sheet has been established to verify coverage at all times each day. 5. The assignment and sign in sheets will be reviewed by the administrator daily so there is no coverage gaps 6. In the event of a call out or other coverage issue the nursing supervisor will assign a staff member to cover the reception desk to ensure no gaps in coverage occur. Staff that will be on duty for the next three shifts were educated on the changes. All other staff will be educated on the changes. Staff educator will educate all on the updated policy to include the requirement not to give out the door key pad codes. Following verification of the implementation of the corrective action plan, a tour of the facility and inspection of the supervision of the front doors, the Immediate Jeopardy was lifted at on January 23, 2020, at 5:00 PM. 28 Pa Code: 201.19(e)(1) Management Previously Cited: 9/20/19, 8/21/19, 7/11/19, 2/22/19 28 Pa Code: 201.18(e)(3) Management Previously Cited: 8/21/19 28 Pa Code: 207.2(a) Administrators Responsibility Previously Cited: 8/21/19 28 Pa. Code: 211.12(a)(c)(d)(3)(5) Nursing Services Previously Cited: 12/23/19, 10/31/19, 9/20/19, 8/21/19, 7/11/19, 5/22/19, 2/22/19

Based on review of clinical records and select facility policy, observations and resident and staff interview, it was revealed that the facility failed to timely identify contributing and/or risk factors for the development of pressure sores (localized injury to the skin and/or underlying tissue usually over a bony prominence (areas where bones are close to the surface of the skin) as a result of pressure, or pressure in combination with shear and/or friction), failed to devise, implement, consistently monitor and evaluate the effectiveness of interventions necessary to prevent the development and worsening of pressure ulcers for three of six residents reviewed (Residents 4, 5, CR1). Findings include: A review of Resident 4's clinical record revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted to the hospital on June 7, 2017, for right quadricep (a large muscle in front of the thigh) rupture. The resident was readmitted to the facility on [DATE], with a cast to her right leg from her ankle to below her knee. A review of the resident's most recent Minimum Date Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 19, 2017, revealed that the resident's BIMS score (Brief Interview of Mental Status - tool to assess cognitive function) was 14, which indicated that the resident's cognition was intact (a score of 13-15 indicates intact cognition). A review of the resident's plan of care dated June 14, 2017, revealed the problem of the potential for pressure ulcer development due to the resident's decreased activity level as the result of the leg cast. Planned interventions were to visually check the resident's skin with morning and evening care and check the circulation of the right leg every shift. A review of nursing progress notes dated June 20, 2017, indicated that the resident was complaining of pain throughout the evening. The MDS nurse noted on June 20, 2017, that the resident complained of constant pain, which made it difficult to sleep at night and the pain was interfering with her activities of daily living. On June 20, 2017, therapy documentation noted the application of additional moleskin to the anterior (front) and proximal (center) aspect of the cast. The resident was described as cooperative with keeping her right leg elevated which was needed to address the [MEDICAL CONDITION] (swelling due to accumulated fluid) that the resident was having in her affected foot. Nursing documentation dated June 21, 2017, revealed that the resident continued to complain of pain, which radiated to her right leg down to her right foot. The resident complained of having discomfort from the base of her cast due to it, pushing into her skin. Adjustments (to the resident's cast) were made according to nursing documentation. According to therapy documentation dated June 21, 2017, the therapy staff identified that the resident had developed an open area (of skin) to the Achilles (band of fibrous tissues that connects the calf muscles to the heel bone), which was caused by pressure from the resident's cast. A review of the initial pressure ulcer assessment revealed that the facility assessed the skin breakdown to be a Stage III (full thickness tissue loss) pressure sore measuring 0.8 cm (centimeter) in length, 2.8 cm in width and 0.3 cm in depth. The resident was examined by her orthopedic physician on June 22, 2017, and the cast was manipulated. When interviewed on July 5, 2017, at 12:25 PM regarding the pressure sore development, the resident stated that she had extensive pain which caused her to be restless in bed. She explained that her cast was rubbing and caused a pressure area to her foot. When asked about the staff's routine examination of her foot prior to the development of the area, she explained that her toes were examined for circulation, but the staff did not consistently check her feet in the involved area unless she complained to them about the cast bothering her. The resident further stated that the cast was currently very loose and now moved up and down her leg when she shifted her weight. Further review of the resident's plan of care revealed that the pressure area to the Achilles had been identified on June 22, 2017, but the facility had not revised the resident's plan of care to ensure consistent and effective monitoring of the resident's skin integrity in that area and to alleviate pressure at the site. The only additional planned intervention was initiated on June 27, 2017, for the application of padding to the upper posterior (back) cast daily. A review of the last Weekly Pressure Ulcer Assessment for the resident completed on July 3, 2017, revealed that the size of the pressure area was unchanged from the prior to assessment of June 22, 2017. The area measured 0.8 cm x 3 cm x .3 cm with slough (a type of necrotic (dead) tissue, separating itself from the body/wound site, and is often stringy) and granulation (healing skin). The facility failed to demonstrate consistent and effective monitoring and assessment of the skin in the area of the resident's cast to timely identify and act upon factors affecting the integrity of the resident's skin to prevent the development of a Stage III pressure sore. A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE]. A review of the resident's plan of care dated on June 12, 2017, revealed that the facility had identified the resident's potential for development of pressure ulcers related to the resident's immobility and incontinence. Interventions included the use of a gel cushion to the resident's wheelchair, specialty (designed to reduce pressure) mattress and a turning and repositioning program. A review of the residents most recent MDS assessment dated [DATE], revealed that the resident required extensive assistance of two staff members for transfers, dressing and bed mobility. The resident's BIMS score was 2 which, indicated severe cognitive impairment (a score of 0-7). On June 25, 2017, the facility completed a Braden scale assessment (standardized tool used to predict risk of developing skin breakdown). The resident was determined to be at moderate risk (score=14) of developing pressure ulcers due to being chairfast, having very limited mobility, probable nutritional problems and issues with friction and shearing. A review of the nursing progress notes dated June 25, 2017, revealed that the staff identified that the resident had developed a 3 cm x 3 cm blister to the right heel. The facility's immediate intervention was to elevate the resident's heels off the bed and to request a consultation for the use of multipodus boots (a foot and ankle orthosis made of plastic and lined with soft material to protect the skin, used while the resident was on bed rest to hold the ankle in a neutral position (90 degree angle) and can control rotation) or a heel flotation (the term float the heels means that a patient's heel should be positioned in such a way as to remove all contact between the heel and the bed) device. A new order for the use of [REDACTED]. Further review of the resident's plan of care, revealed there was no indication that the facility had revised the resident's plan of care following the identification of the pressure sore to specifically include the measures to be implemented to relieve pressure on the resident's heels. There was also no indication that the facility had devised pressure relieving interventions specifically for when the resident, who was noted to be chairbound, was out of bed. When interviewed on July 5, 2017, at 2:45 PM the Director of Nursing and Assistant Director of Nursing stated that the facility concluded that the resident likely developed the pressure area to her heels from wearing non-skid socks and moving her feet back and forth while seated in the chair. A review of the most recent Weekly Pressure Ulcer assessment dated [DATE], revealed the resident's pressure ulcer had increased in size to 4.0 cm x 4.0 cm. The facility failed to timely develop and implement individualized measures to address specific resident risk factors of skin breakdown and prevent pressure sore development. A review of the clinical record for Resident CR1 revealed admission to the facility on [DATE], with a callous-like area to the back of the upper thigh and a small open area due to weeping [MEDICAL CONDITION] (swelling, blistering and leakage of fluid on to the skin), which measured 1 cm x 0.1 cm x 0.1 cm to the front of the lower right leg. Nursing noted that the resident had [MEDICAL CONDITION] from the toes to the knees on both legs. A review of the resident's clinical record and current comprehensive plan of care revealed no identification or treatment and planned interventions to monitor or prevent the worsening of the area to the resident's upper thigh. A review of the facility's Skin Integrity/Wound Protocol policy last reviewed by the facility in May 2012, revealed that the skin integrity of all residents was to be evaluated on a weekly basis during their weekly bath and documented. Any residents with wounds were to be reviewed on a weekly basis and as needed. Upon discovery of pressure ulcers, venous, arterial, diabetic, deep tissue, injury, trauma, surgical, burns, the licensed nurse was to document in the Skin and Wound Assessment. Further review of Resident CR1's clinical record revealed that the resident was to receive showers/baths on Thursdays during the 3 PM to 11 PM shift. A review of the resident's bathing records revealed that she refused bathing/showering on May 18, 2017, but there was no indication that staff had offered the resident a bath or shower at an alternate time when she refused the scheduled bath/shower. Documentation revealed that the resident was showered on May 25, 2017 and June 1, 2017. There was no identification that any areas of impaired skin integrity were identified during those showers. On June 8, 2017 the resident was scheduled for a shower, but there was no documented evidence that it was offered, completed, or refused. According to a review of nursing progress notes dated May 29, 2017, the nurse documented that the resident had a, callus-like area, to the back of the left thigh, upon admission measuring 5 cm x 3 cm. The area was described as, now open as the callus had fallen off. A physician's orders [REDACTED]. The reason noted for this intervention was for protection to the open area since the resident routinely wore shorts. Further review of the resident's clinical record revealed no additional notations of this open area or documentation in the wound and skin assessment according to facility policy, upon the resident's admission or on May 29, 2017, when the dressing was ordered. A review of nursing progress notes revealed that the resident complained of leg pain on June 5, 2017, and, back of the leg pain, on June 8, 2017, at 11:50 AM. According to nursing documentation dated June 8, 2017, the resident and her husband met with Social Service staff because they had concerns with the resident's care. The concerns included pain to the back of the left thigh area. When nursing examined the area in response to the resident's complaints, it was described as a reddened boil/blister. There was no further measurement or description of the area documented in the resident's clinical record or documentation to indicate if this area was the same affected area noted from May 29, 2017, which had been described as open at that time. The facility failed to ensure accurate and consistent assessment and monitoring of resident's skin condition and the implementation of timely and adequate measures to preserve skin integrity based on the resident's individual risk factors. 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Sores Previously cited 10/28/16, 9/25/15 28 Pa. Code 211.5(f) Clinical records Previously cited 10/28/16, 4/25/16, 9/25/15 28 Pa. Code 211.5(g)(h) Clinical records Previously cited 10/28/16, 4/25/16 28 Pa. Code 211.10(a) Resident Care Policies Previously cited 12/28/16, 10/28/16, 1/27/16, 9/25/15 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 12/28/16, 1/27/16, 9/25/15 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing Services Previously cited 3/10/17, 12/28/16, 10/28/16, 4/25/16, 1/27/16, 3/2/16, 10/30/15, 9/25/15 28 Pa. Code 211.12(c) Nursing Services Previously cited 3/10/17, 12/28/16, 11/10/16, 10/28/16, 4/25/16, 1/27/16, 3/2/16, 10/30/15, 9/25/15

Based on a review of clinical records and select facility policies and procedures, observations and interviews with staff, it was determined that the facility failed to effectively monitor and accurately assess skin integrity, timely identify a skin impairment and provide prompt and necessary treatment and services to prevent worsening and promote healing of a pressure sore for one resident (Resident 100) out of 25 sampled. Findings include: A review of the facility's policy, Skin Integrity/Wound Protocol reviewed by the facility on July 30, 2015, revealed that the purpose of the skin integrity/wound protocol is to provide a systematic approach for monitoring skin integrity, and providing ulcer care. To decrease ulcer formation by identifying residents at risk and developing interventions to promote healing of ulcers in an effective and timely manner. The objective is to decrease the incidence of wounds, optimize treatment. Skin integrity of all residents will be evaluated on a weekly basis during their weekly bath and documented in the Kiosk (electronic charting). A review of Resident 100's clinical record revealed that the resident was severely cognitively impaired and required extensive assistance of staff with her activities of daily living to include bathing and hygiene. The resident had a physician's orders [REDACTED]. A review of an Observations by Resident sheet that the nursing staff completed for Resident 100 revealed that at 3:00 p.m. on April 8, 2015, the resident had no skin problems. A review of a nursing progress note dated April 8, 2015, and timed for 9:47 p.m., indicated that the nurse was called to assess the resident due to a black area found on the resident's left heel. The nurse's assessment revealed that the area found was an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough-separation of dead tissue from living tissue, yellow, tan gray, green or brown or eschar-dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) pressure ulcer measuring 2.8 centimeters by 1.3 centimeters. A physician's orders [REDACTED]. An additional current physician's orders [REDACTED]. Observation of the resident on September 23, 2015, at 12:00 p.m. and 1:15 p.m. and September 24, 2015, at 8:45 a.m., 11:00 a.m., and 1:30 p.m. revealed that the resident was not wearing the heel protector as ordered. These observations and the facility's failure to consistently provide the heel protector to promote healing of the pressure sore was confirmed by interview with Employee 2, Nurse Aide, on September 24, 2015, at 1:30 p.m. An interview with the Director of Nursing (DON) on September 24, 2015, at approximately 11:00 a.m., confirmed that the documentation on April 8, 2015, and timed for 3:00 p.m., was inaccurate. The DON stated that nursing staff did not look at the resident's heels, but only at skin that was visible. The Director of Nursing further stated that if nursing staff had assessed the resident's heels at 3:00 p.m., it would not be plausible that the resident would have developed an unstageable pressure area on her heel by 9:47 p.m. on that same date. The facility was unable to provide evidence that accurate skin checks were consistently being performed to identify declines in skin integrity and to prevent pressure sores from developing or worsening. 483.25(c) Pressure Sores Previously cited 8/14/14 28 Pa. Code 211.12 (a) Previously cited 6/11/15, 10/07/15, 8/14/15 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Previously cited 6/11/15, 4/29/15, 10/07/15, 8/14/15

Based on a review of clinical records and select facility policies and procedures and interviews with staff and residents, it was determined that the facility failed to timely act upon an identified skin impairment and provide prompt and necessary treatment and services to prevent worsening and promote healing of pressure sores for three residents (Resident 62, 91, 160) out of 26 sampled. Findings include: A review of the policy titled, "Skin Integrity/Wound Protocol" reviewed by the facility on August 5, 2014, that upon discovery of pressure areas the licensed nurse will document findings in the, "Skin and Wound Assessment". An investigation form for "new facility" acquired ulcers will be initiated by the licensed nurse upon her discovery of the ulcer. The licensed nurse will notify the attending physician within 24 hours, initiate treatment according to Pleasant Valley Manor wound management protocol, document all details, initiate the plan of care according to protocol, and document all details and notification in the resident's medical record. The Resident 91's quarterly Minimum Data Set Assessment (MDS - a standardized assessment conducted periodically by the facility to plan the resident's care) dated May 13, 2014, revealed that the resident was moderately cognitively impaired and required assistance of one staff member for activities of daily living. A review of the resident's Braden score (a skin assessment tool for predicting pressure sore risk) dated July 24, 2014, indicated that the resident was at low risk for the development of pressure sores. A review of the Optimus Clinical System (the documentation system used by the facility) revealed that on August 4, 2014, at 8:00 p.m., the nurse was notified of a change in the condition of the resident's skin. A review of a nursing progress note by Employee 5 dated August 5, 2014, at 10:24 p.m., indicated that the resident has a black opened area on the left hip. The resident had no complaints of pain or discomfort. An additional nursing note by Employee 8 dated August 6, 2014, at 2:49 a.m., indicated that the resident has a left hip opened black area. A physician's orders [REDACTED]. A review of the Treatment Record for August 2014, revealed the treatment to the resident's left hip was initiated on August 7, 2014, at 8:30 a.m. On August 11, 2014, a Skin Condition Report completed by Employee 3 revealed a new first recording of an unstageable pressure area on the resident's left front lateral hip that measured 4.0 cm (centimeters) in length by 2.0 cm in width. The resident's skin was not blanchable, no odor was noted, scant drainage, black wound base 100%, wound base is not visible with 100% eschar (dead tissue, black in color in wound bed). The surrounding tissue was bright red. On August 11, 2014, the physician ordered staff to cleanse the open area to the left hip with soap and water, pat dry, apply Santyl to the wound bed and Sure Prep (skin protectant) to halo, cover with [MEDICATION NAME] 4 x 4, change every other day. Interview with the Assistant Director of Nursing on August 11, 2014, at 1:25 p.m., verified that there was no nursing assessment completed of the wound until August 11, 2014, at approximately 12:00 p.m. The facility did not complete an investigation form for "new facility" acquired pressure ulcer upon discovery of the pressure sore on August 4, 2014, according to facility policy. A statement completed on August 11, 2014, by Employee 11 (Nurse Aide), indicated that the skin breakdown on the resident's left hip was small and pink and that the original size was approximately 1.5 cm x 0.5 cm at which time she reported it to Employee 12 (Licensed Practical Nurse) on August 4, 2014. Employee 12 covered it with a dressing. There was no evidence of any further follow up to the resident's skin impairment until August 6, 2014, when a physician's orders [REDACTED]. The facility was unable to provide evidence that an assessment or evaluation, to include sizing of the wound was conducted between August 4, 2014 and August 11, 2014, in accordance with facility policy or that a treatment was initiated prior to August 7, 2014. Interview with the Director of Nursing and Assistant Director of Nursing on August 12, 2014, at approximately 1:45 p.m., confirmed that they were unaware that the resident developed a pressure area on August 4, 2014, and unable to explain why a treatment was not initiated until August 7, 2014. The facility was unable to provide evidence that the pressure sore was identified and assessed in a timely manner and that appropriate interventions were implemented to prevent the area from worsening. A review of the clinical record revealed that Resident 160 was admitted to the facility on [DATE]. An admission Minimum Data Set assessment dated [DATE], revealed that the resident was highly impaired in cognition, required the assistance of two staff for bed mobility and transfer and was at risk for development of pressure ulcers. Review of the resident's "Skin Condition Report" dated July 25, 2014, at 12:30 p.m., revealed that a closed blister, suspected deep tissue injury in evolution, was found on the resident's left heel. The site measured 4.0 centimeters (cm) length x 2.5 cm width. The resident's skin was not blanchable. The area was not present on the resident's admission. The resident has severe [MEDICAL CONDITION] joint disease of the left hip, which causes him to move his foot up and down on the bed to reach a position of comfort. The report noted that the wounds were most likely from friction. Review of the facility's investigation into the skin impairment dated July 25, 2014, revealed that the resident was at moderate risk for the development of pressure areas on admission and now was at high risk. The investigation noted that the resident could have pressed his left heel into the bed to relieve pain from the resident's left hip or to reposition himself. Observation of the wound on the resident's left heel on August 13, 2014, at 10:45 a.m., revealed a dark red, flat non-fluid filled area covering the bottom of the resident's left heel. Interview with the Registered Nurse Unit Manager on August 13, 2014, at 10:45 a.m., revealed that although the resident was at risk for the development of a pressure area on admission and the facility was aware that friction was being applied to his left heel, specific interventions for protection of the resident's heels were not taken to prevent skin breakdown. A review of the clinical record revealed that Resident 62 had a pressure sore wound to her sacrum and was attending the wound center for treatment. A review of a consultation report from the wound center to the facility, dated July 8, 2014, revealed a note indicating that the sacral wound needs to be kept free of stool-leaking into the wound vac ([DEVICE] used to promote healing of the pressure sore). The report indicated that at the resident's past two visits to the wound care center, stool was observed in the sacral wound vac and tubing. The facility failed to demonstrate the consistent implementation of measures planned to maintain the sacral wound vac and tubing free from stool. 483.25 Quality of Care Previously cited 9/12/13, 1/28/14 28 Pa. Code 211.10 (a)(d) Resident care policies. Previously cited 9/12/13, 1/28/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 9/12/13. 1/28/14

Based on a review of clinical records and resident incident/accident reports, interviews with staff, and observation, it was determined that the facility failed to implement planned interventions to prevent an accident with injuries for one of 25 residents sampled (Resident 100) and failed to maintain an environment free of potential accident hazards. Findings include: A review of the clinical record revealed that Resident 100 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's MDS Assessment (Minimum data set a standardized assessment completed at specific intervals to identify resident needs) dated August 20, 2013, indicated that the resident required extensive assistance of two persons for transfers and extensive assistance with one person for ambulation. A review of the resident's fall risk assessment dated [DATE], indicated that the resident was at high risk for falls (a score of greater than 9 is at risk for falls, the resident's score was 22). A review of the resident's physician's orders [REDACTED]. Nursing documentation dated September 7, 2013, at 12:27 PM indicated that the resident was alert with confusion. A review of a resident incident/accident report dated September 7, 2013, revealed that at approximately 2:45 PM on that date the resident was found on the floor of the resident's room on the left side of her bed. A laceration was noted to her right temple and she was bleeding. The documentation noted that her right shoulder joint appeared dislocated and she was lying on her back. The resident was sent to the emergency room for an evaluation. A review of employee statements obtained from facility staff as part of their investigation into the resident's fall and the details surrounding the incident indicated that Employee 1, an nurse aide, wrote in her statement that she forgot to put the floor mats on the floor next to the resident's bed. She indicated that she was going to get the resident out of bed. This employee also noted in her statement that the resident was confused most of the day, and she laid her down for a nap at 1:30 PM, but the resident kept ringing the call bell "constantly." Employee 1 noted that she was in and out of the resident's room every couple of minutes, but also noted that the floor mats were not in place. Employee 1 further wrote in the statement that she was at the end of the hall, when she heard the resident's alarm ring and when she came into the room the resident was on the floor. The resident was admitted to the hospital on September 7, 2013, with a bilateral subarachnoid hemorrhage, (bleeding surrounding the brain) bruising and laceration to her right eyebrow area and a humeral neck fracture (upper arm bone). The resident remained in the hospital as of September 12, 2013, the end of the survey. An interview with the NHA (nursing home administrator) and DON (director of nursing) on September 11, 2013 at 9:00 AM confirmed that the resident was to have bilateral floor mats in place when she was in bed. The facility failed to implement the planned interventions for this resident and the resident fell from bed and sustained injuries. Observation on the A1 Nursing Unit on September 10, 2013, at 12:10 p.m., revealed an unattended medication cart located outside of the nurses station. Multiple vials of insulin were observed stored in an open tray on top of the medication cart. Interview with the Unit Manager at this time confirmed that Employee 2 (an LPN who was not currently on that nursing unit) had left the vials of Insulin on top of the medication cart. The Unit Manager confirmed that medications were not to be left on top of the medication cart and accessible to residents. 483.25(h) Accidents Previously cited 8/24/12 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 8/24/12