Every finding on record at Sunset Ridge Rehabilitation and Nursing Center

Based on observation, a review of the facility's planned menus, a review of resident group meeting minutes, and resident and staff interviews, it was determined that the facility failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals for residents, which included four out of the 21 residents sampled (Residents 4, 25, 33, and 69), and as expressed by four out of four residents during a resident group interview (Residents 25, 60, 69, and 76). Findings include: A review of resident group meeting minutes dated November 18, 2025, revealed residents in attendance raised concerns that they would like more soup added to the facility menu. A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 19, 2025, revealed that Resident 4 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 to 15 indicates cognition is intact). During an interview with Resident 4 on January 21, 2026, at 1:30 PM, they stated that soup would be nice, and that the request for soup had come up during food committee meetings and was never resolved. A quarterly MDS of Resident 33 dated November 02, 2025, revealed the resident was severely cognitively impaired and was unable to attempt the BIMS score. An interview with Resident 33 and their resident representative (RP) on January 21, 2026, at 2:00 PM, revealed the request for soup had been discussed with the kitchen and management, and there has not been any resolution. Resident 33's RP stated that she often brings in soup for Resident 33. During a resident group interview on January 22, 2026, at 10:00 AM Residents 25, 60, 69, and 76 indicated that they have a concern about the facility dietary menu. Specifically, residents in attendance indicated that they have requested to have soup added to the menu, but the facility has not addressed their preference. During the group interview, Resident 69 indicated that he has brought up soup every meeting for the last few months. He explained he is frustrated and about to give up asking because no one addresses the concerns. Resident 69 indicated that it is winter now and a bowl of soup would be great. He reported that he has asked for vegetable soup, tomato soup and chicken noodle soup, but none of those options were incorporated into the menu. During the group interview, Resident 25 indicated that he would like to see tomato soup on the menu but hasn't had soup for a while. During the group interview, Resident 60 indicated that residents have been asking for soup for more than a few months. She explained that it has been over a year since the facility served soup. Resident 60 indicated she would like the menu to include soup options. During the group interview Resident 76 indicated that she has only been at the facility for a week, but was told by facility staff that soup is not available. She explained that she would enjoy a bowl of soup, especially with the cold weather. A review of the current facility menu, weeks 1 through 5, revealed the menu rotation did not include soup. Also, a review of the facility's always available food list revealed no options for soup were available. During an interview on January 23, 2026, at 10:00 AM, the Registered Dietician (RD) confirmed that residents have requested soup be added to the menu in the past. The RD was unable to provide documented evidence the facility incorporated residents' requests for soup into the menu or as an always-available option. An interview with the foodservice director (FSD) on January 23, 2026, at 11:00 AM revealed that menus are planned at the corporate level. The FSD confirmed the corporation was aware that the residents have been requesting for soup to be added to the menu but that menus have not yet been adjusted to incorporate soup. The FSD confirmed that soup is also not being offered as a choice on the alternate menu. During an interview on January 23, 2026, at approximately 11:15 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to provide documented evidence that efforts were made to accommodate individual food preferences to the extent possible, including for residents 4, 25, 33, 60, 69, and 76, in order to enhance resident satisfaction with meals. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, a review of select facility policies, and staff interviews, it was determined that the facility failed to provide person-centered care and failed to follow professional standards of practice for diabetes management for one of 21 sampled residents (Resident 2). Findings include: A review of the facility policy titled Diabetes Clinical Protocol, last reviewed by the facility on January 5, 2026, indicated it is the policy of the facility that the physician will order appropriate laboratory blood tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results. Further review revealed the resident receiving insulin who is well controlled should monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch, and as necessary) and monitor three to four times a day if on intensive insulin therapy or sliding scale insulin. Adjust monitoring frequency depending on glucose control and resident preference. A review of the facility policy titled Insulin Administration, last reviewed by the facility on January 5, 2026, indicated to check blood glucose per physician order or facility policy before insulin administration. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses to include diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood and urine) and dementia (a progressive syndrome characterized by a decline in cognitive function in memory, language, and problem-solving). A review of the quarterly Minimum Data Set (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 2 dated December 23, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 to 7 indicates severe cognitive impairment). A review of Resident 2's clinical record revealed a laboratory report dated December 4, 2025, of a hemoglobin A1C (HgbA1c) result of 12.9% (a blood test that measures the average blood sugar levels over the past two to three months) with an average blood glucose (sugar) of 324 mg/dL, which was significantly elevated and reflected poor blood sugar control over the prior two to three months. A review of physician orders revealed the following changes in diabetes treatment: On December 1, 2025, the resident was ordered Lantus (long-acting insulin) 12 units SC subcutaneous (under the skin injection) once daily at bedtime, which was discontinued on December 15, 2025. On December 15, 2025, the resident was ordered Lantus 16 units subcutaneous once daily at bedtime. On December 1, 2025, the resident was ordered Jardiance (an oral medication that lowers blood sugar by increasing glucose excretion in urine) 10 mg once daily, which was discontinued on December 15, 2025. On December 15, 2025, the resident was ordered Jardiance 25 mg once daily. On December 1, 2025, the resident was ordered Novolog (short-acting insulin) before meals based on sliding scale (insulin dose dependent on blood sugar result at the time of testing) blood sugar results, which were discontinued on December 8, 2025. On December 8, 2025, the resident was ordered Novolog 4 units subcutaneous before meals, which was discontinued on December 15, 2025. On December 15, 2025, the resident was ordered Novolog 6 units subcutaneous before meals. A review of physician orders revealed that no blood glucose monitoring was ordered by the attending physician despite increases in all three diabetes medications. A review of a physician progress note dated December 8, 2025, indicated the plan was to continue to monitor glucose. Further review of the clinical record revealed that the last documented blood glucose level for Resident 2 was on December 8, 2025, at 12:42 PM, with no subsequent blood glucose monitoring documented after that date. A review of Resident 2's care plan for endocrine system management dated December 30, 2025, indicated the resident used insulin glargine (long-acting insulin), insulin aspart (short-acting insulin), and Jardiance for diabetes management, with interventions to obtain blood glucose readings and report abnormal values as ordered. During an interview, Employee 6, Licensed Practical Nurse, stated the resident was not currently on blood glucose monitoring despite receiving insulin multiple times daily. Employee 6 stated this could be related to the resident complaining of finger pain from blood sugar testing; however, review of the clinical record revealed no documented evidence of such complaints or of an alternative monitoring plan. During an interview with the Director of Nursing on January 23, 2026, at 11:50 AM, Resident 2's diabetes management and review of the information did not reveal evidence of a documented person-centered care plan addressing blood glucose monitoring and individualized diabetes management for Resident 2. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on observations, a review of resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide a comfortable and homelike environment for residents, specifically regarding maintaining comfortable ambient temperatures in common areas for four out of four residents interviewed during a group interview (Residents 25, 60, 69, and 76).Findings include: A review of resident council meeting minutes dated December 9, 2025, revealed that residents in attendance raised complaints the dining room was cold. During a resident group interview on January 22, 2026, at 10:00 AM Residents 25, 60, 69, and 76 indicated that they have a concern about the cold temperatures in the facility's dining room. The residents explained that the room is used for dining and activities throughout the day and into the evening. During the group interview Resident 69 indicated that he has been raising concerns about how cold it feels in the dining room for weeks, but no one has addressed the issue. He explained that he was playing bingo in the room yesterday, and the cold made the activity uncomfortable. During the group interview, Resident 25 indicated that he came down to the dining room for a cup of coffee but did not stay in the area because the temperature of the room was too cold. During the group interview, Resident 60 indicated the dining room is often cold and chilly. She explained that she wraps herself up in additional clothing and wears a jacket when she is in the dining room. During the group interview, Resident 76 indicated that she feels cold right now in the dining room. She explained that she could use a sweater to make her feel warmer. During the resident group interview in the facility dining room on January 22, 2026, at 10:30 AM Residents 25, 60, 69, and 76 indicated the room felt cool. During an observation in the facility dining room on January 22, 2026, at 11:02 AM, the Director of Maintenance took temperatures of four walls in the room. The wall temperatures measured 69.7 F, 69.4 F, 65.6 F, and 68.0 F. The room felt cool. The main dining room wall thermostat temperature gauge indicated the room was 70 F. The wall thermostat is positioned on an interior wall opposite the exterior wall. The thermostat is set to heat the room to 73 F. During a follow-up observation in the facility dining room on January 22, 2026, at 12:37 PM, the Director of Maintenance took temperatures of four walls in the room. The wall temperatures measured 70.3 F, 66.4 F, 68.7 F, and 71.1 F. The room continued to feel cool. The Director of Maintenance explained that the heating system in the dining room is old and the system is not able to raise the room temperature higher during cold days. The thermostat in the dining room was set to 73 F, but the wall thermometer continued reading 70 F. During an interview on January 23, 2026, at approximately 11:15 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to provide documented evidence that efforts were made to address residents' concerns about the cold dining room temperatures or that alternative measures were taken to ensure resident comfort. The facility failed to provide a comfortable and homelike environment for residents who raised concerns about the cold dining room temperatures. The facility failed to maintain comfortable temperatures within the required regulatory range of 71 F to 81 F.28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary medications and failed to ensure nonpharmacological interventions were implemented prior to the initiation of an anticonvulsant medication used as a psychotropic medication (a drug that affects brain activity related to thinking, emotions, and behavior) for the treatment of a mood disorder (a category of mental illnesses in which the primary problem affects a person's emotional state) for one of five residents reviewed for unnecessary medications (Resident 52).Findings included: A review of the facility Psychoactive Medication Use Policy last reviewed January 5, 2026, indicated psychoactive medications may be used when necessary to treat specific conditions or diagnoses for which they are clinically indicated and effective. The psychoactive medication regimen will be regularly reviewed by the physician, and gradual dose reductions will be initiated at routine intervals unless contraindicated. Psychoactive medications may be considered for dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychoactive medications. A review of the facility Behavior Assessment, Intervention, and Monitoring Policy last reviewed January 6, 2026, indicated that behavioral symptoms will be identified using facility approved behavioral screening tools. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Appropriate assessment and treatment of behavioral symptoms require differentiation between behavioral symptoms that can be managed by treating underlying factors, and those that cannot. Current guidelines recommend the use of nonpharmacological interventions (individualized approaches aimed at decreasing behaviors without a medication) before reaching pharmacological means. A review of the clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses that include congestive heart failure (chronic condition where the heart muscle becomes too weak to pump blood efficiently) and depression. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 29, 2025, revealed that Resident 52 was moderately cognitively impaired 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 8-12 indicates moderately cognitively impaired), a mood disorder score of 6 (a score of 5 to 9 indicates mild depression), and had no behavioral symptoms during the assessment seven day look back period. A review of a nursing note dated September 20, 2025, at 6:18 AM revealed that that Resident 52 was sitting in a wheelchair in the hallway, removed the alarm, and was walking around the dining room rearranging furniture. The note stated the resident was educated on asking for help and responded, I know. A review of a nursing note dated September 25, 2025, at 8:56 PM documented the resident had increasingly aggressive behaviors toward staff and peers and was difficult to redirect; however, no description of the specific aggressive behaviors was documented.The physician was made aware. A review of a consultant psychiatric evaluation and consultation note dated October 1, 2025, revealed nursing requested a follow-up visit due to behavioral disturbance. During the visit, the resident was calm and cooperative. The psychiatric history included adjustment disorder with depressed mood and insomnia (difficulty sleeping or falling asleep). Staff reported the resident sometimes had increased behaviors and agitation with recent verbal aggression toward staff and other residents. The psychiatrist reviewed current medications and diagnosed adjustment disorder with depressed mood, moderate severity and chronic illness with progression of symptoms. The psychiatrist recommended Depakote 125 mg by mouth twice daily for mood disorder. Depakote (divalproex sodium) is an anticonvulsant medication primarily used to treat seizures and may be used off label as a psychotropic medication for mood stabilization. A nursing note dated October 3, 2025, at 3:49 PM indicated the physician was aware of the psychiatric recommendation and agreed. The note stated the resident representative was to be notified to determine if in agreement. A review of the resident's Psychoactive Medication Therapy Informed Consent Form revealed verbal consent was obtained from the resident representative on October 12, 2025, for Depakote 125 mg twice daily for mood disorder to improve functional ability and reduce behaviors. A physician order dated October 12, 2025, at 11:23 AM documented Depakote 125 mg by mouth twice daily for mood disorder. A nursing note dated October 12, 2025, at 10:02 PM documented that the resident was aggressive toward staff, attempting to transfer independently, and verbally aggressive; however, no specific behaviors were described, and redirection was documented as ineffective. A review of the resident's care plan, initially dated December 18, 2024, identified occasional verbal aggression and periodic attempts to transfer and ambulate independently. Planned interventions included offering a stuffed bear or cat, providing conversation and one-on-one interaction, changing the environment, and offering food and fluids when behaviors occurred. A review of the clinical record revealed no documented evidence that individualized nonpharmacological interventions, other than redirection, were implemented and evaluated prior to initiating Depakote for treatment of the resident's mood disorder. There was no documentation demonstrating that behavioral triggers were identified that alternative approaches were attempted, or that those approaches were ineffective prior to starting Depakote 125 mg by mouth twice daily. An interview with the Director of Nursing on January 23, 2026, at 11:30 AM failed to provide documented evidence that Resident 52 was free from unnecessary use of an anticonvulsant medication being used as a psychotropic medication for mood disorder. The Director of Nursing acknowledged that documentation of behavioral monitoring and attempted nonpharmacological interventions prior to initiation of Depakote was not consistently present in the clinical record as required by facility policy and federal regulation to justify the clinical indication for the use of the medication. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication storage rooms (East wing medication room).Findings include: A review of the facility policy titled Administering Medications, last reviewed by the facility January 5, 2026, indicated that when opening a multi-dose container, (medication vial that can be punctured with a needle multiple times for more than one dose of the same medication) the date opened for use will be recorded on the container. A review of the facility policy titled Storage of Medications, last reviewed by the facility January 5, 2026, indicated that it is the policy of the facility to ensure all medications housed on premises will be stored in medication rooms according to the manufacturer's recommendations and sufficiently to ensure proper sanitation, temperature, light, moisture control, segregation, and security. An observation of the East wing medication room on January 22, 2026, at 8:37 AM, in the presence of Employee 1, licensed practical nurse (LPN), of medication stored in the medication refrigerator, revealed two multi-dose vials of Aplisol (solution used for screening tuberculosis) that had been opened and available for use but not dated when initially opened. A review of the manufacturer's dosage and administration recommendation for Aplisol revealed that vials in use for more than 30 days should be discarded. An interview with Employee 1 at the time of the observation on January 22, 2026, at 8:37 AM, confirmed the Aplisol had been opened and not dated, and the medications should have been removed from the medication refrigerator and discarded. An interview with the Director of Nursing on January 22, 2026, at 12:00 PM, confirmed that the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, facility policy, observation, and resident and staff interview it was determined the facility failed to ensure the resident environment was free from potential accident hazards for one of 21 sampled residents (Resident 15).Findings include:A review of a facility policy titled 'Storage of Medications', last reviewed on January 5, 2026, indicated the facility will ensure all medications will be stored in the pharmacy and/ or medication rooms according to manufacturer's recommendations. The general guidelines in the policy interpretation direct staff that all drugs and biologicals are to be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control. A clinical record review revealed Resident 15 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure (condition in which one or both of the kidneys no longer work on its own). According to the Brief Interview for Mental Status (BIMS, 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) Resident 15 had a BIMS score of 9 according to the quarterly Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 4, 2026. A BIMS score of 9 indicates moderate cognitive impairment, suggesting Resident 15 may need extra assistance with daily activities and could be experiencing cognitive decline. During an observation on January 21, 2026, at 10:49 AM, in the resident room of Resident 15 (window side), two clear, 30-milliliter plastic cups containing a white, thick substance were observed on the windowsill. One of the plastic cups contained a wooden tongue depressor (a thin piece of wood rounded at both ends) immersed in the substance. Resident 15 was observed resting in bed at the time of the observation. Upon interview, Resident 15 was unaware of the plastic cups on the windowsill and was unable to identify the purpose of the cups or the substance contained within them. The Registered Nurse Assessment Coordinator (RNAC) entered the resident room during the observation and removed the two plastic cups from the windowsill. The RNAC stated the substance in the plastic cups was cream used for Resident 15's skin to prevent skin breakdown. A review of Resident 15's clinical record revealed no documented evidence that the resident had been assessed or determined safe and appropriate to self-administer medications and or treatments. Review of the physician orders revealed an active order for preventive skin care for Resident 15. The order was last revised on January 7, 2026, and remained in effect for an indefinite duration. During an interview on January 21, 2026, at 2:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed there was no documented evidence that Resident 15 had been assessed or determined safe and appropriate to self-administer medications and or treatments. The DON and NHA further confirmed it is the responsibility of the facility to ensure the resident environment is maintained free from potential accident hazards. The facility failed to maintain the resident's environment free of potential accident hazards by leaving topical medication accessible on the windowsill in Resident 15's room without evidence the resident had been assessed and determined safe to self-administer treatment, thereby creating the potential for accidental ingestion or misuse by the resident or others entering the room. 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) Nursing services.

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that reflected the resident's current medical status and required interventions for one of one sampled residents (Resident 7). Findings include: A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses to include 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) and diagnosed with a subdural hemorrhage (brain bleed) after sustaining a fall on September 5, 2025, and diagnosed with a deep vein thrombosis (a blood clot) in the left leg on November 17, 2025. A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 7 dated December 28, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 07 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 to 7 indicates severe cognitive impairment). A physician's order dated November 12, 2025, at 7:23 AM, directed oxygen administration at 2 liters (L) via nasal cannula continuously. A physician's order dated November 18, 2025, at 10:41 AM, prescribed Eliquis 5 mg (blood thinner) every twelve hours for deep vein thrombosis (blood clot). A review of Resident 7's comprehensive plan of care, initiated on December 4, 2024, and most recently revised on December 30, 2025, failed to include updated goals, interventions, or monitoring related to the resident's continuous oxygen therapy or anticoagulant therapy for deep vein thrombosis. During an interview conducted on January 22, 2026, at 12:00 p.m., the Director of Nursing confirmed the facility failed to review and revise Resident 7's care plan to accurately reflect the resident's current medical condition, risks, and required treatments.28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of employee personnel files, select facility policy, and staff interviews, it was determined the facility failed to fully implement its abuse prohibition procedures and ensure a criminal history record check was requested or obtained prior to employment for one out of five employees reviewed (Employee 2). Findings include:A review of the facility policy titled Abuse Prevention Program, last reviewed by the facility on January 5, 2026, revealed it is the facility policy to protect residents from abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. A review of personnel files revealed Employee 2, Licensed Practical Nurse (LPN), start date with the facility was October 21, 2025. A Pennsylvania State Police Response for Criminal Record Check (an official document often called a clearance, detailing an individual's criminal history such as felony and misdemeanor convictions, or arrests within Pennsylvania) with a date of request indicated January 21, 2026. During an interview on January 23, 2026, at 11:15 AM, Employee 3, Human Resources (HR), confirmed that Employee 2, LPN, worked at the facility from October 21, 2025, through January 21, 2026, without a Pennsylvania State Police Response for Criminal Record Check completed. Employee 3, HR, was unable to provide documented evidence that the facility implemented the abuse prevention program policy to ensure the facility did not employ or engage with individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. During an interview on January 23, 2026, at 11:30 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was not able to provide evidence the facility implemented the resident abuse prevention policy by screening Employee 2, LPN, to ensure she had not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law until three months after working with residents at the facility. The facility failed to ensure a criminal history record check was requested or obtained prior to employing Employee 2, LPN. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19(8) Personnel records.

Based on a review of clinical records, grievances filed with the facility, facility documentation, and staff and resident interviews, it was determined the facility failed to ensure a resident's right to privacy and failed to prevent intrusion by another resident (Resident 29) during personal care for one out of 21 residents sampled (Resident 37).Findings include:A clinical record review revealed Resident 37 was admitted to the facility on [DATE], with diagnoses that include muscular dystrophy (a group of diseases characterized by progressive weakness and degeneration of skeletal muscles that control movement). A review of an annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 30, 2025, revealed that Resident 37 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 to 15 indicates cognition is intact). A care plan revealed Resident 37 had activities of daily living deficits (fundamental, routine self-care tasks necessary for independent living and personal health) related to progressive weakness and inability to move extremities due to muscular dystrophy (an inherited condition that causes muscles to become weaker over time because the muscles do not work properly) initiated November 18, 2018. The care plan indicated Resident 37 required extensive staff assistance with showers, moving in bed, dressing, bathing, and toileting. A clinical record review revealed Resident 29 was admitted to the facility on [DATE], with diagnoses that include vascular 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). A review of an annual MDS dated [DATE], Sections C0700 and C0800, revealed that Resident 29 had problems with his short-term (recall after 5 minutes) and long-term memory (recall past events). Section C1000 revealed Resident 29's cognitive skills for daily decision-making were severely impaired. Section C1310 indicated the resident had fluctuating behavior (comes and goes, changes in severity) in his ability to focus attention, being easily distractible, or having difficulty keeping track of what is said. A grievance (documentation of a complaint or concern that can be filed by residents or on behalf of residents in a long-term care facility) filed with the facility dated September 13, 2025, revealed that Resident 29 entered Resident 37's room during care. The document indicated that around 4:30 PM on September 13, 2025, Resident 29 came into Resident 37's doorway. Resident 37's legs were exposed to her belly while she was receiving a bed bath. Resident 37 stated she was extremely upset and angry because Resident 29 came in again while she was on the bedpan and was embarrassed by the incident. During an interview on January 21, 2026, at 10:30 AM, Resident 37 explained that she is very upset about Resident 29 (a male resident) entering her room. She explained it keeps happening and staff reported that there is nothing they can do. She explained that staff need to remove Resident 29 from her room and that it sometimes happens multiple times a day. Resident 37 indicated that last week she was using the toilet in the shower room, and Resident 29 entered the shower room while she was on the toilet. She explained that he continues to come into her room, and she is embarrassed, frustrated, and angry about the situation. During an observation on January 21, 2026, at 10:40 AM Resident 29 was observed sitting in his wheelchair outside of Resident 37's room. During an interview on January 22, 2026, at 11:00 AM, Employee 4, Nurse Aide, indicated the staff try to redirect Resident 29, but he wanders throughout the facility. She explained that she did not have to redirect Resident 29 from Resident 37's room for a few weeks but confirmed that he does go into her room. During an interview on January 22, 2026, at 11:15 AM, Employee 5, Licensed Practical Nurse (LPN), confirmed Resident 29 needs to be redirected multiple times a day. She indicated the facility has attempted to use alarms and stop signs to prevent Resident 29 from entering Resident 37's room, but he still wanders into her room. During an interview on January 23, 2026, at 9:45 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA confirmed that Resident 37 has brought up concerns about Resident 29 entering her room and shower room. The NHA was unable to provide evidence that the facility ensured Resident 37's right to privacy, including the right to privacy during personal care. The NHA was unable to provide documented evidence that the facility sustained corrective action after Resident 37 submitted a grievance on September 13, 2025, regarding Resident 29 intruding on her privacy during personal care. 28 Pa. Code 201.18 (b)(2)(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the attending physician documented a clinical rationale for declining a consultant pharmacist's recommendation to reduce a psychoactive medication for one of five sampled residents reviewed for unnecessary medications (Resident 66).Findings include:A review of the clinical record revealed that Resident 66 was admitted to the facility on [DATE], with diagnoses that included diastolic congestive heart failure (a long-term condition in which the heart cannot pump blood efficiently to meet the body's needs), dysphagia, oropharyngeal phase (difficulty swallowing), and chronic respiratory failure with hypoxia (a condition in which the body does not receive enough oxygen). A review of a consultation report completed by the facility's consultant pharmacist dated December 12, 2025, revealed Resident 66 was receiving Duloxetine Hydrochloride 30 mg one capsule daily, an antidepressant in the class of Serotonin and norepinephrine reuptake inhibitors (SSNRI) a type of medication used to treat depression and nerve pain. The medication order indicated Duloxetine was prescribed to treat depression. The consultant pharmacist's review recommended that the attending physician consider a gradual dose reduction (GDR) of Duloxetine 30mg to achieve maintenance at the lowest dose possible. A gradual dose reduction, or GDR, refers to the stepwise tapering of a medication dosage to determine whether symptoms, conditions, or risks can be managed with a lower dose or discontinued altogether.A review of the physician's response dated December 15, 2025, revealed the attending physician declined the pharmacist's recommendation for a GDR and deferred the decision to psychiatry, stating the medication was also used for pain management. The physician's response did not include documentation of a clinical assessment, monitoring plan, or risk-benefit analysis explaining why the recommended GDR was not appropriate for the resident at that time. Further review of the clinical record, including a document titled Psychiatric Evaluation & Consultation dated December 17, 2025, revealed that Resident 66 continued to receive Duloxetine 30 mg daily for depression. The psychiatric consultation documented that the resident had no mood or behavioral concerns, with mood described as good and sleep and appetite reported as stable. The resident denied depression, anxiety, mood swings, irritability, lack of motivation, and feelings of hopelessness or worthlessness. The consultation further documented there was no evidence of hallucinations (seeing or hearing things that are not present) or delusions (fixed false beliefs). A review of the nurse practitioner's evaluation dated December 17, 2025, revealed no acknowledgment of the consultant pharmacist's recommendation for a GDR and no documented clinical justification for continuing Duloxetine at the same dose. The evaluation did not include a rationale for why a dose reduction was not clinically appropriate despite the pharmacist's recommendation. The above was reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 23, 2026, at 1:45 PM. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director.

Based on review of the facility's planned 4-week menu cycle and menu extensions, resident interviews, and staff interviews, it was determined the facility failed to ensure the planned menu was sufficiently reviewed and updated to ensure that the menu offered variety and avoid repetitive meal selections. Findings included: During a Resident Council meeting conducted on March 12, 2025, at 10:35 AM, with Residents 40, 45, 48, and 264, concerns were raised regarding the lack of variety in the facility's menu. Resident 48 reported that the menu was repetitive, and they get the same meats for days in a row and that the meals offered on the facility's always available menu were the same items rotated throughout the standard regular menu. Residents 40, 45, and 264 also confirmed that meals, especially meats, were frequently repeated over consecutive days. Resident 264, the elected Resident Council President, stated that concerns had been raised in food committee meetings with the Certified Dietary Manager (CDM) but were not addressed, as the facility's menu was provided by a contracted vendor and reportedly could not be modified. A review of the Fall/Winter 2024-2025 menu, signed by the Registered Dietitian on January 16, 2025, and implemented by the facility on February 9, 2025, revealed multiple instances of repetitive meal patterns over the 4-week menu cycle: A review of week 1, revealed Sunday the planned entree for dinner was a cheeseburger on a bun and then for lunch on Monday, the planned lunch was Salisbury steak (beef) with beef served for consecutive meals. Monday week 1 dinner, the planned entree was turkey and Swiss sandwich and then the planned entree for lunch on Wednesday was roast turkey (poultry) with poultry served for consecutive meals. The planned entree for Tuesday week 1 dinner was a Sloppy [NAME] (beef), and the planned entree for Wednesday lunch was lasagna with meat sauce, and Thursday lunch the planned entree served was beef and bean chili, with beef served for consecutive meals. Sunday week 2, the planned entree for lunch was ham steak and then for dinner, the planned entree was BBQ pork rib with pork served for consecutive meals. The planned entree for lunch Monday was beef macaroni casserole and then for Monday dinner the planned entree was a beef hot dog on a bun with beef served for consecutive meals. The planned entree for dinner Tuesday was baked chicken tenders and then for Tuesday lunch the planned entree was oven fried chicken, and then for Tuesday dinner the planned entree was a chicken salad sandwich with chicken served for consecutive meals. Further review of week 2 revealed that Friday dinner the planned entree was Italian sausage sub and then for Saturday lunch the planned entree served was bratwurst on a bun with pork served for consecutive meals. Saturday week 2 dinner, the planned entree served was baked ziti with meat sauce, and then Sunday week 3 lunch, the planned entree served was homestyle meatloaf with beef served for consecutive meals. Sunday week 3 dinner, the planned entree served was a chicken patty on a bun and then Monday week 3 lunch the planned entree served was baked chicken with poultry served for consecutive meals. Monday week 3 dinner, the planned entree served was a hamburger on a bun and then week 3 Tuesday dinner, the planned entree served was beef macaroni casserole with beef served for consecutive meals. Tuesday week 4 lunch, the planned entree served was a Philly cheese steak sandwich, and then week 4 Wednesday lunch, the planned meal served was BBQ beef on a bun, and then Wednesday dinner, the planned meal served was a cheeseburger on a bun with beef served for consecutive meals. The repetitive meal patterns demonstrated that the facility failed to provide a varied menu that met resident preferences and nutritional needs, leading to menu fatigue and reduced meal satisfaction. During an interview with Employee 2, facility's contracted dietary food/menu representative, on March 12, 2025, at 1:05 PM, stated that his company was responsible for proving the facility with a 4-week seasonal menu that was reviewed by the facility's Registered Dietitian. Also, Employee 2 indicated the facility could alter the meals and items offered on the menu to best meet the needs and preferences of the residents. An interview with the facility's Nursing Home Administrator (NHA) on March 13, 2025, at 10:00 AM, confirmed that similar foods were served for consecutive meals and that similar or the same foods/meals were also offered on the resident's always available menu. The NHA confirmed the facility's menu was repetitive and didn't offer variety to deter menu fatigue. The facility failed to ensure the planned menus were reviewed and modified to provide variety, leading to repetitive meal patterns that did not meet the satisfaction of the residents. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.6 (a) Dietary 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, increasing the risk of contamination and foodborne illness in the dietary 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). During an initial tour of the dietary department on March 11, 2025, at 9:10 AM, conducted with the Food Service Director (FSD) and Employee 1, a food service worker (FSW), the following unsanitary conditions were observed: In the cook's area, a metal wire rack used to store clean cooking equipment, felt greasy had a significant buildup of grease and debris, indicating inadequate cleaning practices. The windowsill above the microwave and open bread loaves was cluttered and covered in dust and debris, creating a potential source of contamination. A storage container of butter was placed on top of the microwave with a dirty, uncovered butter spreader resting on it. The butter was discolored, had crumbs adhered to its surface, and appeared soft and melting, indicating improper food handling and storage. The interior of the microwave contained food splatter and peeling surfaces, presenting a potential source of cross-contamination. A food prep station contained an industrial can opener with a sticky blade. Employee 1 stated that it was used earlier to open cans of tuna fish and had not been cleaned afterward, failing to meet sanitary standards for food preparation equipment, The above findings were reviewed with the facility's Nursing Home Administrator (NHA) on March 11, 2025, at 1:30 PM, and it was confirmed that the dietary department should be maintained in a sanitary manner to prevent the potential for food contamination and foodborne illness. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on review of select facility policies, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program. Findings included: A review of a select facility policy entitled, Infection Prevention and Control Program last reviewed by the facility January 2025 revealed the facility must establish an infection prevention and control program under which it identifies, investigates, controls, and prevents infections in the facility. Further it is indicated the objectives of the infection control policies and procedures are to prevent, detect, investigate, and control infections in the facility. A review of facility policy entitled Surveillance for Infections last reviewed January 2025 revealed for residents with infections that meet the criteria for definition of infection the facility will collect the following: A. Identifying information including the residents name, age, room number, unit, an attending physician B. Diagnoses C. admitted , date of onset of infection (may list onset of symptoms) D. Infection site E. Pathogens F. Invasive procedures or risk factors such as surgery, indwelling tubes, or Foley catheter G. Pertinent remarks (symptoms) and record if the resident is admitted to the hospital or expires H. Treatment measures A review of the facility's infection control data revealed the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. Specifically, the facility lacked an effective system which enabled the facility to analyze clusters, track changes in prevalent organisms, or identify increases in the rate of infection in a timely manner. A review of facility infection control logs for May 2024 through March 2025 revealed the facility did not have any tracking of infections for the month of June 2024. Additionally, review of the logs indicated that the facility failed to consistently document critical infection-related details such as: Location of infections Whether infections were community-acquired or facility-acquired Symptoms experienced by residents Onset date of infections An interview with the Assistant Director of Nursing (ADON) who also serves as the facility's Infection Preventionist, conducted on March 13, 2025, at approximately 10:15 AM, the ADON confirmed that no infection control tracking log could be located for June 2024. The ADON further acknowledged that the facility's infection control logs were incomplete and failed to support a comprehensive infection prevention and control program. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of clinical records and staff interview it was determined the facility failed to maintain a system to effectively monitor antibiotic usage in accordance with its antibiotic stewardship program for one of 17 sampled residents (Resident 1). Findings include: A review of select facility policy entitled, Antibiotic Stewardship last reviewed January 2025 revealed antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. The purpose of the antibiotic stewardship program is to monitor the use of antibiotics. A review of select facility policy entitled, Antibiotic Stewardship Orders for Antibiotics Last review January 2025 revealed appropriate indications for use of antibiotics stated that appropriate indications for antibiotic use include meeting the clinical definition of active infection or suspected sepsis and confirming pathogen susceptibility based on culture and sensitivity results. A review of select facility policy entitled, Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes last reviewed January 2025, revealed antibiotic usage and outcome data will be collected and documented using the facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility antibiotic stewardship. Further it is indicated the infection preventionist will review antibiotic utilization as part of the antibiotic stewardship program and at the conclusion of the review the provider will be notified of any review findings. At the time of the survey ending March 13, 2025, the facility failed to demonstrate their actions designed to optimize the treatment of infections through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use Additionally, the facility failed to provide documented evidence that prescribing practitioners were made aware of their prescribing practices. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include history of malignant neoplasm (cancer) of the bladder and dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life). On October 16, 2024, at 8:23 AM, a nursing progress note indicated that Resident 1 had an elevated white blood cell count (WBC) of 15.48 ul but no other symptoms. Despite the absence of multiple clinical symptoms necessary to justify antibiotic use, the physician was notified, and a urinalysis with culture and sensitivity (UA C&S) was ordered. On October 17, 2024, at 8:00 AM, before the culture and sensitivity results were available to confirm an infection or guide appropriate treatment, the physician ordered Bactrim DS (antibiotic) for five (5) days. On October 19, 2024, at 1:34 PM, the urine culture results confirmed the presence of Escherichia coli ESBL (extended-spectrum beta-lactamase-producing E. coli. These enzymes break down certain antibiotics making the bacteria resistant to these medications), which was resistant to Bactrim DS. A review of the October 2024 Medication Administration Record (MAR) showed that the resident received five (5) doses of an unnecessary and ineffective antibiotic, demonstrating a failure in antibiotic stewardship. An interview with the Director of Nursing on March 13, 2025, at approximately 1:15 PM confirmed the facility failed to have a functioning antibiotic stewardship program. The facility's failure to ensure adherence to its antibiotic stewardship policies resulted in the administration of an inappropriate antibiotic. Refer F757 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on a review of clinical records, facility policy, facility investigative reports, and staff interviews, it was determined the facility failed to implement adequate safety measures, including sufficient staff supervision, for a resident identified as at high risk for falls resulting in multiple recurrent falls for one resident (Resident 50) out of 17 sampled Findings include: A review of Resident 50 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), abnormalities of gait and mobility (refer to any unusual or unexpected patterns of movement or changes in the way an individual walks or moves), repeated falls, hypertensive heart disease (refers to heart conditions caused by high blood pressure), and urinary tract infection (UTI - is an infection in the bladder, kidneys, ureters, or urethra). The resident's person-centered fall care plan initiated on January 13, 2023, identified Resident 50 was at risk for falls due to frequent falls and impulsiveness due to diagnosis and history of self-transfers with ambulation attempts and impulsivity with poor safety awareness. A review of a quarterly Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed Resident 50 had severe cognitive impairment. A Fall Risk assessment dated [DATE], confirmed that Resident 50 remained at high risk for falls. Despite this, a clinical record review revealed that Resident 50 experienced 14 falls from July 13, 2024, through February 22, 2025, with 11 of these falls being unwitnessed On July 13, 2024, at 3:58 AM, a progress note documented that Resident 50 was found lying on the floor on his right side. The resident had sustained a 5 cm by 2.5 cm abrasion on the right forehead and a 1 cm by 1.2 cm abrasion on the right shoulder. A clean and dry incontinence brief was found in the bathroom. Following this incident, staff were instructed to check alarms at the beginning of each shift to ensure proper placement and functionality. A therapy consultation was also initiated. On July 27, 2024, at 4:43 AM, another progress note indicated that Resident 50 was found on the floor near the foot of the bed with the alarm sounding. The resident stated that he had attempted to get out of bed to use the bathroom but tripped. He sustained a 1.5 cm by 0.5 cm head wound on the back of his head. Orders were received to cleanse the wound and cover it with a bandage. Additional fall prevention measures were implemented, including placing a fall mat on the left side of the bed and ensuring a urinal was available at the bedside. According to a progress note from August 9, 2024, at 8:50 AM, staff responded to an alarm in the East shower room and found Resident 50 sitting on the floor next to the toilet. His red scoot chair was found damaged on the opposite wall. There were no reported injuries. A therapy referral was made to assess whether the red scoot chair remained appropriate or if an alternative seating option was needed. On September 11, 2024, at 5:15 PM, a progress note described an incident in which a registered nurse (RN) responded to a chair alarm sounding from the visitor bathroom. The bathroom door was locked, and when staff gained entry, they found Resident 50 sitting on the floor with his back against the grab bar and his legs extended toward the wall. No injuries were noted. A subsequent urine culture tested positive for a urinary tract infection (UTI), and new antibiotic orders were placed. A progress note from September 23, 2024, at 1:15 AM, stated that Resident 50 was found by his assigned licensed practical nurse (LPN) and nurse aide (NA) sitting on the floor next to an overturned bedside table. The resident was sitting on part of the metal frame of the table and had abrasions on both posterior thighs. He was assisted into his chair, and frequent visual checks were initiated as a preventive measure. On October 3, 2024, at 10:45 PM, a nursing assistant (NA) found Resident 50 lying on the floor on his right side. His walker was positioned against the wall near the bathroom. The resident stated he had attempted to go to the bathroom. A bowel and bladder diary was initiated, and a referral to therapy was sent. This was documented in a progress note dated October 4, 2024, at 12:00 AM. A progress note from October 12, 2024, at 12:00 AM, reported that Resident 50 was found sitting on the floor on the left side of his bed, with his back against the bed. His bed pad was partially off the bed. He was placed in his chair and taken to the nurses' station for close observation. A therapy referral was also placed. On November 18, 2024, at 11:34 AM, a progress note stated that Resident 50's chair alarm was sounding in another resident's bathroom. When staff entered, they found him lying on his right side on the bathroom floor. He stated, I needed to take a crap, and I still need to. After an RN assessment confirmed no injuries, staff assisted him back into his chair and took him to his bathroom. A medication review was ordered, and the physician prescribed Flomax to address benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) in an effort to improve his toileting frequency. According to a November 27, 2024, at 12:00 AM progress note, Resident 50 was found lying on his left side on the floor, with his walker on top of him. He had a small amount of bleeding from his left elbow and a 1/2-inch scratch in the same area. The wound was treated, with orders for daily wound care until healed. Urine was found on the floor, and it was determined that the resident slipped in his own urine. After the incident, he was toileted and placed in a Broda chair (a type of chair or wheelchair that provides comfort, support, and mobility throughout the day and designed for individuals requiring long-term care and allow for safe and comfortable positioning without the use of restraints) at the nurses' station, as he was not sleeping. A therapy referral was also made. On December 10, 2024, at 1:43 AM, a progress note stated that at 12:15 AM, Resident 50's alarm sounded, and staff found him sitting on the floor next to his bed. He reported that he had rolled out of bed. A 4 cm by 2.5 cm hematoma was noted on the left side of his head. Ice was applied, and the resident was able to move all extremities. After being assisted off the floor, incontinence care was provided, and a body pillow was introduced for positioning support. A therapy referral was sent. On January 14, 2025, at 4:05 AM, Resident 50's alarm alerted staff to another fall. He was found lying on his left side between the foot of his bed and the dresser, with his walker beside him. He was wearing only nonskid socks and a pull-up, and he was incontinent of urine. The resident reported that he had been trying to get up. Staff assisted him into his scoot chair and provided incontinence care. Based on a review of fall incidents, his toileting schedule was adjusted to 3:45 AM to better align with his overnight toileting needs. A therapy referral was also made. A February 22, 2025, at 4:20 PM progress note detailed that at 3:50 PM, an RN was called to the East Hall regarding another fall. Resident 50 was found lying on his left side in the doorway of room [ROOM NUMBER]. He had a 2 cm by 2 cm abrasion/laceration on the left side of his forehead and surrounding bruising measuring 5 cm by 5 cm. A witnessed account from another resident stated that Resident 50 had been standing up, pulling up his pants when he lost his balance, hit the door with his rear, and then struck his head on the door jamb. Staff observed that the resident's speech was significantly delayed, and he was not moving his extremities as usual. Despite this, he denied pain, and there were no visible deformities in his lower or upper extremities. His vital signs remained stable. A neurological assessment revealed significantly delayed speech, reduced movement from baseline, and difficulty following instructions. The resident was found to have a wet brief at the time of the assessment. His head injury was cleaned, and the physician was notified. Orders were received to transfer the resident to the emergency room (ER) for further evaluation. Upon his return, a three-day bowel and bladder evaluation was ordered to determine whether adjustments were needed in his toileting program. Further review of Resident 50's person-centered care plan indicated that frequent visual checks were added as a fall intervention on September 23, 2024. However, there was no documented evidence that these checks were consistently conducted. Despite Resident 50's repeated falls and the documented need for frequent visual checks, a review of the facility's documentation revealed no evidence that these checks were consistently conducted. The resident continued to experience falls in various locations-including the resident's room, bathrooms, and common areas-indicating that the facility failed to provide adequate supervision and effective fall prevention interventions. During an interview on March 13, 2025, at approximately 9:30 AM, the Director of Nursing (DON) confirmed that the facility did not implement the planned intervention of frequent visual checks. The DON also acknowledged that the facility did not provide adequate supervision to prevent the resident's recurrent falls, despite the identified high risk The facility failed to ensure adequate supervision and implement effective fall prevention interventions to protect Resident 50 from recurrent falls, as evidenced by multiple documented falls, injuries, and a lack of follow-through with the planned intervention of frequent visual checks.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 60) and failed to implement interventions to alleviate pain for one resident (Resident 15) out of 17 residents reviewed. Findings include: A review of the clinical record revealed that Resident 60 was admitted to the facility on [DATE], with diagnoses to include multiple rib fractures with routine healing. A review of Resident 60's clinical record revealed physician orders for as-needed (PRN) pain medication included: Oxycodone HCL 5 mg (narcotic pain medication), one tablet by mouth every four hours as needed for pain rated 5 to 7 (scale used to rate pain, with 0 being no pain and 10 being severe pain), initiated on January 13, 2025, and ending January 26, 2025. Oxycodone HCL 5 mg, two tablets by mouth every four hours as needed for pain rated 8 to 10, initiated on January 13, 2025, and ending January 26, 2025. Oxycodone HCL 5mg one tablet by mouth every 4 hours for pain as needed for pain 4 to 7 and two tablets by mouth every 4 hours for pain as needed for pain 8 to 10 initiated on January 27, 2025, and ending February 15, 2025. Oxycodone HCL 5mg give one tablet by mouth every 4 hours for pain rated 4 to 7 and two tablets by mouth every 4 hours for pain rated 8 to 10 initiated on February 18, 2025, and remains active. In January 2025, staff administered Oxycodone 30 times; of these, 23 instances lacked documented evidence of non-pharmacological interventions attempted prior to administration A review of the resident's January 2025 Medication Administration Record (MAR) revealed staff administered the PRN Oxycodone 30 times; of these, 23 instances lacked documented evidence of non-pharmacological interventions attempted prior to administration A review of the resident's February 2025 MAR revealed staff administered Oxycodone 28 times; of these, 8 instances lacked documented evidence of non-pharmacological interventions attempted prior to administration. A review of the resident's March 2025 MAR revealed staff administered Oxycodone one time with no documented evidence of non-pharmacological interventions attempted prior to administration. An interview with the Nursing Home Administrator and Director of Nursing on March 13, 2025, at approximately 1:15 PM both confirmed there was no evidence that non-pharmacological interventions were consistently attempted and deemed ineffective before administering as-needed narcotic pain medication. A clinical record review revealed Resident 15 was admitted to the facility on [DATE], with diagnoses that include 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) and emphysema (a chronic lung disease characterized damage to the air sacs in the lungs. A review of the resident's plan of care dated November 11, 2021, for pain related to arthritis, identified a potential for pain related to arthritis, with planned interventions to encourage/assist to reposition frequently for comfort and therapy evaluation and treatment per orders. The care plan goal was documented as the resident reporting that pain management was within acceptable limits. A review of physician orders revealed that, beginning August 1, 2023, the resident was prescribed: Acetaminophen 325 mg (Tylenol), two tablets by mouth every six hours as needed for mild pain (rated 1 to 5), with required non-pharmacological interventions including repositioning, back rubs, warm/cool compress application, and diversional activities prior to administration. A review of progress notes indicated: On January 12, 2025, at 5:00 PM, the resident complained of left-sided lower back pain, and a new order was placed for a lidocaine patch to be applied at bedtime. On January 13, 2025, at 10:31 AM, the resident continued to complain of low back pain, and a physician was contacted for an x-ray order. On January 13, 2025, at 10:33 AM, the resident refused the lidocaine patch, and the physician discontinued the order. On January 13, 2025, at 1:00 PM, an x-ray was performed. A nursing progress note dated January 14, 2025, at 1:31AM documented Xray results revealed a compression fracture ( a type of broken bone that can cause your vertebrae to collapse, making them shorter) of lumbar vertebrae (bones that make up the lower back) L1, L2, and L3 of an indeterminate age and degenerative disc disease (a condition where the spinal discs, which act as shock absorbers between the vertebrae, wear down and lose their cushioning over time, leading to pain and potentially other issues) of the lumbar vertebrae between L4 and L5. Despite continued complaints of pain, there was no documented evidence that the resident was offered the as-needed acetaminophen or any other alternative pain-relief interventions. During an interview on March 12, 2025, at approximately 11:00 AM, the Director of Nursing (DON) confirmed the facility staff failed to develop and implement appropriate pain management interventions for Resident 15's continued pain. The facility failed to ensure non-pharmacological interventions were attempted prior to administering PRN narcotic pain medication for Resident 60 and failed to implement appropriate interventions to address continued pain for Resident 15. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address and manage the dementia-related behavioral symptoms of one out of 17 residents reviewed (Resident 10). Findings include: A review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The resident exhibited recurrent episodes of increased agitation, aggressive and argumentative behaviors, verbal threats toward staff and residents, and delusional ideation, including believing another resident was her daughter and that staff had taken her daughter. A review of a progress note dated August 25, 2024, at 8:37 PM revealed the resident became increasingly agitated making threats of harm, stating if she gets killed, she will throw every penny at somebody to have someone killed. The resident exhibited paranoid behavior and believed that another resident was her daughter and that someone was in another resident's room with a gun. A review of a progress note dated November 14, 2024, at 6:15 PM revealed the resident was observed arguing with another resident and became upset when her husband left mid-dinner. A review of a progress note dated November 15, 2024, at 6:44 PM indicated the resident was aggressive and argumentative with both staff and residents. A review of a progress note dated November 15, 2024, at 7:32 PM indicated the resident exhibited delusional beliefs that staff had taken her daughter and threatened to strike them. A review of a progress note dated November 16, 2024, at 2:08 PM and again at 5:22 PM, the resident demonstrated increased agitation, verbal threats toward staff, and irritability toward her husband. A review of a progress note dated November 18, 2024, at 2:00 AM revealed the resident was awake, restless, and argumentative with staff. A review of a progress note dated November 20, 2024, at 8:57 PM revealed the resident was observed making agitated statements toward other residents during dinner. A review of a progress note dated December 3, 2024, at 8:00 PM indicated the resident attempted to enter another resident's room, became irate when redirected by staff, and insisted she needed to protect the resident whom she believed to be her daughter. A review of the resident's current care plan revealed it failed to: Identify specific behavioral symptoms exhibited by the resident. Include individualized, person-centered interventions tailored to address each behavior. Incorporate the resident's preferences, social and past life history, customary routines, and interests to support behavior management. An interview with the Nursing Home Administrator on March 13, 2025, at approximately 1:15 PM, confirmed the facility was unable to provide evidence of an individualized, person-centered care plan to address and manage the resident's dementia-related behaviors. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of controlled drugs in sufficient detail to enable accurate accounting of controlled substances when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 62). Findings include: Review of the facility's Discharge Medications policy last reviewed by the facility on January 25, 2025, indicated controlled substances shall not be released upon discharge of the resident unless permitted by current state law governing the release of controlled substances and as authorized (in writing) by the resident's Attending Physician. The nurse will reconcile pre-discharge medications with the resident's post discharge medications and the medication reconciliation will be documented. The nurse shall complete the medication disposition record including the resident's name, the name of the person assisting or administering the medication after discharge, the date of discharge, the name of each medication, the prescription (Rx) number of each medication, the quantity or amount of each medication, the strength of each medication, any special instructions, telephone numbers of the physician, pharmacy, and facility, the signature of the person receiving the medications, and the signature of the nurse releasing the medications. The nursing staff shall forward completed drug disposition records to medical records and the complete list of the resident's medications shall also be provided to the resident upon discharge. A review of Resident 62's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute cystitis (inflammation of the bladder) and weakness. A physician's order dated January 23, 2025, at 3:54 PM, included the following controlled medications: Oxycodone 5 mg (opioid analgesic pain medication, a controlled medication) 1 tablet by mouth every 4 hours as needed for severe pain rated 7-10 (scale used to rate pain, with 0 being no pain and 10 being severe pain),) for 14 days and Tramadol 50 mg - 1 tablet by mouth every 6 hours as needed for mild pain rated 1-3. A nursing note dated February 5, 2025, at 6:51 PM, indicated that Resident 62 signed out Against Medical Advice (AMA) at 6:45 PM. The note documented that the attending physician and the Nursing Home Administrator (NHA) were notified. Further review of Resident 62's closed record failed to provide documented evidence of a controlled medication accountability record for the Oxycodone 5 mg tablets or Tramadol 50 mg tablets, as required by facility policy. During an interview with the director of nursing (DON) on March 13, 2025, at 10:00 AM, the DON was unable to provide documented evidence that the required accountability record for Resident 62's controlled medications had been completed. The DON confirmed that facility policy requires a controlled medication accountability record for all controlled medications to prevent unauthorized use, misappropriation, and ensure accurate tracking and disposition. 28 Pa. Code 211.9 (j.1)(1)(2)(3)(4)(5) Pharmacy services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 17 residents sampled (Residents 1). Findings included: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include history of malignant neoplasm (cancer) of the bladder and dementia (a decline in memory, thinking, and other cognitive abilities, significantly impacting daily life). A nursing progress note dated October 16, 2024, at 8:23 AM indicated the resident's white blood count (WBC) was elevated at 15.48 ul (4.000 ul to 1100 ul normal), but the resident did not exhibit any other signs or symptoms of infection at that time. The physician was notified, and an order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for possible infection. A progress note dated October 16, 2024, at 10:41 AM documented that the resident was catheterized (rubber tube placed in the bladder) to obtain a urine sample, which was then placed in the specimen refrigerator for pick-up. A review of a nursing progress note dated October 16, 2024, at 11:31 PM revealed the resident's urinalysis results were received, and the physician was made aware. A progress note dated October 17, 2024, at 8:00 AM documented that the physician ordered Bactrim DS (an antibiotic) one tablet every 12 hours for five (5) days, despite the culture and sensitivity results not yet being available to determine the type of infection and appropriate antibiotic treatment. A review of the resident's laboratory report dated October 19, 2024, at 1:34 PM, revealed that the urine culture identified Escherichia coli ESBL (extended-spectrum beta-lactamase-producing E. coli. These enzymes break down certain antibiotics making the bacteria resistant to these medications) with bacterial growth exceeding 100,000 CFU/ml. The report further indicated that the prescribed antibiotic (Bactrim DS) was resistant to the bacteria found in the resident's urine, rendering the treatment ineffective. A review of Resident 1's Medication Administration Record (MAR) for October 2024 revealed that the resident received five (5) doses of Bactrim DS, an unnecessary antibiotic, before the culture and sensitivity results confirmed that the prescribed medication was ineffective. During an interview with the Director of Nursing (DON) on March 13, 2025, at approximately 1:15 PM, the DON confirmed that the administration of Bactrim DS was not clinically justified, as the prescribed antibiotic was ineffective against the identified organism. The DON acknowledged that the resident received an unnecessary medication, which did not align with evidence-based infection control and antimicrobial stewardship practices. Refer 881 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, facility investigative reports, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, in accordance with professional standards of practice for two of 17 sampled residents (Resident 8 and 44). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. A review of clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses which included hypertensive (high blood pressure) heart disease. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 19, 2024, revealed the resident was cognitively intact with a BIMs score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact), A review of clinical record revealed that Resident 44 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (nerve damage disrupts communication between the brain and the body causing many different symptoms, including vision loss, pain, fatigue, and impaired coordination). A review of a Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired with a BIMs score of 5 (0-7 indicating severe cognitive impairment). A review of a facility investigative report dated November 28, 2024, at 11:50 AM revealed at 11:00 AM staff observed Resident 8 and Resident 44 holding hands in the hallway. Resident 44 tapped her lips, leaned in, and kissed Resident 8. Staff separated the residents. Resident 44 stated, It was not a big deal; I just gave him a little peck. Resident 8 expressed no concerns regarding the incident. Despite this event a review of Resident 8's clinical record contained no documentation of the interaction, staff intervention, or follow-up assessments to determine any emotional or psychological effects on the resident. Additionally, Resident 44's clinical record lacked documentation of the inappropriate behavior, assessments following the event, or any interventions to prevent recurrence. The failure to document this incident and any follow-up actions resulted in incomplete and inaccurate clinical records, which did not reflect the residents' conditions, behaviors, or staff interventions. An interview conducted on March 13, 2025, at approximately 1:15 PM, the Nursing Home Administrator and Director of Nursing confirmed that nursing staff failed to consistently and accurately document residents' interactions and behaviors in the clinical records. 28 Pa. Code 211.5 (f)(iii) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that two residents (Resident 45 and 42) were free from sexual abuse perpetrated by one resident (Resident 6) out of 19 sampled residents. Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility January 2024, revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility policy entitled Identifying Types of Abuse last reviewed January 2024, revealed sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes but is not limited to unwanted intimate sexual touching of any kind especially to the breasts or perineal area. Further it is indicated that sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. A review of clinical record revealed that Resident 45 was admitted to the facility on [DATE], with a diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) dated January 3, 2024, revealed that the resident was moderately cognitively impaired. A review of clinical record revealed that Resident 6 was admitted to the facility on [DATE], with a diagnosis of hypertensive heart disease. A review of a Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately cognitively impaired. A social services note dated November 20, 2023, at 4:41 PM revealed that the Social Services Director spoke with Resident 6 about his interactions with female residents and told Resident 6 that he will need to refrain from touching female residents. A nursing note dated January 6, 2024, at 5:12 PM revealed that Resident 6 was inappropriate with a peer. Nursing noted on January 8, 2024, at 8:16 AM that a new order was obtained to monitor Resident 6 for socially inappropriate behavior, sexual acts towards residents or staff, every shift, for inappropriate sexual behaviors and provide additional details in the progress notes. A review of a progress note dated January 15, 2024, at 4:57 PM revealed that Resident 6 was in the dining room. Resident 6 wheeled himself over to another resident, a female resident, who was sitting at a table by herself. Staff observed Resident 6 touching the other female resident (Resident 45) under her nightgown in the upper thigh area and the RN (Registered Nurse) was made aware. An interview with Employee 7, a nurse aide, on April 23, 2024, at approximately 1:15 PM revealed Resident 6 can be sexually inappropriate and needs to be told he cannot touch females, residents or staff. Employee 7 stated that she has seen the resident touch other female residents on the arms and hands. She stated that he has touched her on her bottom before and he had to be told to stop, that it was not appropriate. An interview with Employee 3, a nurse aide, on April 24, 2024, at 2:19 PM revealed that the employee witnessed Resident 6 with his hand up under Resident 45's nightgown and touching her in the upper thigh area, near her private area. An interview with Employee 5, a nurse aide, on April 24, 2024, at 2:26 PM revealed the employee stated that she was aware that Resident 6 had his hand up Resident 45's nightgown was touching her upper thigh area, by her private area. An interview with Employee 4, LPN (license practical nurse), on April 25, 2024, at 9:47 AM revealed that this employee was coming down the hall with her medication cart and witnessed Resident 6 and Resident 45 seated at a dining room table. Employee 4 stated that she saw Resident 6's hand up Resident 45's nightgown on her upper thigh area, by Resident 45's private area. The employee stated she made Employee 6, RN Supervisor, aware of the incident. An interview with Employee 6, RN, on April 25, 2024, at 11:06 AM revealed that she was called to the floor the night the incident happened when staff observed Resident 6 inappropriately touching Resident 45 in a sexual manner. Employee 6 stated that staff made her aware that Resident 6 had touched Resident 45 upper thigh area and she then made the Director of Nursing (DON) aware. Employee 6 stated that Resident 6's behaviors have been an ongoing concern, that administration was aware, and it is talked about in report almost every day. A review of Resident 45's clinical record revealed that the facility failed to document that Resident 45 was touched in a sexual nature by Resident 6 on January 15, 2024. Applying the reasonable person concept, in the case of Resident 45, who is unable to speak for herself, and the assessment of how most people would react to the situation of being sexually abused by Resident 6, Resident 45 would have suffered psychosocial harm and humiliation. The facility failed to fully investigate and report this incident of sexual abuse of Resident 45. The facility failed to develop and implement necessary interventions for a resident with a known history of sexual inappropriate behaviors to prevent the sexual abuse of Resident 45. The facility failed to develop and implement interventions after the sexual abuse occurred to prevent further incidents of sexual abuse. A review of behavior tracking for January 2024 revealed that on January 15, 2024, during the night shift and January 16, 2024, during the day shift, staff documented that Resident 6 had continued to display sexually inappropriate behaviors. There was no documentation in Resident 6's clinical record describing these behaviors and to whom they were directed. A review of clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (nerve damage disrupts communication between the brain and the body causing many different symptoms, including vision loss, pain, fatigue, and impaired coordination). A review of a Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately cognitively impaired. An interview with Employee 3, a nurse aide, on April 24, 2024, at 2:19 PM revealed that this employee had witnessed Resident 6 grab Resident 42's breasts. The employee could not remember the exact date but stated that the Resident 6 is known for targeting and being inappropriate with Resident 42 and Resident 45. An interview with Employee 5, a nurse aide, on April 24, 2024, at 2:26 PM revealed that she was aware and had witnessed Resident 6 grope Resident 42's breasts. She stated she was not sure of the date that this occurred, but other staff were aware that this happened. An interview with Employee 4, LPN, on April 25, 2024, at 9:47 AM revealed that the employee stated she, and other employees, had witnessed Resident 6 groping Resident 42's breasts. Employee 4 stated that she documented this behavior in Resident 6's behavior tracking and made Employee 6, RN, aware. An interview with Employee 6, RN, on April 25, 2024, at 11:06 AM confirmed that she was aware that Resident 6 and touched Resident 42's breasts. She stated that everyone knows about the resident's behaviors, and they do their best to keep him away from female residents. Employee 6 stated that she has made the DON aware of these ongoing behaviors. A review of Resident 6's Behavior Tracking For February 2024 revealed that Employee 4 documented that Resident 6 was being sexually inappropriate on February 4, 2024, during the evening shift, but failed to note that Resident 6 had groped Resident 42's breast as reported during employee interviews at the time of the survey ending April 25, 2024. A review of Resident 42's clinical record revealed that the facility failed to document that Resident 42 was the victim of sexual abuse perpetrated by Resident 6. The facility failed to investigate and report this incident of sexual abuse. Further the facility failed to prevent the sexual abuse of Resident 42 perpetrated by Resident 6 who has a known history of being sexually inappropriate with female residents and had sexually abused another female resident on January 14, 2024. Applying the reasonable person concept, in the case of Resident 42, who is unable to speak for herself, and the assessment of how most people would react to the situation of being sexually abused by Resident 6, Resident 42 would have suffered psychosocial harm and humiliation. An interview with the Nursing Home Administrator and Director of Nursing on April 25, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Residents 45 and 42 were free from sexual abuse perpetrated by Resident 6. Refer to F609, F610 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on review of clinical records and select facility policy, observation, and resident and staff interviews, it was determined that the facility failed to consistently provide necessary care and services to promote healing of pressure sores for two residents (Resident 4 and 1) and prevent deterioration and infection, which required surgery and caused the resident increased pain for one resident (Resident 1) out of five sampled residents. Findings include: A review of the current facility policy entitled Pressure Ulcer/Injury Risk Assessment indicated that a resident-centered and interventions should be developed with the resident's stated wishes and goals. The care plan should be modified as the resident's condition changes, or if current interventions are inadequate. Review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) ] to the sacrum [is a large, triangular bone formed by the fusion of five sacral vertebrae] and generalized muscle weakness. The resident's care plan initiated October 6, 2020, revealed that the resident had actual skin breakdown related to a Stage IV pressure area to the coccyx. Planned interventions included to encourage and assist as needed to turn and reposition; use assistive devices as needed, bilateral quarter side rails, float air mattress to bed, pressure reducing specialty mattress-bariatric Flow T mattress with perimeter defining bolsters sewn to mattress cover, Roho cushion to wheelchair (limit seat time in w/c), and a pressure reduction device on bed/chair. A review of the resident's weekly wound evaluations from the time of admission through the time of the survey ending April 19, 2022, revealed that breaks in conducting the weekly tracking to follow the healing status of the resident's Stage IV pressure sore occurred beginning November 2021, The facilty's Wound Evaluation Flow Sheet documentation consists of 12 weeks of evaluation once opened and systematically covers areas to be documented on in regards to the wound to include: wound summary, measurements, exudate, wound bed, periwound, and treatment plan, and then the cycle begins again if not healed after 12 weeks. A Wound Evaluation - Week 1 dated November 3, 2021, completed by an LPN, revealed that the resident had a Stage IV pressure ulcer to the sacrum, that occurred prior to admission on February 20, 2020, and measured 2.0 cm in length by 2.0 cm in width by 1.8 cm in depth. The LPN described that the wound with no tunneling, had light thin serious drainage, a moist and red granulated wound bed, and had defined wound margins with slight maceration. The next Wound Evaluation - Week 2 dated November 19, 2021, revealed that the sacral wound had increased to 3.3 cm x 2.3 cm x 2.0 cm and had tunneling present at 8 o'clock to 10 o'clock with 3.7 cm and had light, thick serosanguineous drainage. The wound bed was noted to have purulent drainage with 50% yellowish slough and pink epithelial in the wound bed. The wound treatment ordered on November 24, 2021, was to cleanse the site with soap and water, apply [MEDICATION(S)] AG to wound and pack wound with bolstering gauze, and cover with a dry sterile dressing The next Wound Evaluation - Week 3 was not completed until February 9, 2022, and the Wound Evaluation - Week 4 was not completed until February 22, 2022. The Wound Evaluation - Week 5 dated March 1, 2022, revealed that the sacral wound measured 2.0 cm x 2.0 cm x 4.0 cm in depth (increased depth since previous evaluation). The noted treatment plan was to continue with the treatment ordered on November 24, 2021, (cleanse the site with soap and water, apply [MEDICATION(S)] AG to wound and pack wound with bolstering gauze, and cover with a dry sterile dressing). A pressure redistribution mattress, wheelchair cushion, and nutrition supplements were also to be in effect. It was noted that the wound had similar measurements from the previous week, but with deeper depth. The evaluation noted that the resident's care plan was reviewed and updated. Observation on April 19, 2022, at 11:45 AM, revealed that there was no bed present on the resident's side of the room. The resident was seated in a recliner chair. Resident 4 stated that she always slept in a recliner, even when she lived in the community, and preferred sleeping in a recliner chair instead of a bed. Observation of the recliner chair revealed that there was no pressure reduction device on the chair and beneath the resident. Resident 4 stated staff give me a chuck (incontinence) pad to protect my recliner cushion, just in case I have an accident, and then the pad will be washed. Interview with the Director of Nursing (DON) on April 19, 2022, at 1:30 PM, reported that any resident with pressure ulcers would have a Wound Evaluation completed weekly and the care plan updated with new interventions as needed. The resident's clinical record failed to reveal that weekly Wound Evaluations were consistently completed weekly as per facility policy. There was no documented evidence that Resident 4's treatment plan was evaluated for adequacy and effectiveness in response to the decline in the resident's wound (increase in size and depth). The facility failed to implement pressure relieving devices to the resident's recliner chair to promote healing and prevent worsening of the resident's pressure sore. The resident's care plan was not revised to reflect to the resident's preference for sleeping in a chair, but included measures for pressure relief to the resident's bed. The DON confirmed during interview on April 19, 2022, at 2:15 PM, that the facility failed to perform weekly wound evaluations according to facility policy, failed to timely evaluate the resident's wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included diabetes mellitus with other diabetic neurological complication and unspecified abnormalities of gait and mobility. A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated November 23, 2021, admission from an acute care hospital, revealed that the resident received a score of 18 (score of 15 to 18 is mild risk), indicating that the resident was at risk for pressure sore development. A review of Resident 1's Admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process completed periodically to plan resident care) dated November 29, 2021, revealed that the resident required extensive assistance of staff for transfers and bed mobility (moving to and from lying position, turning side to side and positioning body while in bed) and toileting. The MDS assessment indicated that the resident did not have pressure ulcers, however was at risk for pressure sore development. A review of Resident 1's current plan of care, initially dated November 23, 2021, and revised on December 12, 2021 revealed that Resident 1 was identified as at risk for alteration in skin integrity related to impaired mobility with a goal of skin will remain free of breakdown within the limits of disease process with the following interventions planned: encourage and assist to reposition; use assistive devices as needed, observe for changes in skin conditions and report abnormalities, pressure reduction device of bed/chair (specify), and provide barrier cream to perianal area/buttocks after each incontinent episode and as needed. A nursing note dated December 23, 2021, at 9:53 AM revealed while CNA (Certified Nursing Aide) was providing care an open area was noted on the resident's right buttocks measuring 3 centimeters x 1 centimeter. Review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Wound Evaluation week 1 documentation indicated that the wound was identified on December 23, 2021, on the right buttocks. The evaluation noted that the wound was non-pressure and identified it as MASD ( Moisture Associated Skin Disorder caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, [MEDICATION(S)], saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection.) and was measured as 3.0 cm in length, 1 centimeter in width, and 0 centimeters in depth. The wound was noted to have light serosanguineous, thin watery exudate/drainage. Review of the wound documentation indicated that the wound was an open area and skin surrounding the open area as reddened but blanchable. The documentation indicated the resident has mixed incontinence (typically a combination of stress and urge incontinence, it shares symptoms of both) and often refusing to be changed. However, a review of the resident's care plan failed to indicate that the resident refuses care and the planned interventions to promote the resident's compliance and acceptance of care. Resident 1's Wound Evaluation documentation revealed that the resident's wound was identified on December 23, 2021. However, week 2 wound evaluation documentation was dated February 2, 2022, approximately 4 weeks from the initial identification of the skin impaired area. The wound had increased in size and now measured 4 centimeters in length, 2.5 centimeters in width, and 0.1 centimeters in depth, a noted increase in surface area indicating a decline in the wound. This assessment was completed by a Licensed Practical Nurse, not a registered nurse. There was no documented evidence the wound on the resident's right buttocks was evaluated during the month of January 2022. Review of Resident 1's January 2022 Treatment Administration Record Revealed the order dated December 23, 2021, for [MEDICATION(S)] was discontinued on January 6, 2022. Further Review of Resident 1's January 2022 Treatment Administration Record revealed that from January 6, 2022 through January 27, 2022, there was no treatment ordered and administered for the open area on the resident's right buttocks. There was no indication that the open area was evaluated by professional staff after the discontinuation of the ordered treatment on January 6, 2022, or any documentation that the area was healed. Review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ® ([MEDICATION(S)] is a hydropolymer, adhesive foam island dressing that is waterproof and has a high fluid-handling capacity). However, there was no documented assessment of the open area in the resident's clinical record related to the change in the wound treatment. A review of Resident 1's quarterly MDS assessment dated [DATE], revealed that the resident now had one Stage IV pressure ulcer that was not present on admission. Interview with the Director of Nursing on April 19, 2022 at approximately 11:00 AM when asked about the 4 week lapse in wound evaluations revealed that the DON stated that it was the result of the incorrect classification of the open area. The DON stated that the open area was as pressure sore and not MASD. The facility then restarted the Wound Evaluation paperwork on February 2, 2022. In response to surveyor inquiry regarding the lack of consistent wound monitoring and assessment, the facility provided documentation of the resident's wound on the right buttocks dated February 16, 2022, which failed to reflect a continuation of the wound tracking of the open area that was identified on December 23, 2021. This documentation was created in a manner to reflect a new wound identified on February 13, 2022. The DON confirmed during interview on April 19, 2022, at 12 PM that this provided documentation was in error and the wound on the resident's right buttocks was initially identified on December 23, 2021. The DON confirmed that there was no documented evidence of any evaluations of the resident's wound during January 2022. A review of Resident 1's Wound Evaluation dated February 16, 2022, indicated that the week 1 wound evaluation for the wound identified on February 13, 2022 was completed on February 22, 2022. The wound area was classified as non-pressure and identified as severe MASD developing into ulcer; but not pressure. The documentation indicated that the wound measured 5.9 centimeters in length, 3.8 centimeters in width, and 1 centimeter in depth. The exudate was identified as purulent, thick and moderate with odor. The documentation indicated there was odor and purulent drainage and that an infection or colonization was present. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's wound care specialist documentation dated March 2, 2022 indicated the encounter date of the initial wound consult was on March 1, 2022. Review of the wound specialist documentation indicated the wound on the right buttocks was a Stage IV pressure injury with necrotic tissue and surrounding [CONDITION(S)] which measured 6.5 centimeters in length, 4 centimeters in width and 5.3 centimeters in depth. Recommendations were to discontinue Santyl and start ½ strength Dakins Solution moistened gauze packing to right buttocks and change daily, [MEDICATION(S)] 875 milligrams two times a day for 10 days, turn and reposition every 2 hours, low air loss mattress and ROHO cushion when using wheelchair and all sitting surfaces and follow up in 4 weeks. The wound specialist documentation indicated that the resident was advised an x-ray was recommended for possible bone involvement, but it was noted that the resident declined. Review of Resident 1's wound care specialist documentation dated March 17, 2022 for a follow up visit revealed that on March 3, 2022, a CT (A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do) of lower extremity without contrast was performed which revealed, decubitus ulcer over the right ischial tuberosity with cortical irregularity and lucency equivocal for [CONDITION(S)]. Correlate for exposed bone. The wound specialist documentation indicated that the resident was advised this may need additionally bone debridement in the operating room. The resident had surgery on April 5, 2022, during which some necrotic and abundant thick fibrinous tissue overlying right ischium, which was excised with cautery (procedure using electricity or chemicals to burn tissue in order to close a wound) and a large portion (walnut-sized) of soft bone was removed with an osteotome (instrument used for cutting or preparing bone). Observation of Resident 1 on April 19, 2022 at 11:36 AM revealed the resident in bed with a pillow between her knees. At this time both of the resident's heels were observed directly on the bed. Observation also revealed a pair of heel boots on the resident's recliner, which the resident confirmed belonged to the resident. When asked about the heel boots the resident stated that the staff don't always put them on. Further observation revealed that at the foot of the resident's bed was an air pump Air Flowt which was not turned on to provide air flow as pressure relief to the resident's mattress. Interview with Employee 2, Licensed Practical Nursing on April 19, 2022, at 11:36 AM confirmed that the resident did not have the heel boots in place and these were ordered on April 9, 2022. Employee 2 stated that the employee was not sure what type of mattress Resident 1 was using but believed that it was a pressure reducing mattress. Employee 2 stated that the employee believed that Resident 1 is to have an air mattress and then confirmed that the air pump at the foot of the bed was not on. Employee 2 then contacted maintenance staff. Interview with Employee 3, Maintenance Director at 11:52 AM confirmed that the resident's air mattress was not functioning and stated that the machine had been unplugged. Interview with Resident 1 on April 19, 2022 at approximately 2:00 PM revealed that she presently experiences excruciating pain during treatment changes and at times repositioning. Resident 1 allowed for observation of her wound at this time, but the depth of the right buttocks pressure wound could not be observed because the resident stated that enough time had passed for the treatment to be completed and as she was in pain. The length was measured as 6.5 centimeters and the width was measured as 6 centimeters. The facility failed to accurately assess skin impairment, consistently and effectively monitor wound status to timely identify deterioration, consistently implement pressure relieving measures planned and evaluate the effectiveness of planned treatments in promoting healing of pressure sores. The facility was unable to demonstrate that the worsening of the resident's wound and development of infection was unavoidable as a result of these noted failures. Interview with the Director of Nursing (DON) on April 19, 2022 at approximately 2:30 p.m. failed to provide documentation to demonstrate consistent evaluation of the wound in order to implement timely interventions to prevent worsening of wounds, which resulted in a continued decline in the resident wound and infection, which required surgical removal of bone. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services.

Based on a review of clinical records, facility provided documentation and select investigative reports, observations and staff and resident interviews, it was determined that the facility failed to provide necessary staff supervision with activities of daily living (bathing) to prevent a fall resulting in a serious injury, a fractured left femur, for one out of seven sampled residents (Resident 32). Findings include: A review of the clinical record revealed that Resident 32 was admitted to the facility on [DATE], with diagnoses, that included muscle weakness, lack of coordination, abnormalities of gait and mobility, left [CONDITION(S)] (paralysis of one side of the body), [CONDITION(S)] (an eye disease causing vision loss) and [CONDITION(S)] (a disease which the immune system eats away at the protective covering of nerves, causing nerve damage, possibly resulting in vision loss, fatigue, clumsiness, and dizziness). An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 5, 2021, revealed that Resident 32 was cognitively intact and required extensive assistance with activities of daily living including bed mobility, transfers, dressing, toileting, and personal hygiene (combing hair, brushing teeth) and bathing. A review of the resident's care plan, initially dated April 20, 2018, revealed that the resident required extensive assistance of two staff members for bathing. The resident's plan of care, initially dated July 9, 2018, revealed that the resident was identified at risk for falls due to history of falls. A fall assessment (documentation tool used to predict falls) dated January 22, 2019, indicated that Resident 32 scored a 10, indicating that the resident was at high risk for falls. A review of a facility incident investigation, nursing documentation in the clinical record and facility provided documentation indicated that on February 15, 2021, at approximately 9:20 a.m., one staff member, Employee 1 (Nursing Assistant), was washing Resident 32, while the resident was seated in a shower chair in the West Wing shower room. During the provision of this care, Employee 1 left the shower stall to retrieve towels and upon returning to the shower stall, heard Resident 32 yelling for help and found her on the floor of the shower room. The facility incident investigation continued to reveal that Resident 32 was observed lying on her back, head facing toward the entrance of shower stall, feet against back wall of shower, left leg displaying internal knee rotation complaining of pain. 911 emergency services were called and Resident 32 was transferred to the hospital. The physician, and family aware. Review of Employee 1's witness statement dated February 15, 2021, revealed that, I then asked her if she was okay, if I grabbed the towels that were in the room, for after she got out. I was walking back with towels and I heard Resident 32 yell help. Interview on March 3, 2021, at approximately 12:33 p.m., with alert, oriented and cognitively intact Resident 32, revealed that the resident explained that prior to her fall on February 15, 2021, she was in the shower chair facing the shower head, with Employee 1 assisting her with showering. At some point during the shower, Employee 1 left the shower stall to retrieve the towels for the resident. While unattended in the shower room, Resident 32 learned forward to retrieve a bottle of shampoo that had fallen on the floor and the resident fell out of the chair onto the floor. Interview on March 3, 2021, at approximately 1:43 p.m., with Employee 2 (Nursing Assistant), revealed she assisted Employee 1 on February 15, 2021, in the morning with the transfer of Resident 32 from the resident's motorized wheelchair into the shower chair. Employee 2 then exited the shower room, leaving Employee 1 alone with Resident 32 to shower the resident. Employee 2 was then called shortly thereafter to return to the shower room. Upon entering the West Side shower room, Employee 2 observed Resident 32 lying on the floor in the shower stall. A review of hospital emergency department documentation dated February 15, 2021, at 11:09 a.m., revealed that Resident 32 had sustained a comminuted fracture (a break or splinter of the bone into more than two fragments) of the left femur (leg bone) as the result of the fall. A review of hospital documentation dated February 16, 2021, at 8:19 a.m., revealed that Resident 32 had underwent surgical intervention of the left femur, with an IM nail placed (a type of surgery in which a permanent nail or rod is placed into the center of the bone to keep it stable). A telephone interview on March 3, 2021, at approximately 2:30 p.m., with Employee 1, revealed that she brought Resident 32 into the furthest back shower stall and assisted with bathing/showering the resident. Employee 1 stated that she stood by the resident to assist with showering. At some point in the process of showering the resident, Employee 1 left the resident unsupervised in the shower stall to retrieve towels, which according to Employee 1 had been placed on the rim/edge of the tub (located approximately 7.5 feet away from the entrance of the shower stall - as measured by Employee 3, Maintenance). This area was located in the shower room, but outside and around the corner from the shower stall as observed during the survey ending March 3, 2021. The facility failed to provide the necessary supervision of Resident 32 during bathing on February 15, 2021, to prevent a fall, resulting in a serious injury, a fractured left femur. During an interview on March 3, 2021, at approximately 2:50 p.m., the Nursing Home Administrator verified the circumstances of the resident's fall and that Employee 1 left Resident 32 unsupervised in an unsafe area (shower room) and while unattended the resident fell and sustained a serious injury. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previous cited 7/26/19, 11/23/2020

Based on a review of clinical records and select investigative reports and staff interviews, it was determined that the facility failed to implement effective interventions and monitor and modify safety measures as necessary for a resident with a history of falls, resulting in repeated falls and head injury requiring hospitalization on e out of one sampled resident with falls (Resident 58). Findings include: A review of the clinical record revealed that Resident 58 was admitted to the facility on (MONTH) 5, 2019, with diagnose to include dementia (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability), muscle weakness, and repeated falls. A review of the admission Minimum Data Set (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated (MONTH) 16, 2019, revealed that Resident 58 had a BIMS (Brief Interview for Mental Status- a tool used to access cognitive function) score of 5,which indicates severe cognitive impairment. Section G (functional status) of the admission MDS Assessment indicated that Resident 58 needed physical assistance with transfers and ambulation and the resident required the use of walker (mobility device). A review of the clinical record revealed that on (MONTH) 5, 2019 10:49 PM resident noted with several I (independent) transfers this eve. Redirected to use RW (rolling walker) with ambulation. On (MONTH) 6, 2019 at 1:30 AM it was documented that resident non-compliant with asking for assistance and on (MONTH) 8, 2019 at 3:54 AM the resident was observed ambulating in hallway x 1 unassisted. The clinical record revealed also that on (MONTH) 20, 2019 at 11:09 PM resident redirected several times this eve about using RW with ambulation. A review of the resident's plan of care, identified on admission that the resident was at risk for falls due to impaired mobility and history of falls. Interventions designed to prevent falls were initiated on (MONTH) 8, 2019, and included having commonly used articles within easy reach, maintain bed in low position and provide assistance to transfer. On (MONTH) 17, 2019, additional interventions were put in place, which included call bell in reach, bilateral fall mats, non-skid shoes/slippers - when out of bed if resident will allow, non-skid traction strips to both sides of bed and in front of toilet, reinforce the need to call for assistance and scoop/perimeter defining mattress. These safety measures were all initiated prior to the resident's first fall on (MONTH) 27, 2019. A review of a facility incident report dated (MONTH) 27, 2019, and nursing documentation revealed at approximately 6:15 PM Resident 58 was observed ambulating wearing her sneakers in the hallway without use of her rollator (walking device), carrying a pile of clothes. She leaned forward toward the floor and then fell face first. Upon notification, the nurse arrived and observed the resident lying face down on the floor just inside the doorway leading to her room. The resident's [NAME]et, purse and night gown were noted on the floor next to her. She was unresponsive for approximately 5 minutes and blood was noted on the floor by the right side of her head. The resident was transferred and hospitalized from (MONTH) 27 to (MONTH) 1, 2019 with [DIAGNOSES REDACTED]. Review of the interdisciplinary team conclusion dated (MONTH) 2, 2019 revealed that Resident 58 continued to be a fall risk and had required 1 to 1 (staff supervision) related to her attempts to rise from bed and chair and not bearing weight on her legs. She had fall mats in place and a perimeter mattress on the bed. She had been provided with a scoot chair for OOB seating. As the result of this Interdisciplinary team meeting on (MONTH) 2, 2019, a scoot chair was being trialed with the instructions for staff not to leave Resident 58 alone when in chair as stated by the Therapy Manager. A review of a facility incident report dated (MONTH) 4, 2019, and nursing documentation revealed that at approximately 10:45 PM Resident 58 was heard yelling and staff observed resident's feet in hallway. When staff approached the resident was found on floor lying on her right side wearing only a brief and 1 non-skid sock. Her right arm was tucked under her body. A 3-centimeter U shaped skin tear and 1-centimeter skin tear was observed on her right elbow along with a 2 centimeter by 3-centimeter lump with abrasion on her right forehead. Area was cleansed and steri strips applied and attempts were made to place ice on forehead. Review of the Interdisciplinary team conclusion dated (MONTH) 6, 2019, revealed that Resident 58 attempted to ambulate without assistance and without use of walker. Prior to fall she was observed in bed and last toileted at approximately 9:30 PM prior to going to bed. The resident's call bell was in reach and not used. 1 to 1 was implemented related to restless behavior. A review of a facility incident report dated (MONTH) 17, 2019, and nursing documentation revealed that at approximately 2:30 AM Resident 58 was sitting in her chair being supervised by staff. As the staff provided care to other residents, Resident 58 was brought along and left outside the door to keep watch over her. While providing care to a peer, staff heard Resident 58 fall. Resident 58 was observed lying on floor in hallway, face down with arms at her side. No apparent injuries noted. Review of the Interdisciplinary team conclusion dated (MONTH) 17, 2019 revealed that Resident 58 had a medication review and adjustments made. Staff will continue to provide 1 to 1 as needed. It was noted that she enjoys folding towels and singing hymns. A review of a facility incident report dated (MONTH) 2, 2019, and nursing documentation revealed that at approximately 3:25 PM Resident 58 was seated in her scoot chair in hallway within view of nursing staff without any foot wear. She then tumbled forward onto the floor. She was examined and found to have an abrasion on top of her right foot and a red area on 5th toe on her left foot. No treatment required. Review of the Interdisciplinary team conclusion dated (MONTH) 3, 2019 revealed that staff were to observe the resident for any sign of restless behavior and provide stand-by supervision, attempt to take for walks, provide with tasks to complete such as folding towels, assist to the bathroom, provide with a snack as a diversional activity. Assess for pain, fatigue, and offer rest period in bed. A review of a facility incident report dated (MONTH) 4, 2019, and nursing documentation revealed that at approximately 1:00 AM Resident 58 was sleeping in her chair at the nurse's station entrance. Staff responded to a call bell. While still in view of the charge nurse and supervisor, Resident 58 moved her chair and was attempting to ambulate without assistance. Before staff was able to reach her, Resident 58 stumbled and fell to the floor. She was lying face down slightly on her left side, with her left arm underneath her with legs outstretched. Resident 58 was unresponsive for 3 minutes and when she regained consciousness, she was agitated, hitting, biting and grabbing at staff. After examination a 7-centimeter x 3-centimeter hematoma was noted on her left temple, along with a laceration with deformity of her left index finger. Resident 58 was transported to hospital ER and a left-hand x -ray was taken and revealed a dislocated finger requiring 3 sutures and a splint. While in the ER a CT (computed tomography - a diagnostic test) of the head/brain and neck x ray was obtained and were negative for any bleed, trauma or fracture. Review of the Interdisciplinary team conclusion dated (MONTH) 12, 2019, revealed that the resident continues to require close supervision and the pharmacist completed a medication review with adjustments. The facility failed to consistently provide this resident with known unsafe behaviors and a history of falls with necessary staff supervision, at the level and frequency required, to deter unsafe behaviors and prevent repeated falls, and injuries resulting in hospitalization for right subdural hematoma, right focus subarachnoid hemorrhage and left-hand index finger dislocation. Interview on (MONTH) 18, 2019 at approximately 1:05 PM with Nursing Home Administrator (NHA) confirmed Resident 58 had multiple falls with injury and required 1 to 1 staff monitoring to prevent falls. Further interview on (MONTH) 18, 2019 at approximately 2:05 PM with the NHA and Director of Nursing (DON) indicated the facility failed to provide evidence that the resident, who had a history of [REDACTED]. 28 Pa. Code 211.12(a) Nursing services Previously cited 6/29/2018 28 Pa. Code 211.12(c) Nursing services Previously cited 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 6/29/2018 28 Pa. Code: 211.12(d)(3)(5) Nursing Services Previously cited 6/29/2018

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to effectively monitor fluid intake and output for a resident with a change in condition to timely identify and act upon risk factors to prevent dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated) for one of 14 residents reviewed (Resident 23). Findings include: Review of the facility's, Hydration Policy, dated January 2016, indicated that residents will receive sufficient amounts of fluid to maintain proper hydration. The dietitian will assess all residents for hydration adequacy at least quarterly, and more often as necessary as per resident need. A change in hydration shall be assessed by the nurse. A review of the clinical record revealed that Resident 23 had [DIAGNOSES REDACTED]. A review of the resident's monthly physician's orders [REDACTED]. kidneys work including dehydration makes [MEDICATION NAME] toxicity more likely) 125 mcg (microgram) one tablet by mouth daily for the treatment of [REDACTED]. Review of a, Nutrition Risk Review, (a facility form used for nutritional assessment of residents) dated March 17, 2016, noted that the resident's weight was 156.4 pounds and the resident's hydration need was 2,100 ccs (cubic centimeters) of fluid per day. The resident's appetite at meals was noted as 25% to 75%. A Healthshake (a 120 cc nutritional supplement) was being offered with all meals and a Magic Cup (a 120 cc nutritional supplement) was being offered with lunch and dinner. The review noted that the resident's current lab values dated February 18, 2016, were indicative of adequate fluid and electrolyte balance (proper levels of minerals in the blood which help maintain fluid balance and adequate kidney function). Review of the resident's, Risk Scoring for Pressure Ulcers, Dehydration, and Nutrition, (facility form assessing risk factors for skin breakdown and nutrition and hydration concerns) dated March 17, 2016, noted that the resident was at a high risk for dehydration and moderate risk for weight loss. No specific interventions for monitoring and meeting the fluid needs for the resident who was identified to be at high risk for dehydration were noted. A, SBAR Communication Form (Situation Background Assessment Recommendation, a facility form used to communicate important resident information to the physician) dated April 18, 2016, at 3:00 p.m. indicated that the resident had an emesis (vomit) of digested food. The physician was made aware and no recommendations were noted as being received from the physician. A nurses' note dated April 23, 2016, at 11:45 a.m. noted that the resident complained of nausea in the morning and was offered and accepted ginger ale with positive results. A, SBAR Communication Form dated April 28, 2016, at 12:45 p.m. noted that the resident had ongoing emesis since April 18, 2016, which had worsened since it started. The assessment by the Registered Nurse noted that the resident had a decreased appetite, nausea and vomiting and emesis of liquids consumed and medications. The resident had three episodes of emesis on the dayshift. The physician was made aware on April 28, 2016, (the time of the notification was not documented). A physician order [REDACTED]. A nurses' note dated May 1, 2016, at 9:30 a.m. noted that the resident had two episodes of emesis. The resident was given her morning pills and vomited them immediately. The [MEDICATION NAME] 4 mg was given, but the resident vomited that medication also. A nurses' note dated May 7, 2016, at 5:30 a.m. noted that the resident vomited a scant amount of yellow liquid. A nurses' note dated May 9, 2016, at 1:50 p.m. noted that the physician was made aware of continued nausea and vomiting. A physician's orders [REDACTED]. an order for [REDACTED]. Glucose is a type of sugar your body uses for energy. Electrolytes keep your body's fluids in balance) and a urinalysis (analysis of urine by physical, chemical, and microscopical means to test for the presence of disease, drugs) with culture and sensitivity (lab test used to diagnose a urinary tract infection and to identify the bacteria or yeast causing the infection done in conjunction with testing to determine which antibiotics will inhibit the growth of the microbe causing the infection and the drug most effective in treating a person's infection) were ordered for May 11, 2016. Review of the resident's April 2016 and May 2016, Meal Reports, (facility records of the resident's meal consumption for the dates beginning April 18 through May 11, 2016) noted that the resident's appetite was frequently 0% to 25%. Review of the resident's April 2016 and May 2016, Medication Administration Record, revealed that the resident's consumption of the nutritional supplements, Healthshakes and Magic Cups, also varied with frequent instances of 0% consumed. There was no documented evidence that the facility was actively monitoring the adequacy of the resident's daily fluid intake and fluid loss from frequent vomiting to prevent dehydration. There was no documented evidence that the dietitian was made aware of the resident's vomiting and decreased oral intake to assess the resident for the potential need for dietary changes and nutritional interventions in an attempt to maintain adequate hydration. There was no documented evidence that the licensed nurse had notified the dietitian of the resident's change in ability to maintain hydration due to vomiting and decreased food and fluid intake and that the licensed nurse had assessed these factors as noted in facility policy. A nurses' note dated May 11, 2016, at 10:45 a.m. noted that the physician was notified of the resident's BMP results, which included a critically elevated BUN (blood urea nitrogen: measure of serum urea, a by-product of the breakdown of blood, muscle and protein. Urea is cleared by the kidney; diseases that compromise renal function lead to increased BUN) of 105 mg/dl (normal 7-30 mg/dl), an elevated Creatinine (test that helps determine whether the kidneys are functioning normally) level of 4.3 mg/dl (normal less than 1.2 mg/dl) an elevated Sodium (test is usually done as part of an electrolyte or basic metabolic panel blood test. Your blood sodium level represents a balance between the sodium and water ) level of 148 mmol/L (normal 135-146) and Potassium (a chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells) level of 5.3 mmol/L (normal 3.5-5.2 mmol/L). These lab tests and values are also indicators of hydration status, which may become elevated with dehydration. The physician ordered that the resident be transferred to the emergency room . Review of the, Emergency Medicine Note, (from the hospital) dated May 11, 2016, noted that the resident was admitted to the hospital with [REDACTED]. Intravenous (IV therapy is the infusion of liquid substances directly into a vein) fluids were administered at the hospital. A Foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine) was inserted to monitor the resident's intake and output. An interview with the Director of Nursing (DON) on June 28, 2016, at 10:00 a.m. failed to provide documented evidence that the facility timely acted upon the resident's decreased oral intake of food and fluids, which was combined with repeated episodes of nausea and vomiting and had developed and implemented sufficient measures to increase the resident's fluid intake and maintain adequate hydration status to the extent possible. The DON confirmed that there was no documented evidence available to demonstrate that the facility had considered possible adverse drug consequences ([MEDICATION NAME]) as a contributing factor for the resident's change in condition, which the resident continued to display for an extended period of time without evidence of timely interventions to effectively address the causative factor for the resident's decreased appetite combined with nausea and vomiting. Refer F329 28 Pa. Code 211.5 (f)(g)(h) Clinical records 28 Pa. Code 211.6 (d) Dietary services Previously cited 7/1/15 28 Pa. Code 211.10 (a)(d) Resident care policies Previously cited 7/1/15 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 2/11/16, 1/11/16, 7/1/15

Based on review of clinical records and staff interview, it was determined that the facility failed to effectively monitor a resident for adverse consequences from a prescribed medication with a known potential for drug toxicity (caused by a buildup of the medication in the blood and may be life threatening) and further failed to implement timely and necessary measures to address the resident's change in condition resulting in the resident's admission to the hospital with a [DIAGNOSES REDACTED]. Findings include: A review of the clinical record revealed that Resident 23 had [DIAGNOSES REDACTED]. A review of the resident's monthly physician's orders [REDACTED]. work including dehydration makes [MEDICATION NAME] toxicity more likely) 125 mcg (microgram) one tablet by mouth daily for the treatment of [REDACTED]. enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated)) 20 mg (milligrams) one tablet by mouth every other day for the [DIAGNOSES REDACTED]. The resident's monthly physician's orders [REDACTED]. A CBC (complete blood count: blood test used to evaluate your overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]. A complete blood count test measures several components and features of your blood, including: red blood cells, which carry oxygen) and BMP (basic metabolic panel: a blood test that measures your sugar (glucose) level, electrolyte and fluid balance, and kidney function. Glucose is a type of sugar your body uses for energy. Electrolytes keep your body's fluids in balance) were also ordered every 6 months (CBC and BMP results can be used to help evaluate kidney function and hydration status). Further review of the resident's clinical record revealed that the resident had been receiving the prescribed dose of [MEDICATION NAME] 125 mcg (micrograms) by mouth once daily for a [DIAGNOSES REDACTED]. Review of the resident's most recent 6 month [MEDICATION NAME] level dated February 8, 2016, revealed that the level was 1.9 ng/ml (nanogram per milliliter- normal range is 0.8 -2.0 ng/ml). The physician was made aware of the lab value with no new orders given. Review of a, Nutrition Risk Review, (facility form used for nutritional assessment of residents) dated March 17, 2016, noted that the resident's weight was 156.4 pounds and the resident's hydration need was 2,100 ccs (cubic centimeters) of fluid per day. The review noted that the resident's current labs dated February 8, 2016, were indicative of adequate fluid and electrolyte balance (proper levels of minerals in the blood which help maintain fluid balance and adequate kidney function). Review of the resident's, Risk Scoring for Pressure Ulcers, Dehydration, and Nutrition, (facility form assessing risk factors for skin breakdown and nutrition and hydration concerns) dated March 17, 2016, noted that the resident was at a high risk for dehydration and moderate risk for weight loss. No specific interventions for monitoring and meeting the fluid needs for the resident who was identified to be at high risk for dehydration were noted. A, SBAR Communication Form, (Situation Background Assessment Recommendation, a facility form used to communicate important resident information to the physician) dated April 18, 2016, at 3:00 p.m. noted that the resident had an emesis (vomit) of digested food. The physician was made aware and the physician made no recommendations. A nurses' note dated, April 23, 2016, at 11:45 a.m. noted that the resident complained of nausea in the morning and was offered and accepted ginger ale with positive results. A, SBAR Communication Form, dated April 28, 2016, at 12:45 p.m. noted that the resident had ongoing vomiting since April 18, 2016, which had worsened. The assessment by the Registered Nurse noted that the emesis began with a decreased appetite, before nausea and vomiting and then emesis of the liquids and medications the resident had consumed. The resident was noted to have had three episodes of emesis on the dayshift. The physician was made aware, but the time of the notification was not documented. A physician's orders [REDACTED]. A nurses' note dated May 1, 2016, at 9:30 a.m. revealed that the resident had vomited twice. The resident was given her morning pills and vomited them immediately. The [MEDICATION NAME] 4 mg was given, but the resident vomited that also. A nurses' note dated May 7, 2016, at 5:30 a.m. noted that the resident vomited a scant amount of yellow liquid. A nurses' note dated May 9, 2016, at 1:50 p.m. noted that the physician was made aware of the resident's continued nausea and vomiting. A physician's orders [REDACTED]. an order for [REDACTED]. Review of the resident's April 2016 and May 2016, Meal Reports, (facility records of the resident's meal consumption for the dates beginning April 18 through May 11, 2016) noted that the resident's appetite was frequently 0% to 25%. Review of the resident's April 2016 and May 2016, Medication Administration Record, noted that the resident's consumption of Healthshakes and Magic Cups (nutritional supplements) also varied with frequent instances of 0% consumed. There was no documented evidence that the facility was effectively monitoring the resident's daily fluid intake and loss via vomiting. There was no documented evidence that the dietitian was made aware of the resident's emesis and decreased food and fluid intake to assess the need for dietary changes and nutritional interventions in an attempt to maintain adequate hydration. There was no documented evidence that the resident's change in ability to maintain hydration was assessed by the nurse. A nurses' note dated May 11, 2016, at 10:45 a.m. noted that the physician was notified of the resident's BMP results, which included a critically elevated BUN (blood urea nitrogen: measure of serum urea, a by-product of the breakdown of blood, muscle and protein. Urea is cleared by the kidney; diseases that compromise renal function lead to increased BUN) of 105 mg/dl (normal 7-30 mg/dl), an elevated Creatinine (test that helps determine whether the kidneys are functioning normally) level of 4.3 mg/dl (normal less than 1.2 mg/dl) an elevated Sodium (test is usually done as part of an electrolyte or basic metabolic panel blood test. Your blood sodium level represents a balance between the sodium and water) level of 148 mmol/L (normal 135-146) and Potassium (a chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells) level of 5.3 mmol/L (normal 3.5-5.2 mmol/L). These lab tests and values are also indicators of hydration status, which may become elevated with dehydration. The physician ordered that the resident be transferred to the emergency room . Review of the, Emergency Medicine Note, (from the hospital) dated May 11, 2016, noted that the resident was admitted to the hospital with [REDACTED]. Intravenous (IV therapy is the infusion of liquid substances directly into a vein) fluids were administered at the hospital. A Foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine) was inserted to monitor the resident's intake and output. The resident's [MEDICATION NAME] level, which was collected at the hospital on May 11, 2016, at 12:00 p.m. was 4.8 (normal range is 0.5-2.0 ng/ml). The resident was identified as critically ill in the hospital documentation. Digibind (an antidote for [MEDICATION NAME] toxicity) was administered to the resident. The, Emergency Medicine Note, indicated that it was likely that the resident had [MEDICATION NAME] toxicity, which resulted in vomiting and [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on June 28, 2016, at 10:00 a.m. confirmed that there was no documented evidence that the facility had promptly evaluated the resident's [MEDICATION NAME] use, a medication with the potential for drug toxicity, when resident presented with a change in condition and signs and symptoms of decreased appetite, nausea and vomiting, which resulted in the resident's admission to the hospital with diagnoses, which included [MEDICATION NAME] toxicity. Refer F327 28 Pa. Code 211.5 (f)(g)(h) Clinical records 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 2/11/16, 1/11/16, 7/1/15

Based on observations and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards. Findings include: A tour of the West Wing resident unit on January 11, 2016, at 2:10 PM revealed that the door leading to the clean laundry room was propped door. A sign was observed on this door indicating that the Door must be kept closed and locked at all times when not occupied. The surveyor entered this room from the West Wing corridor and observed no other person was present in this room. At the time of this observation two gas clothes dryers were running. The flames from the gas supply to each dryer, located on the top of the two gas clothes dryers, were observed flaming up intermittently, the vents open with the flames easily accessible to residents. Piles of clean clothing were folded on shelves near these dryers. A container with scissors was on the counter top of the shelf. An open basket with a large number of wire hangers was on the floor. Three thermos cups were set on the counter near small compartments holding clean clothing. The surveyor remained in this unsecured clean laundry room until 2:20 PM when the Director of Nursing Services (DON) also entered the room. The DON verified that this room should not be left unsecured unless the room is supervised for resident safety. The DON was not aware of where the laundry staff was at the time of the observations. 483.25 (h) Free of Accident Hazards/supervision/devices Previously cited 7/1/2015 28 Pa. Code 201.18 (e)(1) Management Previously cited 7/1/2015 28 Pa. Code 207.2 (a) Administrator's responsibility Previously cited 7/1/2015

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide a physician prescribed supportive device to one resident and effective pain management for one resident out of 15 sampled (Residents 53 and 56). Findings include: Clinical record review revealed that Resident 53 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observation of Resident 53 on June 30, 2011, from 11:30 a.m., thru approximately 1:15 p.m., revealed the resident was out of bed sitting in a chair without the sling in place. Observation of the resident on July 1, 2011, from 8:00 a.m., thru 11:30 a.m., revealed that the resident was out of bed sitting in a chair without the sling in place. The Occupational Therapy notes dated June 14, 2011, indicated that the use of a right arm sling would benefit the resident to control leaning in the chair and to prevent the right arm from falling off the arm rest of the chair. Interview with Employee 1, Nurse Aide, on July 1, 2011, at approximately 9:00 a.m., revealed that there was no documentation as to when the resident's sling was applied. Employee 1 stated that the resident has a sling, but there was no wearing schedule. Employee 1 stated that it had not been in place for "many days." During an interview on July 1, 2011, at 10:15 a.m., the Director of Nursing was unable to provide evidence that this resident's physician ordered device was routinely applied. The facility's "Pain Management Policy and Procedure" reviewed by the facility April 28, 2011, indicated that it is the facility's policy to ensure that all residents maintain optimum comfort levels and are provided with appropriate pain management. The policy also states that the physician will be notified as needed for medication adjustment regarding pain management and that pain medications will be ordered and written based on the level of pain the resident is experiencing using the number system one to ten with ten being the worst. The clinical record revealed that Resident 56 had [DIAGNOSES REDACTED]. The slough or eschar may be present on some parts of the wound bed often includes undermining and tunneling) on the right ischium (lower portion of the hip bone) and [MEDICAL CONDITION]. A physician's orders [REDACTED]. The resident also had a current order dated June 2011, for Tylenol 325 mg, two tablets every four hours as needed for pain level 1-10. The resident's Tylenol doses, the regular scheduled and as needed doses, were not to exceed four grams in a 24 hour period per physician's orders [REDACTED]. The measurement of the resident's pressure sore on June 27, 2011, revealed a Stage IV pressure area that measured 2.8 cm (centimeters) in length by 2.4 cm in width by 2.4 cm in depth with undermining (tunneling or a pocket under the edges of a wound) of 1.5 cm located between 11 o'clock and 1 o'clock (a clock face method of describing with 12 o'clock towards the resident's head). On June 30, 2011 at 9:45 a.m., Employee 6, Registered Nurse, Wound Nurse, was observed performing the resident's pressure sore treatment, which included cleansing the wound with normal saline and packing the wound with [MEDICATION NAME] (antimicrobial cream) soaked gauze cover and change two times a day. During the observation of the wound care, the resident was observed to display signs of extreme pain and discomfort, including opening her eyes wide, increased restlessness as evidenced by moving her arms up in the air, and grasping the nurse aide's hand. The resident was also noted to be moaning during the treatment. During the treatment, Employee 6 said to the resident, " I know this is going to hurt." Review of the resident's care plan for the problem of skin ulcer dated March 8, 2011, indicated that the resident would be monitored for pain daily. Review of the June 2011, Acute Pain Assessment Sheet failed to indicate that the resident was having any pain. No documentation was evident to indicate that the resident was being assessed for pain on a daily basis. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Employee 7, Medication Nurse, verified this finding during an interview at 10:00 a.m., on June 30, 2011. During an interview on July 1, 2011, at approximately 11:00 a.m., the Director of Nursing failed to provide evidence that the resident received effective pain management prior to wound treatment. 483.25 Quality of Care Previously cited 7/2/09, 8/19/10 28 Pa Code 211.10(a)(c) Resident care policies Previously cited 8/19/10 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 7/2/09, 8/19/10

Based on review of select facility policy and clinical records, observation and staff interview, the facility failed to provide timely and effective treatment and services to promote healing and prevent worsening of pressure sores for two residents out of 15 sampled (Resident 56 and 32) Findings include: Review of the Wound Policy dated April 25, 2011, provided by the Director of Nursing, revealed that it is the practice of this facility to assess each resident for the risk of developing pressure ulcers, identify risk factors and provide care and services to reduce the risk for developing pressure ulcers. If the pressure ulcer is present or occurs, it is the practice of this facility to provide care and services to prevent new pressure ulcers from developing. Review of the policy titled "Physician Notification" dated as revised January 5, 2004, indicated that it is the policy of the facility to ensure timely and efficient notification of the resident's status changes and/or issues. The nursing staff will be observant to any changes in the resident's physical or mental status. The altered resident assessments will be reported immediately to the charge nurse. The charge nurse will notify the physician following the attached physician notification guidelines. There was no mention made of when to notify the physician for changes in the status of a wound. The clinical record review of Resident 56 revealed [DIAGNOSES REDACTED]. A review of a Physician Prescription and Letter of Medical Necessity dated December 27, 2010, revealed that an orthotic management system was being recommended for the resident and the physician prescribed orthotic management utilizing custom fitted orthoses for the spine, hip, lower and upper extremities (Total Body Orthotic Chair). The resident's annual Minimum Data Set (MDS, an assessment tool completed periodically to identify resident care needs) assessment dated [DATE], revealed that the resident was severely cognitively impaired and required assistance with all of her activities of daily living. The clinical record indicated that on March 8, 2011, the resident was noted to have a Stage II (partial thickness skin loss) pressure area on her right ischium (lower portion of the hip bone) that measured 0.5 centimeters (cm) by 0.3 cm with a depth that measured 0.2 cm. A physician's orders [REDACTED]. According to the Ulcer Assessment on March 10, 2011, the wound measured 0.7 cm by 0.8 cm with depth 0.1 cm. The wound increased in size and on March 18, 2011, the wound measured 1.3 cm by 1.2 cm by 0.1 cm. The measurement of the wound on March 22, 2011, was 1.8 cm by 2.0 cm by 0.2 cm. On March 29, 2011, the wound measured 2.0 cm by 2.6 cm by 0.2 cm. On April 5, 2011, the wound was found to be a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) with the measurements 3.1 cm by 2.6 cm with a depth of 0.3 cm. The physician was not notified until April 5, 2011, that the resident's wound was increasing in size. On April 5, 2011, upon physician notification, a new treatment order was obtained to cleanse the open area with wound cleanser, apply Saf Gel (a hydrating wound dressing), cover with Allevyn dressing and change every day. The resident was to be out of bed for meals only and was to be turned and repositioned every two hours while in bed. The nursing notes revealed that on June 7, 2011, the pressure sore now was identified as a Stage IV with serous (watery yellow) drainage, tan slough (dead tissue separating from living tissue), and the perimeter of the wound was dark pink. The nursing notes did not indicate that the physician was notified of this change in the wound condition until June 10, 2011, at 6:00 p.m. an order for [REDACTED]. On June 23, 2011, the results of a wound culture (laboratory test to identify microbial growth in the wound) was received and the resident was noted to have [MEDICAL CONDITION] in the wound (a drug resistant bacterial infection). On June 23, 2011, [MEDICATION NAME] Double Strength (an antibiotic) was ordered two times a day for 21 days and the resident was to continue on the [MEDICATION NAME]. A Review of the POS [REDACTED]. A review of the product information for the Total Body Orthotics Positioning System revealed that the TBO provides a memory foam pressure relief cushion. The chair is designed to minimize and correct contractures however, in doing so, applies different amounts of pressure to the body of the individual resident. In this case, the tension of bilateral legs being corrected applies pressure to the buttocks due to the resident's seating style being changed. The interventions to be taken were listed as alter the chair mechanics, adjust tension on contracture correction to lessen pressure, and Physical Therapy to evaluate the chair. The review of the Rehab/Nursing Communication Log dated March 10, 2011, revealed that the physical therapist recommended not to leave the mechanical lift sling (a device used under a resident for lifting) under the client (resident) while seated in the total body orthotic. The review of the Physical Therapy log dated January 24, 2011, indicated that the resident's skin integrity was at risk. The resident was discharged from physical therapy on February 22, 2011. On March 31, 2011, the resident again began receiving physical therapy (PT) and no change was made to the resident's position in the total body orthotic chair. PT noted that the resident is sitting in a more upright position, which has shifted the weight from the sacrum to the ischials. Interview with the Physical Therapist on July 1, 2011, at 11:15 a.m., verified that his initial assessment of the wound was that it was from the Hoyer (mechanical ) lift pad. The Physical Therapist further stated that the positioning in the chair did increase pressure on the resident's ischium and that the resident's positions should have been changed periodically while she was in the TBO chair. The Physical Therapist stated that this position change could be done by tilting the chair backwards. The resident's pressure sore treatment was observed on June 30, 2011, at 9:45 a.m. The physician's orders [REDACTED]. Change twice a day." Employee 6, Registered Nurse Wound Nurse, was noted to be using wound cleaner and not the normal saline as ordered. Interview with the Director of Nursing on July 1, 2011, at 11:00 a.m., revealed that there was no evidence that when the resident was in the TBO chair that she was being repositioned to relieve/redistribute pressure. The Director of Nursing verified that the pressure sore was acquired in the facility at a Stage II and was now a Stage IV wound that was infected [MEDICAL CONDITION]. There was no evidence that the facility timely consulted with the physician regarding the lack of healing and worsening of the pressure sore and had consistently provided the resident with adequate pressure relieving/redistribution related to her use of the TBO to prevent worsening and promote healing of the pressure sore. The clinical record review indicated that Resident 32 has multiple [DIAGNOSES REDACTED]. The review of a quarterly MDS assessment dated [DATE], revealed the resident requires extensive assistance of two for bed mobility and transfers. According to a review of her current comprehensive plan of care dated March 18, 2011, the resident was identified at risk for skin integrity with interventions to include a pressure reduction mattress, personal lounge chair for alternate seating and comfort and a turning/repositioning schedule. There were no measures specifically planned to address pressure relieving measures for the resident's heels. The review of the resident's "Pressure Ulcer Risk Screen" completed on March 1, 2011 and May 12, 2011, identified the resident at risk for pressure sore development. According to an "ULCER ASSESSMENT"dated May 13, 2011, the resident was discovered with a pressure area on the right heel on this same date, measuring 1.6 cm x 3.5 cm without depth and described as unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown,) and/or eschar (tan, brown or black) in the wound bed). On June 28, 2011, the area was described as a healing Stage II area measuring 1.1 cm x .8 cm x 0.01 cm. Review of an "INCIDENT REPORT" dated May 13, 2011, at 5:15 a.m., revealed that the resident was observed with a 1.6 cm x 3.5 cm closed blister with calloused skin with the perimeter of the area colored yellow, brown and purple on the resident's right heel. The facility's investigation into the skin impairment indicated that this area could have been caused from shoes or bed linens. Interview with the Employee 6, Registered Nurse (RN) Wound Nurse, on the West Unit on July 1, 2011, at approximately 11:30 a.m., revealed that the resident was ill with a upper respiratory infection (URI) and it was felt that she probably could no long turn to position herself while in bed during the course of her illness and she rubbed her feet on the sheets. (According to the resident's quarterly MDS assessment the resident required extensive assistance of two for bed mobility/transfers). The resident's decreased ability to turn while in bed as described by Employee 6, RN, as compared to her quarterly MDS assessment, was not noted in the facility's investigation into the skin breakdown, which was confirmed by Employee 6 during interview on July 1, 2011, at 11:30 a.m. Observation of the resident's heel on July 1, 2011, at approximately 1:30 p.m., revealed a superificial area approximately the size of a quarter on the right heel. Interview with the Director of Nursing (DON) on July 1, 2011, at approximately 1:45 p.m., revealed that the facility utilizes pressure reduction mattresses, low loss air mattresses, foot cradles, gel heel floats, pillows, pressure reducing cushions, Keen cushions (contoured moisture wicking cushion to relieve pressure), turning and repositioning and off loading (redistributing weight to relieve pressure) as a means for pressure relief/reduction. The DON was unable to explain how the facility determines which interventions would be the most appropriate for an individual resident. The DON stated that there is established criteria, procedure or protocol for specific pressure relieving/reducing measures. The facility failed to implement interventions to provide pressure reliving devices to the resident's heels in and/or out of bed for this at risk resident until she experienced skin breakdown on May 13, 2011. 483.25 (c) Treatment/services to prevent /heal pressure sores Previously cited 7/2/09 28 Pa. Code 211.10(a)(c)Resident care policies Previously cited 8/19/10 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5)Nursing services Previously cited 7/2/09, 8/19/11