Every finding on record at Susquehanna Health and Wellness Center

Based upon clinical record review, staff interviews, and observations, it was determined that the facility failed to ensure residents are provided with dignity while receiving care for one of 33 residents reviewed (Resident 156).Findings include:Review of Resident 156's diagnosis list revealed diagnoses including Parkinson's Disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), seizures and anxiety disorder).Review of Resident 156's clinical record revealed Resident 156 is receiving hospice services.Observation on June 15, 2026, at 9:52 a.m. revealed Resident 156 sitting in a Broda chair in the hallway near the B Wing nurses' station.Further observation on June 15, 2026, in the hallway near the nurses' station revealed that a hospice nurse was standing near Resident 156 and conducting a comprehensive physical examination of Resident 156 including taking blood pressure readings, pulse oximeter readings and questioning Resident 156 regarding resident's overall health and pain levels.Observation on June 15, 2026, at 10:00 a.m. revealed Resident 156's hospice nurse received a face-time phone call from the hospice agency nurse practitioner at the B Wing nurses' station. This call was also placed on speaker phone.Further observation of the phone call revealed the hospice nurse and the hospice nurse practitioner speaking via facetime and speaker phone about Resident 156's overall health and his continuing need for hospice services. This face-time phone conversation consisted of discussions including continence, pain, seizures, medication doses, diet and fluid intake. Further observation of the phone call also revealed the hospice nurse practitioner requesting an arm circumference measurement which the hospice nurse obtained while in the hallway at the nurses' station. Further observation of this phone call revealed the hospice nurse practitioner asking the hospice nurse questions regarding Resident 156's diet and nutrition intake. The hospice nurse then called out to a nurse aid who was walking by and asked about the quantity of food consumed by Resident 156 daily.The face-time phone call ended at approximately 10:19 a.m.Interview with the Nursing Home Administrator on June 15, 2026, at 10:30 a.m. revealed that the above conversations and subsequent phone call should not have occurred in the hallway at the nurses' station as it does not provide dignity in the care setting for Resident 156.28 Pa. Code 211.12(c)(d)(3) Nursing Services

Based on interviews with residents, review of facility policy, observations, and interviews with staff, it was determined that the facility failed to serve food that was at an appetizing temperature on one of four units (B wing - Countryside). Findings include:An interview held with alert and oriented residents on June 15, 2026, at 10:00 a.m. revealed that food is cold for all meals. Review of facility policy, Food Presentation, undated, indicated foods will be served at proper temperatures. Hot foods hot and cold foods cold. A test tray conducted on June 16, 2026, on B-wing Countryside, in the presence of Employee E3, revealed that the meal cart left the kitchen at 12:03 p.m. Food temperatures taken at 12:37 p.m. after all residents had been served revealed the following: [NAME] Pilaf - 119.8 degrees FahrenheitCrab Cake - 123.7 degrees FahrenheitMixed Vegetables 109.0 degrees Fahrenheit Interview at that time with Employee E3 indicated that food could be a little hotter. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of one resident. (Resident 164)Findings include: Review of Resident R164's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes (insufficient production of insulin, causing high blood sugar), and congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle). Interview on June 16, 2026, at 9:33 a.m. with Resident R164 revealed the resident does not have dentures and had requested dentures several times. Review of Resident R164's clinical record revealed no evidence that the facility arranged for or followed up on dental services to obtain dentures following the request. Interview on June 17, 2026, at 10:22 a.m. with Director of Social Services confirmed there was no documentation about further dental consults for Resident R164. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon medication insert review, observation, and staff interview it was determined that the facility failed to ensure medications were labeled with open and expiration dates for three of six medication carts observed (A South Medication Cart, A South Back Medication Cart and B South Back Medication Cart).Findings include:Review of medication packaging inserts for Novolog (short acting) Insulin and Lantus (long acting) Insulin revealed that Novolog Insulin Pens and Lantus Insulin Pens are to be refrigerated until opened. If unrefrigerated, the pens must be marked with the date of removal from the refrigerator and used within 28 days.Observation of the A South Medication Cart on June 17, 2026, at 11:00 a.m. revealed three unopened and undated Novolog Insulin Pens and two unopened and undated Lantus Insulin Pens.Observation of the A South Back Medication Cart on June 17, 2026, at 11:08 a.m. revealed one opened and undated Novolog Insulin Pen.Observation of the B South Back Medication Cart on June 17, 2026, at 11:14 a.m. revealed one unopened and undated Novolog Insulin Pen; one opened and undated Novolog Insulin Pen and one opened and undated Lantus Insulin Pen.Interview with the Nursing Home Administrator and Director of Nursing on June 17, 2026, at 12:00 p.m. confirmed that the above insulin pens should have been marked with open or unrefrigerated dates.28 Pa. Code 211.12(c)(d)(3) Nursing Services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of eight residents reviewed for nutrition (Resident 45).Findings Include:Review of facility policy Weight Assessment and intervention revised September 2008 revealed that .Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Interventions for undesirable weight loss shall be based on careful consideration.Review of Resident 45's clinical record revealed recorded weights of 151.4 pounds January 7, 2026; 140.2 pounds February 2, 2026, with a reweight on February 18, 2026, of 162 pounds; 140.4 pounds March 4, 2026.Further review of Resident 45's clinical record revealed a dietary note dated March 4, 2026, indicating the resident's weight. Further review of the same dietary note failed to reveal recommendations to address the weight loss from January 7, 2026, to February 2, 2026 (loss of 11.2pounds or 7.40% in one month).Interview with Employee E4 on June 17, 2026, at 11:39 a.m. confirmed that further dietary interventions should have been implemented to address Resident 45's weight loss.28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on staff interviews, clinical record review, and facility documentation review it was determined the facility failed to ensure that one of five residents reviewed was free from accidents and provided adequate supervision for Resident 12. Review of Resident 12's diagnosis sheet revealed diagnoses type 2 diabetes (insufficient production of insulin, causing high blood sugar), and Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions). Review of Resident 12's June 2026 Medication Administration Record revealed an order for Metformin HCl Tablet 500 MG Give 1 tablet by mouth two times a day. Review of facility documentation revealed that on June 12, 2026, Resident 12 was administered crushed Metformin HCL tablet 500mg in coffee by Licensed Nursing Employee E6. Licensed Nursing Employee E6 then failed to observe Resident 12 until they had finished the coffee with the medications crushed inside. Resident 12 drank some of the coffee with the medication and set the coffee cup on the table. Licensed Nursing Employee E6 then failed to observe Resident 12 until they had finished the coffee with the medications crushed inside. Resident 170 went over to the table, took the cup and drank Resident 12's coffee. Review of Resident 170 progress notes revealed a nursing entry dated June 12, 2026, at 7:18 p.m. stating Resident 170 got up and went to this resident's table and took the coffee and when staff attempted to intervene and retrieve the cup from her, she gulped down the entire contents. Writer observed pill fragments in the bottom of the cup after she sat it down. MD (medical doctor) notified, new orders for obtain vitals for alert charting q (every) shift x3days, obtain blood sugar q shift x3 days. RP (responsible party) updated, DON (Director of Nursing) notified. Further review of Resident 12's facility documentation revealed that there was no supervision for Resident 12 while taking medication to ensure all medication had been administered. Review of Resident 12's active care plan failed to reveal a care plan or interventions for putting crush medication in coffee. Interview with the Director of Nursing on June 17, 2026, at 1:20 p.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on resident interview, review of clinical records, and interviews with staff, it was determined that the facility failed to provide timely care and services for two of 33 residents reviewed (Residents 2 and 11). Findings include:Findings Include: Review of Resident 2's clinical record finds an SBAR (Situation, Background, Assessment, Recommendation) Summary on June 12, 2026, at 11:24 p.m. that states, 2246 Notified by staff that resident was having a seizure, resident had tonic-clonic movements, with muscle spasms, lasting 20 minutes in bed . PRN (as needed) seizure med was not available from pharmacy . Notified on call provider, ordered for resident to be sent to ER, 911 was called. Further review of Resident 2's electronic medication administration on June 12, 2026, record reveals that there was not an administration of Nayzilam Nasal Solution (Anticonvulsant) which was ordered as needed for breakthrough seizures. Further review of Resident 2's progress notes on June 12, 2026, at 11:24 p.m. finds that, EMT came at 2315 gave resident 2 rounds of IV versed resident was still seizing. Interview with the Director of Nursing (DON) on June 17, 2026, at approximately 9:50 a.m. reveals that the nurse assigned to Resident 2 on June 12, 2026, was on break at the time Resident 2 began seizing. The nurse covering during the break did not have the keys to access the medication cart that contained Resident 2's PRN seizure medication and was unable to locate the original nurse to obtain them. The covering nurse then contacted the DON via phone for instructions on how to access additional cart keys from the DON's office. While the DON was on the phone, EMS arrived and began treating Resident 2. Further interview with the DON on June 17, 2026, at approximately 10:30 a.m., finds that no investigation was completed nor statements from staff obtained. Interview with Resident 11 on June 15, 2026, at 1:13 p.m. revealed that resident was having pain in both knees. Review of Resident 11's physician's assistant note of May 19, 2026, revealed that given the resident's persistent pain recommending still to get CT [computed tomography also called a CAT scan, is a medical imaging technique that combines multiple X-ray images taken from different angles to produce detailed 3D images of bones, organs, blood vessels, and soft tissues] scans however referring to orthopedics. Review of progress note of May 26, 2026, revealed resident was seen by the physician's assistant on May 19, 2026, with new recommendations approved by the CRNP (certified registered nurse practitioner). New order for CT scan bilateral knees and ortho (orthopedics) referral. Review of physician's order dated May 26, 2026, indicated refer to orthopedics related to bilateral knee pain and CT scan for left and right knee without contrast. Order was faxed to CT facility. Review of progress note of May 29, 2026, revealed resident went to appointment for CT scan of bilateral knees, but facility received a call that a written order was needed. Review of physician's assistant note of June 2, 2026, revealed that resident was seen for bilateral knee pain and resident indicated the pain was still present. Resident stated he/she went to get the CT scans on his/her knees, however, did not have scans. Note indicated that CT scan appointment was made for 5/27 however he/she did not get it done because there was no order. Will await CT scan to be completed. There is also an order to have her/him follow up with orthopedics and will see patient after that. Recommendations indicated to reschedule/reorder CT scan of bilateral knees, refer to orthopedic appointment. Review of order dated June 1, 2026, indicated CT without contrast to bilateral knees. Interview with the Director of Nursing (DON) on June 17, 2026, at 11:44 a.m. confirmed that the resident went for the CT scan on May 26, 2026, but it was not completed due to the order not having a diagnosis code, so the CT scan was reordered. The DON confirmed that the the appointment for orthopedics was scheduled today (22 days after the initial order) and that the CT scan was rescheduled today (15 days after the reorder). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to accurately assess residents for two of two residents reviewed. (Residents 24 and 149)Findings Include: Review of Resident 24's clinical record reviewed Resident 24 was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure.Further review of Resident 24's clinical record revealed resident was discharged to an acute care facility on January 28, 2026.Further review of Resident 24's clinical record failed to reveal evidence that a discharge MDS (periodic assessment of resident needs) was completed upon discharged .Review of Resident 149's clinical record revealed resident was admitted [DATE], and discharged [DATE].Further review of Resident 149's clinical revealed that a Discharge MDS (Minimum Data Set - periodic assessment of resident needs) was not completed.Interview with Licensed Employee E5 on June 17, 2026 at 2:15 p.m. confirmed that no discharge MDS was completed for Resident 24 and Resident149 after discharge from the facility.The above information was conveyed to the Nursing Home Administrator on June 17, 2026 at 12:00 p.m.28 Pa Code 211.5(f) Clinical Records28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review and facility documentation, it was determined that the facility failed to ensure notification to the State ombudsman's office occurred for hospital transfers for two of thirty-three residents reviewed. (Resident 18 and Resident 25).Findings include:Findings Include: Review of Resident 18's clinical record revealed Resident 18 was transferred to an acute care facility on February 7, 2026, and readmitted to the nursing facility on February 18, 2026. Further review of Resident 18's clinical record revealed Resident 18 was also transferred to an acute care facility on March 23, 2026, and returned to the nursing facility on March 31, 2026. Review of facility documentation failed to reveal evidence that the facility notified the State Ombudsman's office of Resident 18's two transfers and admissions to an acute care facility. Interview with the Nursing Home Administrator on June 17, 2026, at approximately 10:00 a.m. confirmed that the State Ombudsman's office was not properly notified of the transfers. Review of Resident 25's clinical record revealed Resident 25 was transferred to an acute care facility on April 26, 2026, and subsequently admitted with a diagnosis of pneumonia. Further review of Resident 25's clinical record reveals that Resident 25 returned to the facility on April 28, 2026. Review of facility documentation failed to reveal evidence that the facility notified the State Ombudsman's office of Resident 25's admission to an acute care facility. Interview with the Nursing Home Administrator on June 17, 2026, at approximately 10:00 a.m. confirmed that the State Ombudsman's office was not properly notified of the transfers. 28 Pa. Code 211.5(b) Medical Records

Based on review of clinical record, hospital record, and facility documentation, and staff interviews, it was determined the facility failed to ensure that one of three residents (Resident R1) were free from significant medication errors which resulted in actual harm to Resident R1 requiring transfer to hospital and in patient monitoring due to medication administration. This was identified as a past non-compliance. Findings include: Review of facility policy titled Administering Medication dated April 2019 revealed 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record and c. if necessary, verifying resident identification with other facility personnel. Review of Resident R1's clinical record revealed diagnoses including Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle) and paroxysmal Atrial Fibrillation (irregular heart rhythm that starts and stops spontaneously). Review of Resident R1's clinical record revealed progress note dated March 21, 2026, (15:00 aka 3:00 p.m.) revealed Notified by LPN (Licensed Practical Nurse) that resident received the wrong medications. Resident assessed. Alert and oriented to person place situation and time. Resident states no pain, no blurred vision, or any new/onset symptoms. Vitals signs: temp 97.4 (normal temperature ranges 97.7 F to 99.5 F); bp (blood pressure) 105/58 (normal blood pressure range 120/80); hr (heart rate) 66 (normal heart rate ranges 60 to 100 beats per minute) and oxygen 91% (normal oxygen range 95%-100%). No noted allergies to medications administered. RP (Responsible Party) notified and updated on situation. CRNP (Certified Registered Nurse Practitioner) was notified of all medications resident received. At 1:08 p.m. CRNP stated to only give resident (his/her) eliquis (oral anticoagulant used to prevent and treat blood clots) and hold all other medications. When LPN was going to give resident (his/her) eliquis it was observed resident was slightly lethargic (drowsy, fatigued or having lack of energy). VS (Vital Signs) checked by RN (Registered Nurse) and resident assessed mental status. Vital signs: BP 85/50, temp 98 HR 70 RR 15 O2 92%. Resident alert and oriented to person, place, time, and situation. Resident still showing signs of lethargy. CRNP notified of drop in blood pressure. New order for vital signs q (every)15 minutes for 1 hour. Next vital sign set collected BP 78/52 and resident has increased lethargy. CRNP ordered to administer Narcan (medication used to reverse the effects of opioid overdose) at 1403 (aka 2:03 p.m.). CRNP called with update that resident continued to show signs of lethargy. Mental status assessed and resident unable to state where (he/she) was. Resident stated (he/she) was at the general, CRNP ordered to have resident sent out to be evaluated. 911 called at 1423 (aka 2:23 p.m.) to send resident to ED. EMS arrived to facility at 1440 (aka 2:40 p.m.) Resident left facility at 1457 (aka 2:57 p.m.) via litter with EMS (Emergency Medical Services) to hospital emergency department. RP notified of transfer. Resident sent with POLST (Physician Orders for Life- Sustaining Treatment), face sheet, transfer notification and bed hold. Further review of Resident R1 clinical record revealed medications received in error; Aspirin 325 mg (milligram) (medication to reduce pain, swelling, and/or fever); Xcopri 300 mg (medication used to treat seizures in adults); Aptiom 800mg (is a medication used to treat and or prevent seizures); Levetiracetam 1500mg (medication used to treat seizures); Lorazepam 1mg (medication used to treat anxiety and insomnia); Morphine Sulphate 0.25 ml (milliliter) (medication used to treat moderate/severe pain); Acetaminophen 650 mg (medication used as pain reliever and/or fever reducer); Carbidopa-Levodopa 25 -100 mg two tablets (medication used to treat Parkison's disease a condition that affects the brain and causes symptoms such as shaking, stiffness and slow movement) and Gabapentin 600 mg (helps reduce pain and controls seizures). Review of Licensed Practical Nurse (LPN) Employee E3 written statement dated March 21, 2026, stated that When this writer entered room [ROOM NUMBER]. Writer called out (Resident R2) name and the B bed (Resident R1) said yes, help me, this writer asked the patient what did (he/she) need, patient said (he/she) wanted to be turn facing the door. This writer gave the patient (Resident R1's) medication. Review of documentation provided by the facility indicated LPN Employee E3 was suspended and will return to assignment once additional mentoring and a medication administration is completed. Review of Resident R1's hospital records dated March 21, 2026, revealed Resident R1 was admitted on [DATE]. Hospital record revealed under section Impression/Plan Accidental drug ingestion: pt (patient) residents at Susquehanna N&R (Nursing&Rehabilitation) and was accidentally given (his/her) roommates medications including Ativan (lorazepam), Keppra (levetiracetam), Gabapentin, Morphine, and Xcorpi with resultant lethargy and hypotension. Improving with Narcan, IVF (intravenous fluids) and time. Monitor Telemetry. May need additional fluids and reversal agents. Interview conducted with the Nursing Home Administrator on March 31, 2026, at 12:30pm confirmed the above findings. The facility self-identified the deficient practice at the time of the incident, March 21, 2026. The facility implemented a corrective action of education and medication pass audits. The facility's immediate action plan included the following: QAPI (Quality Assurance Performance Improvement) conducted March 21, 2026. Reviewed LPN Employee E3's file to ensure she had received education on Medication Administration prior to the incident. This was verified as completed on March 19, 2026. Evaluated all other residents on the same unit as Resident R1 who had received medication from Employee E3 to observe for adverse effects, which included obtaining vitals. This was verified and completed March 21, 2026. Education was initiated for all facility nursing on the policy of Medication Administration, which includes proper identification of residents prior to medication administration and documentation of medication administration. All nurses completed training by March 23, 2026. Education was completed on March 23, 2026, by the DON (Director of Nursing) with RN supervisor Employee E4 regarding notification of the DON for significant medication errors and the RN's ability to transfer a resident to the hospital when a significant change in condition is noted. Medication pass audits for competency will be completed by all current licensed nurses. This was verified and completed March 28, 2026. During an interview on March 31, 2026, at 10:20 a.m. LPN Employee E5 verified he received education on Medication Administration and was able to verbalize understanding. During an interview March 31, 2026, at 10:30a.m. RN Employee E6 verified that she had received education on Medication Administration and was able to verbalize understanding. During an interview on March 31, 2026, at 10:40 a.m. LPN Employee E7 verified that she had received education on Medication Administration and was able to verbalize understanding. She added that all residents have an updated picture in their chart, and that if you cannot identify the resident, you can ask another staff member. The facility has demonstrated compliance with the above since March 28, 2026.28 Pa Code 201.18(b)(1)(e)(1) Management28 Pa Code: 211.10 (c) Resident care policies

Based upon review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure proper infection control procedures were followed during medication administration observation and pressure ulcer wound treatments for three of three residents observed (Resident 6, Resident 22 and Resident 136.)Findings include: Review of facility policy and procedure titled Administering Medications revealed “Staff follows established facility infection control procedures (e.g. handwashing, aseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.” Observation of Medication Administration on July 22, 2025, at 11:44 a.m. revealed Licensed Employee E9 placing medication pills for administration into Licensed Employee E9’s ungloved hands and then placing the medication pill into the medication cup for administration. Observations on all days of the survey revealed no system in place to communicate to staff that resident required enhanced barrier precautions. Additionally, no PPE (personal protective equipment) was readily available to staff providing high contact care. Review of resident 6’s progress notes on July 24, 2025, revealed resident had a stage III pressure ulcer to the sacrum (bone at the bottom of the spine). Observations of Resident 6’s room showed no indication of enhanced barrier precautions being communicated to staff entering the room. No PPE was observed to be available to staff providing care to Resident 6. Observation of Resident 6’s wound care on July 25, 2025, at 11:28 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. Review of Resident 22’s progress note of July 15, 2025, revealed resident had a stage II pressure ulcer (wound with partial thickness skin loss) to the sacrum (triangular bone at the base of the spine). Observation of Resident 22’s wound care on July 25, 2025, at 10:17 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. Review of resident 136’s progress notes on May 6, 2025, revealed resident had a stage III pressure ulcer to the sacrum (wound full-thickness skin loss) to the sacrum (triangular bone at the base of the spine). Observations of Resident 136’s room showed no indication of enhanced barrier precautions being communicated to staff entering the room. No PPE was observed to be available to staff providing care to Resident 136. Observation of Resident 136’s wound care on July 24, 2025, at 9:40 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 11:00 a.m.

Based on review of facility documentation and staff interviews it was determined that the facility failed to complete a performance review at least once every 12 months for five of five nurse aides (Employees E4, E5, E6, E7, and E8).Findings include:Review of Employee E4's personnel record revealed a date of hire of October 11, 2023.Review of Employee E5's personnel record revealed a date of hire of May 24, 2023.Review of Employee E6's personnel record revealed a date of hire of June 8, 2022.Review of Employee E7's personnel record revealed a date of hire of September 3, 2019.Review of Employee E8's personnel record revealed a date of hire of October 6, 2021.Further review of the personnel records revealed no evidence that the employees had a performance review at least once every 12 months.Interview with the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 10:10 a.m. confirmed that performance reviews had not been completed for the above employees.28 Pa. Code 201.19(2) Personnel policies and procedures

Based on observations, clinical record review and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula.Review of Resident 1's clinical record revealed no care plan for oxygen use.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have a care plan for oxygen use.483.21 Develop/Implement Comprehensive Care PlanPreviously cited 8/22/2428 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/22/24

Based on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to maintain acceptable parameters of nutritional status for two of three residents reviewed (Residents 4 and 22). Findings include:Review of facility policy, Weight Assessment and Intervention revised September 2008, revealed monthly weights will be completed no later than the 7th day of the month. Additionally, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.Review of Resident 4's clinical record revealed that the resident weighed 150.0 pounds on April 28, 2025. The resident was admitted to the hospital on [DATE], and readmitted to the facility on [DATE].Review of a weight warning note on May 9, 2025, revealed a weight of 181.3 pounds and indicated a suspected discrepancy in weight. A reweight was requested. Review of the clinical record revealed a reweight of 135.0 pounds was obtained on May 20, 2025 (11 days later).Interview with Employee E3 on July 24, 2025, at 9:40 a.m. confirmed that Resident 4's reweight was not completed timely after the readmission discrepancy.Review of Resident 22's clinical record revealed that the resident weighed 96.8 pounds on February 1, 2025 and 88.4 pounds (decrease of 8.4 pounds or 8.7% decrease) on March 5, 2025. Review of weight warning note of March 6, 2025, indicated suspected significant weight change and a reweight was requested. Review of the clinical record revealed that a reweight of 85.6 pounds was obtained on March 19, 2025 (14 days later).Review of Resident 22's clinical record revealed a weight of 92.6 pounds on April 8, 2025 (increase of 7.0 pounds or 8.3% since previous weight). There was no documented evidence that a reweight was obtained.Review of Resident 22's clinical record revealed a weight of 81.0 pounds on May 15, 2025 (decrease of 11.6 pounds or 12.5% since previous weight). Review of weight warning note of May 16, 2025, revealed suspected significant weight change from previous month and a reweight was requested. A reweight of 78.6 pounds was obtained on May 21, 2025 (5 days later).Interview with Employee E3 on July 24, 2025, at 11:25 a.m. indicated that reweights should be done as soon as possible. Employee E3 indicated that a reweight for Resident 22's April 2025 weight was not completed because the weight change did not trigger for a reweight. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review and staff interview it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one resident reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula (tube that delivers oxygen) at a flow rate of 2.0 liters per minute.Review of Resident 1's clinical record revealed no order for oxygen or respiratory care.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have an order for oxygen use.483.25 Respiratory/Tracheostomy Care and SuctioningPreviously cited 3/5/25, 8/22/2428 Pa. Code 211.12(d)(3)(5) Nursing ServicesPreviously cited 8/22/24

Based upon observation, it was determined that the facility failed to ensure adequate and competent staffing levels were maintained to promptly respond to resident call bells on one day of three days of the survey.Findings include:Observation on July 23, 2025, at 12:07 p.m. on the B Wing nursing unit revealed five resident call bells with the lights on and audibly ringing, as well as lunch carts in the hallway that had been delivered to the unit from the kitchen.Observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed four employees gathered in a side room with the door closed.Further observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed a licensed employee sleeping in front of the computer at the desk.Observation of the B Wing resident call bells revealed the resident call bells remained unanswered and the lunch trays not delivered for approximately 15 minutes.The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 11:30 a.m. 28 Pa. Code 201.18(b)(1)(2)(5)(e)(1) ManagementPreviously cited 8/22/202428 Pa. Code 201.29(c)(4) Resident RightsPreviously cited 8/22/202428 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/22/2024

Based on review of facility policies and procedures and observation, it was determined that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered for one of three medication carts reviewed (B Wing Medication Cart).Findings include:Based upon facility policy and procedure titled Storage of Medications revealed Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Review of facility policy and procedure titled Administering Medications revealed The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of package insert instructions for Humalog Insulin (medication used to treat high blood sugar levels) Pens revealed unopened Humalog pens should be stored in the refrigerator.Further review of package insert instructions for Humalog Insulin Pens revealed that once opened, Humalog can be kept at room temperature for up to 28 days. Review of package insert instruction for Lantus Insulin (medication used to treat high blood sugar levels) revealed Lantus Insulin should be used within 28 days after opening.Review of package insert instructions for Insulin Aspart (Novolog insulin) (medication used to treat high blood sugar levels) revealed that Insulin Aspart expires 28 days after opening.Review of package insert instructions for Insulin glargine (medication used to treat high blood sugar levels) revealed Insulin glargine must be discarded 28 days after opened. Observation of the B Wing Medication Cart on July 24, 2025, at 11:00 a.m. revealed a Humalog Insulin Pen opened on June 20, 2025, with no expiration date. The expiration date for this Humalog Insulin Pen would have been July 17, 2025, 28 days after opening the pen. Further observation revealed an unopened and undated Humalog Insulin Pen in the medication drawer.Further observation revealed two open and undated insulin aspart pens.Further observation revealed one open and undated insulin glargine vial. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing ServicesPreviously cited 8/22/2024, 3/5/2025

Based on observation, clinical record review, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and follow the physician's orders for two of the two residents reviewed (Resident CL1 and Resident 1). Findings include: A review of Resident CL1's hospital records dated February 2, 2025, revealed that the resident was sent to the hospital on January 26, 2025, for shortness of breath and was admitted with a diagnosis of Acute Respiratory Failure. The same report revealed that the Resident was using a BIPAP (a non-invasive ventilator technique that provides pressurized air to assist with breathing) in the hospital. A review of the hospital record BIPAP order dated February 10, 2025, revealed Auto Bipap Max-18 Min-5 PS-5 for associated diagnosis of Acute Respiratory Failure and Obstructive Sleep Apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts). A review of the hospital discharge summary order dated February 11, 2025, revealed DME (Durable medical equipment) SUPPTY-RT-CPAP/BiPAP A review of Resdient CL1's clinical records revealed the resident was admitted to the facility on [DATE]. Further review of resident CL1's clinical record revealed there was no physician order for Bipap or that the physician was notified of Resident CL1's Bipap order from the hospital. An interview with the supply staff, Employee E3 conducted on March 5, 2025, at 11:00 a.m., revealed that the facility liaison sent her/him Resident CL1's Bipap order supplies and settings from the hospital so she/he could order it and have it ready for the resident's admission to the facility. Employee E3 reported that the order was made from [name of the DME company] and got a confirmation email that the machine and supplies would be delivered on February 11, 2025. A phone interview with the DME representative conducted on March 5, 2025, at 11:30 a.m., confirmed that Resident CL1's Bipap (with supplies) was delivered to the facility on [DATE]. An interview with the Director of Nursing conducted March 5, 2025, at 1:00 p.m., revealed that hospital reports are reviewed by the facility's liaison and communicated to the facility to determine the Resident's device and treatment needs for admission. The DON was unable to provide an explanation as to why Resident CL1 did not have a Bipap order despite it being on the Resdient CL1's hospital orders when discharged from the hospital on February 10, 2025. A review of Resident 1's hospital record revealed resident was hospitalized from January 8-10, 2025, for a diagnosis of Acute Respiratory Failure with Hypoxemia (A life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low oxygen level). Further review revealed resident was ordered Bipap with the setting of: Total Inspiratory pressure-14, and expiratory pressure-6 while in the hospital. A review of Resident 1's Hospital Discharge Summary report dated February 10, 2025, revealed: Should use Noninvasive ventilator with all naps and during bedtime. A review of the physician's order dated February 19, 2025, revealed an order for a BIPAP every night shift. A review of the nursing progress notes dated February 11, 2025, at 10:51 p.m., revealed resident had been taking off his/her BIPAP throughout the night as he/she felt as though he/she could not breathe. An interview conducted with Resident 1 on March 5, 2025, at 10:30 a.m., revealed that he/she felt that the machine (BIPAP) was not properly working because the pressure was too much causing his/her mouth and throat to be severely dry. The resident reported that someone checked the machine, but he/she was told that it was properly working. An observation of Resident 1's Bipap machine in the presence of the Director of Nursing on March 5, 2025, at 11:00 a.m., revealed that the machine had a setting of IP-18, and EP-5. Instead of the ordered of setting of IP-14, EP-6 from the hospital. An interview with the DON on March 5, 2025, at 11:10 a.m., revealed that the Bipap machine was already set up to the setting ordered from the hospital when it was delivered to the facility by the DME company. A phone interview with the DME representative conducted on March 5, 2025, at 11:30 a.m., confirmed that Resident 1's Bipap machine had a setting order of IP-14, EP-6. The machine with a serial number [B ----------] was delivered to the facility. The DME representative also reported that A Bipap for Resident CL1 with a setting order of IP-18, EP5 with a serial number of [B----------] was delivered to the facility on [DATE]. An observation of Resident 1's Bipap machine conducted on March 5, 2025, at noon., in the presence of the DON revealed that Resident 1 had Resident CL1's machine based on the serial number reported by the DME representative. An interview with the DON on March 5, 2025, at 1:00 p.m., was conducted. The DON was unable to explain why Resident 1 was using Resident Cl1's Bipap machine instead of his/her machine with physician ordered setting. The facility failed to ensure physician orders for Residents CL1 and 1 for Bipap were followed when admitted to the facility following hospitalization . 28 Pa. Code 211.5(f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative, in writing, regarding the reason for hospitalization for five of 56 residents reviewed (Residents 18, 36, 38, 77, 85). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 18, dated June 17, 2024, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and had diagnoses that included dementia. A nursing note for Resident 18, dated June 11, 2024, revealed that the resident was transferred to the hospital for evaluation of abdominal pain and to have his indwelling urinary catheter flushed or replaced. He was admitted to the hospital with a urinary tract infection. There was no documented evidence that a written notice of Resident 18's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A quarterly MDS assessment for Resident 36, dated July 23, 2024, indicated that the resident was understood and able to understand others, required substantial to moderate assist from staff for his personal care needs, and had diagnoses that included dementia. A nursing note for Resident 36, dated June 7, 2024, at 6:41 a.m., revealed that the resident had an unwitnessed fall resulting in a possible right arm fracture. The physician was notified, and the resident was sent to the emergency room for evaluation. A nursing note for Resident 36, dated July 4, 2024, at 10:46 p.m., revealed that the resident had a significant change in condition. The certified registered nurse practitioner was notified, and the resident was sent to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 36's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer. A quarterly MDS assessment for Resident 38, dated May 21, 2024, indicated that the resident was severely cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included idiopathic epilepsy (a genetic seizure disorder). A nursing note for Resident 38, dated May 7, 2024, at 2:40 p.m., revealed that the resident had a seizure and was not responding to treatments provided and his condition was worsening; therefore, he was transferred to the emergency room for evaluation. A nursing note for Resident 38, dated June 21, 2024, at 6:34 a.m., revealed that the resident's feeding tube came out of his body. The physician was notified, and the resident was sent to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 38's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer. A quarterly MDS assessment for Resident 77, dated May 2, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia and heart failure. A nursing note, dated June 24, 2024, at 7:46 p.m. revealed that Resident 77 was found coughing and wheezing, was flushed, and had an oxygen saturation (amount of oxygen in the blood) in the 70's (normal 95-100 percent). The physician was notified, and the resident was transferred to the hospital. There was no documented evidence that a written notice of Resident 77's transfer to the hospital was provided to the resident or the resident's representative regarding the reason for transfer. A quarterly MDS assessment for Resident 85, dated May 16, 2024, indicated that the resident was severely cognitively impaired, required assistance from staff for personal care needs, and had diagnoses that included dementia, seizure disorder, and a stroke. A nursing note, dated July 27, 2024, at 10:10 a.m. revealed that Resident 85 was observed lying in bed with his eyes closed with right-sided facial droop and facial edema (swelling). The resident stated, I don't feel well, and the physician was notified and an order was received to send him to the hospital for evaluation and treatment. A nursing note, dated July 27, 2024, at 12:28 p.m. revealed that Resident 85 was admitted to the hospital with a diagnosis of encephalopathy (a condition that causes brain dysfunction). There was no documented evidence that a written notice of Resident 85's transfer to the hospital was provided to the resident or the resident's representative regarding the reason for transfer. Interview with the Nursing Home Administrator on August 20, 2024, at 3:48 p.m. confirmed that the facility did not provide a written notice to the residents or their responsible party when a resident was transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 56 residents reviewed (Residents 28, 52, 53, 91, 94, 139, 162). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated [DATE], revealed that Section O0110G1b (non-invasive mechanical ventilator) was to be checked if a CPAP/BIPAP device (respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle) was used while a resident within the last 14 days. Physician's orders for Resident 28, dated [DATE], included an order for the resident to use a CPAP/BIPAP with distilled water every evening and night shift. A quarterly MDS assessment for Resident 28, dated [DATE], revealed that Section O0110G1b was not checked, indicating that the resident did not use a CPAP/BIPAP device during the seven-day assessment period. Review of the MAR for Resident 28, dated [DATE], revealed that the resident used a CPAP/BIPAP device every night during the seven-day assessment period. The RAI User's Manual, dated [DATE], indicated that Section P0200 (alarms) was to be coded if the resident had various types of alarms in use. This section was to be coded (A) if a bed alarm was used, (B) if a chair alarm was used, (C) if a floor mat alarm was used, (D) if a wander/elopement alarm was used, (F) if any other alarm was used during the seven-day look-back period. A quarterly MDS assessment for Resident 52, dated, dated [DATE], revealed that Section P0200 was coded D, indicating that the resident used a wander/elopement alarm. Review of the clinical record for Resident 52 for July and [DATE] revealed no documented evidence that the resident was using a wander/elopement alarm during the MDS assessment look-back period. The RAI User's Manual, dated [DATE], revealed that Section H0100 (bowel and bladder appliances) was to be coded (A) if the resident had and indwelling catheter (small tube inserted into the bladder to drain urine), (B) if the resident had an external catheter, (C) if the resident received intermittent catheterization (insertion and removal of a catheter to drain urine), and (Z) if none of the above applied during the seven-day look-back period. Section H0300 (urinary incontinence) was to be coded (0) if the resident was always continent, (1) if the resident occasionally incontinent of urine, (2) if the resident was frequently incontinent of urine, (3) if the resident was always in incontinent of urine, and (9) if the resident's urinary continence was not rated because the resident had a catheter. A care plan for Resident 53, dated [DATE], indicated that the resident had a suprapubic catheter for overactive bladder symptoms unresponsive to multiple interventions. An admission MDS assessment for Resident 53, dated [DATE], revealed that Section H0100 was coded (A) indicating that the resident had an indwelling catheter during the seven-day look-back assessment period and Section H0300 was coded (3) always incontinent, indicating the resident was always incontinent of urine during the seven-day look-back assessment period. The Long-Term Care Facility RAI User's Manual, dated [DATE], revealed that Section N0415C1 should be checked if the resident received an antidepressant medication and Section N0415I1 was to be checked if the resident received an anti-platelet medication during the seven-day assessment period. Physician's orders for Resident 91, dated [DATE], included an order for the resident to receive 81 milligrams (mg) of aspirin (antiplatelet) one time a day, and physician's orders, dated [DATE], included an order for the resident to receive 60 mg of duloxetine (an antidepressant) one time day. A quarterly MDS for Resident 91, dated [DATE], revealed that Section N0415C1 and Section N0415I1 were not checked, indicating that the resident did not receive an anti-depressant or an anti-platelet medication during the seven-day look-back assessment period. Review of the MAR for Resident 91, dated [DATE], revealed that the resident received 81 mg of aspirin once a day and 60 mg of duloxetine once a day during the seven-day assessment period. The Long-Term Care Facility RAI User's Manual, dated [DATE], revealed that Section N0415B1 should be checked if the resident received an anti-anxiety medication during the seven-day assessment period. Physician's orders for Resident 94, dated [DATE], included an order for the resident to receive 0.25 milliliters (mL) of 2 mg/mL of Ativan (anti-anxiety) at bedtime for anxiety. A quarterly MDS for Resident 94, dated [DATE], revealed that Section N0415B1 was not checked, indicating that the resident did not receive an anti-anxiety medication during the seven-day look-back assessment period. Review of the MAR for Resident 94, dated [DATE] revealed that the resident received 0.25 mL of Ativan at bedtime during the seven-day assessment period. Physician's orders for Resident 139, dated [DATE], included an order for the resident to receive 50 mg of Trazadone (anti-depressant) at bedtime for depression. A quarterly MDS for Resident 139, dated [DATE], revealed that Section N0415C was not checked, indicating that the resident did not receive an anti-depressant medication during the seven-day look-back assessment period. Review of the MAR for Resident 139, dated [DATE], revealed that the resident received 50 mg of Trazadone at bedtime during the seven-day assessment period. The Long-Term Care Facility RAI User's Manual, dated October, 2023, revealed that Section A2105 was to capture the discharge status of the resident by checking the appropriate type of discharge from the facility from the types listed, (1) home/community, (2) nursing home (long term care facility), (3) skilled nursing facility (SNF, swing beds), (4) short term general hospital, (5) long term care hospital, (6) inpatient rehabilitation facility, (7) in-patient psychiatric facility, (8) intermediate care facility, (9) hospice (home, non-institutional), (10) hospice (institutional facility), (11) critical access hospital, (12) home under care of organized home health service organization, (13) deceased , and (99) not listed. A discharge MDS for Resident 162, dated [DATE], revealed that section A2105 indicated that the resident was discharged to a short-term general hospital. A physician's order for Resident 162, dated [DATE], included an order to discharge to home with personal belongings on [DATE]. Interview on [DATE], at 3:09 p.m. with the Registered Nurse Assessment Coordinator confirmed that the assessments mentioned above were coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the appropriate monitoring, care, and services for two of four residents receiving parenteral nutrition (Residents 18 and 37) which resulted in actual harm to Resident 18, who developed an infection to the site of the parenteral tube feed which caused pain, multiple hospital trips, and required IV (intravenous) antibiotic therapy. Findings include: Observation of Resident 18 on March 26, 2024, and March 27, 2024, revealed the resident had a percutaneous endoscopic gastrostomy (PEG tube - tube placed through the abdomen directly into the stomach to provide nutrition and medication when oral intake is not adequate). Further observation revealed the resident had an IV placed in the right arm. Review of Resident 18's care plan for the PEG tube revealed an intervention added September 6, 2022, to provide care to the tube site per (physician) orders. Review of Resident 18's physician orders revealed an order dated April 2, 2023, and discontinued October 11, 2023, to cleanse the PEG insertion site with soap and water, apply Bacitracin (antibiotic ointment) and leave open to air every shift for skin care. Review of Resident 18's October 2023, November 2023, December 2023, and January 2024 Treatment Administration Records (TARs) failed to reveal evidence of documented care to the PEG insertion site until January 11, 2024, when an order was obtained to apply clotrimazole 1% (antifungal) cream to the PEG site twice a day for yeast for 10 days. Review of Resident 18's February 2024 TAR failed to reveal evidence of documented care to the PEG insertion site. Review of Resident 18's progress notes revealed a provider note dated January 11, 2024, when the resident returned from a hospitalization occurring January 7, 2024, until January 10, 2024, for gastritis (inflammation of the stomach). Further review of the progress note revealed, while at the hospital, the resident's PEG site was believed to be infected and positive for a yeast infection, so the resident was started on clotrimazole until January 21, 2024. Additional review of Resident 18's progress notes revealed a nurse's note on February 24, 2024, which stated that the resident's PEG tube bandage was changed, and skin surrounding is red/irritated/moist and painful to the touch. Cleaned with [normal saline] and bacitracin applied. Further review of Resident 18's progress notes revealed a nurse's note on February 27, 2024, which stated that the resident's PEG tube bandage was changed, and skin surrounding is red/irritated/moist and painful to the touch. Cleaned with [normal saline] and bacitracin applied. Will continue to monitor. Further review of Resident 18's clinical record failed to reveal evidence that the provider was made aware of the resident's PEG site following the February 24th and February 27th nursing progress notes. Review of Resident 18's progress note revealed a nurse's note dated March 2, 2024, which indicated Resident has brown color drainage from [PEG] site. Drainage has a foul odor. Resident abdomen area is distended. Resident 18 was sent to the hospital at approximately 4:20 p.m. and returned the same day at 10:45 p.m. with a diagnosis of abrasion of abdominal wall with infection and an order for Cephalexin (Keflex) (antibiotic) 500 milligrams every 12 hours from March 3, 2024, through March 17, 2024. Further review of Resident 18's progress notes revealed a nurse's note dated March 6, 2024, indicating the PEG site was fire red, active bleeding this shift. [NAME] drainage. Area cleansed and dressing applied [twice.] .Right side of stoma site bubbling liquid. Asked resident if in pain at first said no. Explained to resident the importance of letting us know. He then said he is in pain Culture collected. Additional review of Resident 18's progress notes revealed a nurse's note dated March 7, 2024, indicating Resident peg site is red with purulent drainage and blood. Area cleaned and dry dressing applied. Further review of Resident 18's progress notes revealed a nurse's note dated March 8, 2024, at 6:59 a.m. indicating Resident with moderate amount blood from [peg] tube. Blood bubbling from stoma site. Area cleansed and dressing applied. Gown and sheet needed to be changed also. Additional review of Resident 18's clinical record revealed a progress note dated March 8, 2024 at 3:15 p.m. indicating Peg tube [stoma] has bloody and dark drainage seeping around tubing. Air and 'bubbling' noted around site. Cleaned and dressing applied. Further review of Resident 18's progress notes revealed a nurse's note on March 9, 2024, at 1:57 a.m. indicating Notified by Nurse that Resident is having significant increased bleeding [and] possible stool coming out around [PEG] tube. The physician was contacted for orders to send to the emergency room . Further review of Resident 18's progress notes revealed the resident was sent to the emergency room of three different hospitals and returned to the facility the same day March 9, 10, and 11, 2024, due to no sources of bleeding being identified and the resident already being on antibiotics. Further review of Resident 18's progress notes revealed a provider note on March 12, 2024, which stated that the resident's culture returned positive for klebsiella (bacteria), MRSA (bacteria resistant to many antibiotics), and candida (yeast.) The resident's Keflex was discontinued and the resident was started on Bactrim (antibiotic) DS one tablet twice daily for 14 days. Review of Resident 18's March 2024 TAR revealed the resident was ordered to have the PEG site cleansed with normal saline and covered with a dry dressing twice daily from March 14, 2024, through March 18, 2024. Review of Resident 18's progress notes revealed the physician discontinued the treatment on March 18, 2024, and ordered to cleanse the site with Hibiclens (antiseptic skin cleanser) twice daily. Further review of Resident 18's progress notes revealed the resident was started on fluconazole (antifungal medication) 200mg daily for seven days and Lotrimin (antifungal) cream daily for seven days. Further review of Resident 18's progress notes revealed a physician's note on March 25, 2024, which stated: follow up of abdominal abscess/dermatitis near his PEG tube insertion .Bactrim DS twice a day for the infection. He is also being seen by our wound physician. His wound culture returned positive for Klebsiella pneumoniae as well as MRSA, both susceptible to Bactrim. Despite this, he does not seem to be improving and continues to have dark brown mucus and bloody drainage from the PEG tube site. The physician ordered daptomycin (antibiotic) 350 mg IV every 24 hours for 7 days at this time. Observation of Resident 18's PEG tube care with licensed nurse, Employee E3, who is also the Infection Preventionist, on March 29, 2024, at 9:20 a.m. revealed the PEG site was red with dark drainage surrounding the site. Resident 18 complained of pain during care. Interview with Employee E3 at this time revealed all residents with PEG tubes are expected to have at least daily care to the PEG site to prevent infection. Interview with the Nursing Home Administrator and Assistant Director of Nursing on March 29, 2024, at 12:00 p.m. confirmed that Resident 18 did not receive daily consistent PEG tube care from October 2023 until March 2024. The facility failed to provide consistent, daily PEG tube care to Resident 18, which resulted in the actual harm of infection, multiple hospital trips, antibiotics, and pain. Review of facility's enteral tube feeding via continuous pump policy with a revision date of November 2018 states Check the enteral nutrition label against the order before administration. Check the following information a. resident name, ID and room number, b. type of formula, date and time formula was prepared, rate of administration (mL/hour). The policy also states under Initiate feeding the following On formula label document initials, date, and time the formula was hung/administered, the resident's name and flow rate. On flush bag (if applicable) document initials, date and time the water was hung/administered, the resident's name and prescribed flush amounts/intervals. Clinical medical record review for Resident 37 revealed an active physician's order dated January 19, 2024, that instructed staff to provide enteral feeding (provision of food and fluids via the gastrointestinal tract, e.g., directly into the stomach, not through the mouth) of Isosource 1.5, 75 ml (milliliters) continuously with 60 ml water every hour, start feeding at 4pm, stop at 10am.(for a total of 1350 ml of Isosource and 1080 ml of water). Clinical medical record review of Resident 37 revealed the following diagnosis: Generalized Idiopathic Epilepsy and epileptic syndromes (causes seizures that involve electrical discharges all over the brain at the same time), Quadriplegia (paralysis of all four limbs and the torso), Oropharyngeal Dysphagia (affects the ability to swallow). Observation of Resident 37 on March 27, 2024, at 9:39 A.M. revealed Isosource 1.5 liquid nutrition infusing via a pump set at a rate of 70 ml per hour. Additional observations revealed the Isosource did not contain the initials, date, or time the formula was hung. Observations of Resident 37 on March 28, 2024, at 8:17 A.M. revealed Isosource 1.5 liquid nutrition infusing via a pump set at a rate of 70 ml per hour, with a total volume of 1828 ml Isosource infused and a total volume of 1624 ml of water flushed. Isosource 1.5 did not contain the initials, date, or time the formula was hung. Interview conducted with the Assistant Director of Nursing (ADON), Nursing Home Administrator (NHA), and Registered Dietitian Employee (E4), on March 29, 2024, at 10:02 A.M. confirmed Resident 37's Isosource 1.5 rate should have been set to 75 ml/hr. Observation of Resident 37's feed pump on March 29, 2024 at 10:38 A.M. with the ADON and E4 revealed the feed pump was set to 70 ml/hr and the Isosource 1.5 was missing the initials, date, and time the bag was hung. ADON performed a 24-hour lookback function on Resident 37's pump. The 24 hour lookback revealed Resident 37 only received 1083 ml of Isosource 1.5 in a 24 hour period. Additional observations on March 29, 2024 at 10:40 A.M. revealed Resident 37's pump was still active and infusing Isosource 1.5. The above information was confirmed by the Assistant Director of Nursing and Employee E4 at 10:41 A.M 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record and facility documentation and staff interviews, it was determined that the facility failed to follow care plan interventions to prevent falls for one of seven residents, resulting in actual harm to Resident 106, who fell , requiring emergency care and three staples to treat a laceration to the head. The facility also failed to develop a comprehensive care plan regareding aggressive behaviors for one of 30 residents reviewed (Resident 39). Findings include: Review of Resident 106's clinical record revealed diagnoses including Dementia (loss of cognitive functioning that interferes with daily life and activities), Down's syndrome (genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), cognitive communication deficit, unspecified Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and generalized Muscle Weakness. Review of Resident 106's Annual Minimum Data Set (MDS - periodic assessment of resident care needs) dated November 2, 2023, revealed the resident scored a BIMS (Brief Interview for Mental Status) of 02, indicating severe cognitive impairment. Further review of the resident's MDS revealed under Section J (Health Conditions) the resident had two falls with no injury and one fall with injury within the lookback period. Review of Resident 106's progress notes revealed a nurse's note dated November 8, 2023, which indicated the nurse entered room resident was seen sitting on the bathroom floor facing the sink .Resident was laid down in bed about 60 minutes prior to fall for a nap. Resident ambulated unassisted to the bathroom and fell . Review of facility documentation regarding Resident 106's fall on November 8, 2023 revealed Resident 106's fell at 3:30 p.m. Review of the IDT (Interdisciplinary Team) Review revealed the resident fell in the bathroom attempting to toilet self without staff assistance. The new intervention approved by the IDT was to offer the resident toileting on the last round of the 7-3 (day) shift. Review of Resident 106's care plan revealed the resident's care plan for falls was updated on November 9, 2023, with the intervention to offer resident toileting on the last round of the 7-3 shift. Review of Resident 106's progress notes revealed a nurse's note dated November 22, 2023, which stated that the nurse was called to the resident's room because the resident was found on the floor, and resident was seen lying on her back with her head facing the footboard on her fall mat. Resident was wearing shirt, pants, regular socks, and a soiled brief. Resident was laid down for a nap after lunch. Some time between then and the fall resident had a large BM (bowel movement) which made her restless. Resident attempted to ambulate unassisted to the bathroom. Review of facility documentation regarding Resident 106's November 22 nd fall revealed the resident's fall occurred at 3:00 p.m. Review of the IDT review revealed the new intervention was to offer the resident toileting prior to the end of 7-3 shift. Review of Resident 106's progress notes revealed a nurse's note on November 23, 2023, which stated called to resident room around [3:30 p.m.] resident observed laying on her back on top of her fall mat. head by footboard of the bed and feet towards the wall. wheelchair at the end by resident head .prior to fall resident was resting in bed .nursing intervention check on resident at the end of 7-3 shift, if resident is awake offer resident [to get out of bed.] Review of facility documentation regarding Resident 106's November 23rd fall failed to reveal when the resident was last toileted prior to the fall. Further review of Resident 106's progress notes revealed a nurse's note dated December 1, 2023, which stated: At about [3:10 p.m.] this writer was walking out of the B wing nurses station and heard a thud. This writer then heard sounds coming from [Resident 106's room] and walked in and observed the resident on the fall matt, beside her bed, laying on her back, with her head resting on the bottom edge of the bedside stand. Resident was able to move all extremities per usual. Blood was noted on resident's hand and when staff assisted her to a sitting position, it was noted that the back of the resident's head was bleeding. Upon inspection, it was noted that the resident had a laceration that was bleeding and needed stitches. [Physician] also heard the thud and assessed the resident's head wound, agreeing that the resident needed stitches. When asked what she was trying to do, the resident stated that she had to go to the bathroom [ROOM NUMBER] notified. Review of Resident 106's emergency room documentation revealed the resident was diagnosed with a closed head injury and required staples to the head. Review of Resident 106's nurse's note revealed the resident returned from the hospital the same night at approximately 9:15 p.m. with three staples to the laceration to the back of the head. Review of facility documentation revealed a witness statement from nurse aide, Employee E7, taken on December 1, 2023, which indicated: I was told to toilet resident and lay her down in bed for a nap after lunch. I did not know I was supposed to get her out of bed before 3pm. The facility's failure to follow Resident 106's care plan by offering toileting at the end of 7-3 shift, resulting in Resident 106's fall with laceration to the head requiring staples, was discussed with and confirmed with the Nursing Home Administrator and Assistant Director of Nursing on March 29, 2024, at 12:00 p.m. Review of Resident 39's diagnosis list includes Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), and Depression. Review of Resident 39's Annual Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated March 1, 2024, revealed the Resident had a moderate cognitive impairment. Review of the nursing progress notes dated February 4, 2024, at 6:25 p.m., revealed that the resident was in their power chair with a wheelchair leg rest looking for another resident who he thought had threatened him/her. When asked, Resident 39 reported that another resident shook a fist at him/her and said something. Will continue to observe. Review of the nursing progress notes dated February 9, 2024, at 2:17 p.m., revealed Resident 39 was in the lobby showing signs of aggression towards another resident. Both residents were observed yelling at each other, staff separated them and redirected them to different locations. The same note indicated that Resident 39 walked with the social worker back to the unit and expressed a desire to find a wheelchair leg to come after the other resident. After speaking to the resident, he/she calmed down and stated that he/she would stay away from the other resident. 15-30 minutes later, Resident 39 was seen coming back to the lobby looking for the other resident, he/she was redirected back to the unit. Interview conducted with licensed social worker Employee E10 on March 29, 2024, at 9:40 a.m. at which time, Employee E10 reported, she/he spoke with the resident after the February 4, 2024, incident but did not have any recollection of the event. Review of Resident 39's clinical records failed to reveal a comprehensive care plan for Resident 39's aggressive behavior towards another resident was developed after the above incidents. The facility was unable to provide documentation of a comprehensive care plan for Resident 39's aggressive behavior towards another resident was developed. The above information regarding Resident 39 was conveyed to the Nursing Home Administrator on March 29, 2024, at 1:00 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon review of facility documentation and clinical record review, it was determined the facility failed to ensure that residents were free from significant medication errors resulting in one resident suffering actual harm from seizures that required hospitalization and treatment for one of 18 residents reviewed (Resident 240). Findings include: Review of Resident 240's clinical record revealed diagnoses including Lennox Gestaut Syndrome (severe form of epilepsy - seizure disorder). Review of pre-admission hospital documentation provided to the facility from a previous acute care facility dated April 7, 2023, revealed patient with hx [history] of Lennox-Gestaut and is on multiple oral seizure medications. Additional review of hospital documentation dated April 7, 2023 revealed Resume home medication Lamictal (medication used to prevent and control seizures) 400 mg (milligrams) BID [two times per day]; Keppra (medication used to treat seizures) 1000 mg BID; patient is on Banzel (medication used in conjunction with other medications to prevent or control seizures associated with Lennox-Gastaut syndrome) 800 mg every 12 hours which is non- formulary and there is no substitution. Will need to order from outpatient pharmacy, get from nursing home or discuss with neurology alternative medication. Further review of the hospital documentation dated April 7, 2023 revealed Resident 240's current medication list included Clobazam (used with other medications to treat seizures caused by Lennox-Gestaut Syndrome) 5 mg, Lamotrigine (Lamictal) 400 mg and Levetiracetam (Keppra)1000 mg (anti-seizure medications). Review of Resident 240's clinical record revealed Resident 240 was admitted to the facility on [DATE]. Review of Resident 240's admission physician orders dated April 25, 2023 revealed orders for Clobazam 10 mg 0.5 tablet (5 mg) to be administered every 12 hours; Lamotrigine 200 mg administer 2 tablets (400 mg) two times per day and Levetiracetam 1000 mg to be administered every 12 hours. Review of Resident 240's clinical progress notes dated April 26, 2023, at approximately 12:00 p.m. revealed Resident 240 began to experience seizure activity that continued every 15-30 minutes. Review of Resident 240's clinical record revealed Resident 240 was sent to an acute care facility on April 27, 2023, and was admitted at approximately 4:25 a.m. for treatment of seizures. Review of Resident 240's April 2023 Medication Administration Record (MAR) revealed Resident 240 did not receive Clobazam 5 mg between admission on April 25, 2023, and discharge to the hospital on April 27, 2023; approximately 3 doses. Further review of Resident 240's April 2023 MAR revealed Resident 240 received one dose of Lamotrigine (Lamictal) 400 mg on April 26, 2023, at 8:00 p.m. and further review revealed Resident 240 received one dose of Levetiracetam (Keppra) 1000 mg on April 26, 2023, at 9:00 p.m. Resident 240 missed two doses of Lamotrigine 400 mg and two doses of Levetiracetam (Keppra) 1000 mg. Review of Resident 240's hospital records dated May 1, 2023, revealed [resident] presented from [facility] with status epilepticus after not receiving AED's [anti-epileptic drugs] for approximately 36 hours. Review of Resident 240's hospital records dated May 10, 2023, revealed Status epilepticus [continuous seizure activity] with baseline epilepsy, Lennox Gestaut Syndrome. Further review of Resident 240's hospital records dated May 10, 2023, revealed Keppra [Levetiracetam] level low on admission in setting of missed AED [anti-epileptic drugs] doses at rehab. No other obvious precipitant noted. Further review of Resident 240's hospital records revealed acute hypoxemic respiratory failure - intubated for airway protection on admission. Interview with the Director of Nursing on May 10, 2023, at 10:00 a.m. revealed that Resident 240's physician did not review Resident 240's admission orders until April 26, 2023, one day after admission and, further, that Resident 240's medications were not ordered until after 9:00 a.m. on April 26, 2023, one day after admission. The medications, Lamotrigine and Levetiracetam, were not received until the evening of April 26, 2023, one day after admission. Interview with Director of Nursing further revealed that Resident 240 did not receive any doses of Clobazam as ordered by the physician,during stay at the facility from April 25, 2023 to April 27, 2023. The Director of Nursing confirmed that information regarding Resident 240's diagnoses including Lennonx- Gestaut Syndrome and resident's list of medications including Lamictal, Keppra, and [NAME] were received by the facility on April 7, 2023, eighteen days prior to resident admission on April 25, 2023. The facility failed to provide Resident 240's seizure medication causing seizure activity and resulting in hospitalization and intubation causing harm to Resident 240. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 5/19/2022, 2/9/2022, 7/28/2021, 6/30/2021 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 5/19/2022, 2/9/2022, 7/28/2021, 6/30/2021 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 2/14/2023, 12/19/2022, 6/23/2022, 519/2022, 2/9/2022, 7/28/2021

Based upon review of facility documentation and clinical record review, it was determined the facility failed to ensure that upon admission, Resident 240 had appropriate medications necessary to prevent and treat seizures which resulted in hospitalization for one of 27 residents reviewed. Findings include: Review of Resident 240's clinical record revealed diagnoses including Lennox Gestaut Syndrome (severe form of epilepsy - seizure disorder). Review of pre-admission hospital documentation provided to the facility, dated April 7, 2023, revealed patient with hx [history] of Lennox-Gestaut and is on multiple oral seizure medications. Additional review of pre-admission documentation dated April 7, 2023 revealed Resume home medication Lamictal (medication used to prevent and control seizures) 400 mg (milligrams) BID [two times per day]; Keppra (anticonvulsant classified medication used to treat seizures) 1000 mg BID; patient is on Banzel (medication used in conjunction with other medications to prevent or control seizures associated with Lennox-Gastaut syndrome) 800 mg every 12 hours which is non formulary and there is no substitution. Will need to order from outpatient pharmacy, get from nursing home or discuss with neurology alternative medication. Further review of the hospital documentation dated April 7, 2023 revealed Resident 240's current medication list included Clobazam (used in conjunction with other medications to treat seizures caused by Lennox-Gestaut Syndrome) 5 mg, Lamotrigine (Lamictal) 400 mg and Levetiracetam (Keppra) 1000 mg (all anti-seizure medications). Review of Resident 240's clinical record revealed Resident 240 was admitted to the facility on [DATE]. Review of Resident 240's admission physician orders dated April 25, 2023 revealed orders for Clobazam 10 mg 0.5 tablet (5 mg) to be administered every 12 hours; Lamotrigine 200 mg administer 2 tablets (400 mg) two times per day and Levetiracetam 1000 mg to be administered every 12 hours. Review of Resident 240's clinical progress notes dated April 26, 2023, at approximately 12:00 p.m. revealed Resident 240 began to experience seizure activity that continued every 15-30 minutes. Review of Resident 240's clinical record revealed Resident 240 was sent to an acute care facility on April 27, 2023, and was admitted at approximately 4:25 a.m. for treatment of seizures. Review of Resident 240's April 2023 Medication Administration Record (MAR) revealed Resident 240 did not receive Clobazam 5 mg between admission on April 25, 2023, and discharge to the hospital on April 27, 2023; approximately 3 doses. Further review of Resident 240's April 2023 MAR revealed Resident 240 received one dose of Lamotrigine (Lamictal) 400 mg on April 26, 2023, at 8:00 p.m. Further review of the April 2023 MAR revealed Resident 240 received one dose of Levetiracetam (Keppra) 1000 mg on April 26, 2023, at 9:00 p.m. Resident 240 missed two doses of Lamotrigine 400 mg and two doses of Levetiracetam (Keppra) 1000 mg. Review of Resident 240's hospital records dated May 1, 2023, revealed [resident] presented from [facility] with status epilepticus after not receiving AED's [anti-epileptic drugs] for approximately 36 hours. Review of Resident 240's hospital records dated May 10, 2023, revealed Status epilepticus [continuous seizure activity] with baseline epilepsy, Lennox Gestaut Syndrome. Further review of Resident 240's hospital records dated May 10, 2023, revealed Keppra [Levetiracetam] level low on admission in setting of missed AED [anti-epileptic drugs] doses at rehab. No other obvious precipitant noted. Additional review of Resident 240's hospital records revealed acute hypoxemic respiratory failure - intubated for airway protection on admission. Interview with the Director of Nursing on May 10, 2023, at 10:00 a.m. revealed, Resident 240's physician did not review resident's admission orders until April 26, 2023, the day after admission. The interview with the Director of Nursing also indicated, Resident 240's medications were not ordered until after 9:00 a.m. on April 26, 2023, the day after admission. The medications, Lamotrigine and Levetiracetam, were not received until the evening of April 26, 2023, the day after admission. Further interview with Director of Nursing on May 10, 2023 revealed, Resident 240 did not receive any doses of Clobazam as ordered by the physician, while at the facility from April 25, 2023 to April 27, 2023; approximately 3 doses The Director of Nursing confirmed the facility received Resident 240's diagnoses including Lennox- Gestaut Syndrome and resident's list of medications including Lamictal, Keppra, and [NAME] were received by the facility on April 7, 2023; eighteen days prior to the resident admission on April 25, 2023. The facility, with advanced knowledge of condition and medical needs failed to ensure that Resident 240 received necessary seizure medication causing seizure activity which resulted in hospitalization and intubation causing harm to Resident 240. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 5/19/2022, 2/9/2022, 7/28/2021, 6/30/2021 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 5/19/2022, 2/9/2022, 7/28/2021, 6/30/2021 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 2/14/2023, 12/19/2022, 6/23/2022, 519/2022, 2/9/2022, 7/28/2021

Based on clinical record review, hospital documentation, and staff interview; it was determined that the facility failed to ensure appropriate catheter care by nursing staff causing Resident R1 extreme pain, abdominal distention and emergency transport to the emergency room for one of three residents reviewed. Findings include: Review of the clinical record for Resident R1 revealed an admitted [DATE], with diagnoses of Multiple Sclerosis (disease that impacts the central nervous system) and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve dysfunction). Review of Resident R1's clinical record revealed a physician's order for a supra-pubic catheter (surgically created connection between the urinary bladder and the skin, used to drain urine from the bladder in individuals with obstruction of normal urinary flow) to be flushed with 10cc (cubic centimeter) normal sterile saline in the morning one time a day for leakage or blockage. Review of Resident R1's clinical record including a quarterly MDS (periodic assessment of resident needs) dated December 1, 2021 which revealed the resident's cognitive status score of 14 out of 15 indicating no cognitive impairment. Review of Resident R1's clinical record including January 2022 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed, non licensed staff, Employee E3 performed a suprapubic catheter flush of saline solution during dayshift on January 28, 2022. Review of Resident R1's clinical chart revealed a nursing note dated January 29, 2022 indicating resident reported to this nurse that after her routine flush of her suprapubic catheter she was experiencing uncontrollable pain to the suprapubic area. Abdominal distention noted greater than resident's baseline. Complained of pain with touch to abdomen and foley line. Minimal urine output noted. Resident was sent to the ER [emergency room ]. Further review of Resident R1's clinical record revealed that staff assessed Resident R1 for abdominal distention and pain with touch at catheter line before initiating contact with attending physician who determined the resident needed to have further assessment and treatment at the emergency room of local hospital. Review of the hospital record review dated January 29, 2022, revealed Resident R1 is considered alert and oriented. The record also indicated that Resident R1 reported to the hospital staff that she has been experiencing pain since the nurse, on day shift Friday, put the saline in her balloon port when they flushed her. Review of facility documentation of the investigation revealed interview notations indicated, on January 29, 2022 at approximately 7:06 a.m., resident reported that she was having pain in her abdomen after her routine catheter flush. When staff question resident she stated that the nurse on day shift Friday had put the saline in her balloon port when she flushed her. Review of information dated January 29, 2022 submitted by the facility to Department of Health, revealed that Resident R1 had a foley flush approximately 20 cc of normal saline into the balloon port of supra-pubic catheter. An interview conducted with the NHA on February 8, 2022, at 11:00 a.m. confirmed that the staff improperly treated Resident R1 by inserting saline into the wrong port of the supra-pubic catheter causing uncontrollable pain to the resident. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and procedure, clinical record review, and staff interviews, it was determined the facility failed to identify increased risk of pressure ulcer development and have interventions in place to prevent pressure ulcers, causing actual harm of advanced stage pressure ulcers to three of nine residents reviewed (Residents 45, 51, 191). Findings include: Review of facility policy and procedure titled, Prevention of Pressure Injuries, revised April 2020, revealed to assess the resident on admission (within eight hours) for existing pressure ulcer risk factors. Repeat the risk assessment weekly and upon any changes in condition. Use a standardized pressure ulcer injury screening tool to determine and document the risk factors. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Teach residents who change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage resident to change positions. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Review the interventions and strategies for effectiveness on an ongoing basis. Review of facility policy and procedure titled, Pressure Ulcer Risk Assessment, revised March 2020, revealed that the purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed and which will take time to modify. Risk factors that increase a resident's susceptibility to develop or to not heal PIs (pressure injuries) include but are not limited to, impaired or increased mobility and decreased functional ability; elevated body temperature. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as required based on the resident's condition. Conduct a structured pressure ulcer risk assessment using a facility-approved tool. Conduct a comprehensive skin assessment with every risk assessment. Develop the resident centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the residents overall clinical condition, and the residents stated wishes and goals. The interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. The care plan must be modified as the resident's condition changes, or if the current interventions are deemed inadequate. Review of facility policy and procedure titled, Pressure Injuries Overview, revised March 2020, revealed, Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; Revision of the interventions as appropriate. Review of Resident 45's MDS dated [DATE], revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's Braden Assessment (tool used to determine residents risk of developing pressure ulcers), dated November 10, 2020, revealed the resident was not at risk for pressure ulcer development. Review of Resident 45's record indicated there was a care plan related to skin integrity specifically regarding dry skin, and long finger nails, but there was no care plan related to prevention of pressure ulcers or skin breakdown. Review of Resident 45's progress notes revealed a nursing entry dated December 9, 2020, at 11:10 p.m. that stated, Resident tested positive with rapid test for COVID-19. Resident put in isolation and PCR (was performed to detect genetic material from a specific organism, such as a virus) test completed and sent to lab. Further review of Resident 45's progress notes revealed a CRNP entry dated December 10, 2020, at 6:05 p.m. that stated, staff report member spending much time sleeping, eating little. Member sleeping in bed, wakes to name & light touch to arm, makes eye contact when prompted, nonsensical conversation. Further review of Resident 45's progress notes revealed a CRNP entry dated December 14, 2020, at 8:24 p.m. that stated, staff report member requires assistance with meals. Member seated in wheelchair in day room, awake, calm, cooperative, in no acute distress, appears comfortable. Further review of Resident 45's progress notes revealed a CRNP entry dated December 18, 2020, at 5:14 p.m. that stated, staff reports member eating, continues to require feeding assistance. Member alert, calm, cooperative, seated in wheelchair, in no acute distress. Interview with Registered Nurse Employee E3 on April 29, 2021, at approximately 10:30 a.m. revealed the resident was 'hit hard' by COVID-19 and prior to was able to walk on his own on the unit and in his room and would do so frequently. After his COVID-19 diagnosis, he spent most of his time in bed and then required a wheelchair. Review of the ADL (Activities of Daily Living- routine activities people do without assistance, such as eating or bathing, and help to decide care needed as one ages) documentation revealed prior to Resident 45's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After December 9, 2020, the documentation showed that the resident was not walking in his/her room or the corridors at all. Review of Resident 45's Physical Therapy Discharge Summary revealed the resident was receiving physical therapy from October 20, 2020, to December 8, 2020. Resident was discharged from therapy due to COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Therapy to re-evaluate as physically able. Interview with Nurse Aide Employee E4 on April 29, 2021, at 10:30 a.m. revealed Resident 45 was able to walk in his/her room and the corridor prior to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in Resident 45's record indicating that the resident was reassessed for risk of skin breakdown or care plan to prevent skin breakdown after the resident had a change in condition with the COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's progress notes revealed a nursing entry dated January 8, 2021, that identified a verbal order received for the resident to have left buttocks cleansed with NSS (Normal saline- sterile water with salt) pat dry and apply bordered foam dressing (foam surrounded by adhesive material used to cover a wound) daily and PRN (as needed). Interview with licensed nurse Employee E3 on April 29, 2021, indicated that she was not able to recall what the wound looked like when it was discovered on January 8, 2021. This was the first indication of a wound for this resident but there was no indication of the wound, just treatment. Review of Resident 45's weekly skin/body check, dated January 14, 2021, the first documentation in the record of the wound, revealed an unstageable pressure ulcer (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) pressure ulcer to the right sacrum (large wedge shaped vertebra at the base of the spine) that measured 2 centimeters (cm) by 1.4 cm and a left buttock unstageable pressure ulcer that measured 8 cm by 6 cm. The clinical record lacked evidence of an assessment of the wound from when it was first documented in a progress note on January 8, 2021, and this skin/body check on January 14, 2021. Review of Resident 45's wound physican note, dated February 8, 2021, revealed Resident 45 had a Stage 4 (full thickness tissue loss in which the base of the ulcer exposes bone, tendon, muscle or cartilage) measuring 6.4 cm long by 6. 2cm wide and 2.7 cm deep to the left buttock and a Stage 3 pressure ulcer (full thickness skin loss exposing subcutaneous tissue) measuring 4.6 cm long by 2.3 cm wide by 1.7 cm deep to the right buttock. This was the last wound physician note before signing off when the resident signed on to hospice services. Observation of Resident 45's wound care on April 30, 2021, at 9:45 a.m. revealed Resident 45 continued with a Stage 4 pressure ulcer to the left buttock and a Stage 4 wound to the right sacrum with granulation tissue and slough in the wound base with an area of undermining between the two wounds (skin is separating the wounds but is not attached to the underlying connective tissue). Interview with the Nursing Home Administrator and the Assistant Director of Nursing on April 30, 2021, at 11:30 a.m. confirmed Resident 45 had a change in condition and there was no assessment completed to determine if there was an increased risk of pressure ulcer development. Resident 45 was diagnosed with COVID-19 causing the resident to become less mobile. The facility failed to identify the change in condition and conduct a skin assessment to determine if there had been an increase in the risk of developing pressure ulcers and failed to develop interventions to prevent those pressure ulcers, resulting in actual harm when Resident 45 developed a Stage 4 pressure ulcer. Review of Resident 51's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's clinical record revealed a nursing note dated March 30, 2021, that the resident had a new reddened area to his/her sacrum. The resident was noted with Stage 2 pressure ulcer (involving loss of the top layers of the skin) measuring 1.1 cm x .9 cm. No drainage noted. The physician was notified, and treatment order obtained to cleanse with Normal Saline Solution (NSS), apply Iodosorb (a sterile antimicrobial dressing) and cover with dry dressing daily and as needed. Resident 51's clinical record revealed that on April 5, 2021, a Wound Physician's note identified that the wound was now unstageable due to necrosis (death of cells or tissue through disease or injury) of the sacral wound. The wound measured 4.5 cm x 5.5 cm and it was recommended for a treatment change to Calcium Alginate with silver (a sterile primary dressing for wounds with moderate to heavy exudate to assist with infection reduction), apply once daily for 30 days with a foam border dressing. A note in Resident 51's clinical record dated April 8, 2021, was recorded as a late entry for April 5, 2021, and stated that a treatment change was phoned into Hospice and the power of attorney. There was no documentation that indicated that the primary physician was notified with the recommended change in treatment. Review of Resident 51's Treatment Administration Record (TAR) revealed that the order was not changed until April 9, 2021 (a delay of four days). Further review of the clinical record revealed a Wound Physician's note dated April 12, 2021, that identified the wound had deteriorated to 7 cm x 6.7 cm x 1 cm with heavy serous exudate (a clear, thin and watery plasma) with 100% thick adherent necrotic tissue and the wound was debrided (the removal of dead or infected skin tissue to help a wound heal). It was now labeled a Stage 4 pressure wound. A new treatment was ordered to discontinue Calcium Alginate with silver and to add Dakin's solution (a strong antiseptic that kills most forms of bacteria and viruses) soaked gauze and to continue with a foam border dressing. There was no documentation that indicated that the primary physician was notified with the recommended change in treatment. The April 2021 TAR revealed that the treatment was not changed until April 17, 2021 (5 days later). Further review of the clinical record revealed on April 17, 2021, the Primary Care Physician was notified that the wound had a foul odor and a wound culture was done. Results of the culture were positive for infection and IV antibiotics were ordered for every 24 hours for six weeks. Review of Resident 51's Wound Physician's note dated April 19, 2021, revealed the wound site measured 8 cm x 7.5 cm x 2 cm with undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) was 4 cm at 9 o'clock with moderate serous exudate and 40% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process). Debridement of the wound was performed. An interview with the Nursing Home Administrator on April 29, 2021, at 8:15 a.m. confirmed the resident was not on Hospice services on April 5, 2021, resulting in the treatment modifications being delayed for four days. It was also confirmed that the new treatment orders received on April 12, 2021, was delayed for five days resulting in actual harm when the resident's wound increased in size with undermining. The facility failed to recognize that the resident was not on Hospice, therefore when Hospice was notified for changes in treatment they were not acknowledged or acted upon. The facility did not follow up to ensure the primary care physician was notified of recommendations for order changes until 4 days and 5 days later, delaying treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 191's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 191's progress notes revealed a nursing entry dated December 9, 2020, at 9:26 p.m. that stated, Resident tested positive with rapid test for COVID-19. Resident put in isolation and PCR test completed and sent to lab. There was no assessment or interventions put into place after the resident had a change in condition when diagnosed with COVID-19 severe enough to require intravenous hydration. Review of Resident 191's progress notes revealed a nursing entry on January 1, 2021, at 12:09 p.m. that stated, This writer was notified by PT (Physical Therapy) resident had an area on her right heel. Upon observation resident was noted to have a 3.5 x 3.5 cm DTI (Deep Tissue Injury- area of deep red maroon or purple discoloration indicating intense or prolonged pressure on a bony prominence) to her right heel and a 1.5 x 1.5 cm DTI to her left heel. Review of Resident 191's Wound Evaluation and Management Summary from the consulting Wound Physician, dated April 26, 2021, revealed the left heel is a Stage 3 pressure ulcer measuring 0.3 cm by 0.6 cm and the depth was not measurable. The right heel is a Stage 4 pressure ulcer measuring 6.2 cm by 4.3 cm by nm and required surgical debridement (thoroughly cleaning the wound and removing all thickened or callused skin, infected, and nonviable dead tissue, foreign debris, and residual material from dressings). Observation of Resident 191's wound care April 30, 2021, at 10:30 a.m. revealed the resident continued with a Stage 3 wound on the right heel that was the size of the resdient's entire heel and had a red beefy granulation tissue with undermining. Review of Resident 191's clinical record revealed there was no assessment completed to determine the resident's pressure ulcer risk after the change of condition of diagnosed with COVID-19 that required IV hydration to prevent further or worsening pressure ulcers. Interview with the Nursing Home Administrator and the Assistant Director of Nursing on April 30, 2021, at 11:30 a.m. confirmed there was no assessment completed to determine pressure ulcer risk when Resident 191 was diagnosed with COVID-19 and required IV hydration. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services

Based on clinical record review, facility policy, and interviews with staff, it was found that the facility failed to monitor a resident's weight resulting in harm of an unplanned 27.4-pound weight loss (19%) in 58 days, for one of three residents reviewed, (Resident R1). Findings include: Review of the facility policy titled Weighing Residents, dated October 27, 2016, states, to obtain weight accurately with consistency upon admission, daily, weekly and monthly or otherwise ordered by physician. Monthly weights are obtained with the first shower of each month, within the first week of each month. Unless otherwise ordered by the physician or weight has already been obtained for that month * a weight loss or gain of 5 lbs or more requires a reweigh be done immediately. If a weight/reweigh is required the nursing assistant must get the charge nurse and reweigh resident with charge nurse present. If weight continues to be +/- 3 lbs or more, charge nurse will notify RN Supervisor/ Unit Manager immediately of weight changes. RN/Unit Manager will notify dietitian and physician. Review of Resident R1's clinical record revealed an admitted [DATE], with the following diagnoses, but not limited to, [MEDICAL CONDITION] (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to eat, sleep, dress, and bathe independently), major [MEDICAL CONDITION], hypertension (high blood pressure), diabetes (a disorder in which the body has high sugar levels for prolonged periods of time) and [MEDICAL CONDITION] (a disease of the joints). Further review of Resident R1's clinical record revealed a weight on August 3, 2020, of 144.8 lbs. The next weight recorded was September 30, 2020, at 117.4 lbs, a weight loss of 27.4 lbs in 58 days, equal to a 19% weight loss. There was no further documentation stating why the weight was not taken the first week of the month (per their facility policy) or that the dietitian was notified prior to this date. Their was no documentation that the physician was notified about the weight loss documented on September 30, 2020, until October 7, 2020 (7 days after the weight loss discovered on September 30, 2020). The clinical record revealed on October 7, 2020, a dietitian note indicating a weight loss warning --7.5% change (19.7%, 28.4 lbs) in two months (this is an additional 1.4 lb weight loss since September 30, 2020), resident is taking 50-100% of her supplements. Recommendations to increase calorie intake. There was no note regarding weight loss from the dietitian prior to this date. A request to interview the dietitian, Employee E3, was made to the Nursing Home Administrator (NHA), on December 22, 2020, at 10:30 a.m. The surveyor was informed by the NHA, that the dietitian did not want to speak with the surveyor, and instead gave a statement to the Nursing Home Administrator at 10:45 a.m., that she was unaware of the weight loss prior to September 30, 2020, and she could not find an explanation of why the weight was not taken the first week of September. The dietitian stated that she requested a reweigh be completed on October 2, 2020, and again on October 5, 2020, with copies of the request put in the NHA's mailbox. An interview with the Nursing Home Administrator and the Assistant Director of Nursing on December 22, 2020, at 11:12 a.m. revealed that when a weight is entered into the electronic record it will automatically trigger an alert of a significant weight loss. The facility failed to weigh the resident and record it in the record for the first week of September, therefore, a weight loss was not identified. The Nursing Home Administrator and the Assistant Director of Nursing could not explain why the weight loss was not identified during resident care and could not explain why the resident had a significant weight loss of 19% (27.4 lbs) in this amount of time. The facility failed to obtain weights on a schedule as dictated by their policy, failed to do a timely reweigh as dictated by their policy, which resulted in a 23 day delay in monitoring Resident R1's weight. The facility also failed to notify the physician of the weight loss, until 7 days after the weight was loss was discovered. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review, facility documentation, facility policy and staff interview, it was determined that the facility failed to provide sufficient fluid intake to maintain proper hydration resulting in harm to a resident as evidenced by a change in mental status, abnormal vital signs, admission to the hospital and subsequent death for one of 11 residents reviewed (Resident CL1) Findings include: A review of the Resident CL1's [DIAGNOSES REDACTED]. The Hydration and Nutrition Policy (a policy developed to ensure that all residents receive an adequate amount of fluids and nutrition daily) last reviewed on [DATE], stated that the physician should be notified of any changes in nutrition and hydration status as they occur. Review of the Resident CL1's fluid intake records titled, Meals and Fluids Detailed Entry Report (a computerized flow sheet used to document the percentage of a resident's meal consumption and fluid intake on a daily basis) and the resident's record titled, Food Chart (a handwritten report where the percentage of the resident meal consumption is documented by staff) from [DATE], to [DATE], revealed that the resident had the following fluid intake: [DATE] - 480 cubic centimeters, [DATE] - 240 cubic centimeters, [DATE] - 315 cubic centimeters. The resident's recorded intake for the entire three day period was 1,035 cubic centimeters. An interview with Employee E5, a Registered Dietitian, on [DATE], at 11:30 a.m. revealed that based on the resident's ideal body weight and height, the resident should have a fluid intake of 2,100 to 2,150 cubic centimeters daily. Review of the nursing notes revealed that on [DATE], at 3:54 p.m. the nurse documented that Resident CL1 was lethargic on occasion during that shift. On [DATE], at 4:25 p.m. the progress notes stated that the resident was difficult to arouse on occasion during the shift. The progress note of [DATE], at 3:53 p.m. revealed that the resident was lethargic today and did not eat. Food that was offered, came out of mouth. He spit most of the medications out as well. Oral care was given to remove any food left in mouth. When resident was positioned in bed after lunch, the NA (nursing assistant) alerted the LPN (Licensed Practical Nurse) that the resident's breathing was labored. The nurse's assessment of the resident revealed a pulse rate of 102, a respiratory rate of 32 and a pulse oximeter (an electronic device for determining the percentage of hemoglobin in arterial blood saturated with oxygen) of 67% and was verbally and physically unresponsive. The physician was notified on [DATE], at 5:36 p.m. and the resident was transferred to the emergency room . Review of emergency department admission documentation dated [DATE], revealed that the resident's admission preliminary [DIAGNOSES REDACTED]. Elevated level signifies impaired kidney function), hyperosmolarity (hyperglycemic state is a complication of Diabetes Mellitus in which high, blood sugars cause severe dehydration, increases in osmolarity (relative concentration of solute) and a high risk of complications, coma and death) and [MEDICAL CONDITION] (elevated sodium level in the blood over 145mM (millimolar). Normal concentration of sodium in the plasma is ,[DATE] mM). A change in mental status in the setting of severe dehydration and renal insufficency. The resident also had an elevated white cell count of 22,000 in the setting of severe dehydration. Further review revealed a BUN (blood urea nitrogen test is used to determine how well your kidneys are working. In general around 7 to 20 milligrams/deciliters is considered normal) of 124, Sodium of 168 and an elevated Troponin level of 0.3 could be in the setting of [MEDICAL CONDITION] and dehydration. Review of the hospital discharge summary dated [DATE], revealed that the resident died on [DATE], with death [DIAGNOSES REDACTED]. Review of Resident CL1's [DATE] nursing notes failed to reveal any documented evidence that the nursing staff reviewed the fluid intake documentation recorded on the Meals and Fluids Detailed Entry Report and/or the Food Chart to identify inadequate fluid intake and there was no evidence that the facility notified the physician of the resident's limited fluid intake from [DATE], to [DATE]. The findings were discussed with the Director of Nursing on [DATE], at approximately 11:00 a.m. The facility failed to ensure that Resident CL1 was provided with sufficient fluid intake to maintain proper hydration resulting in harm to Resident CL1 as evidenced by change in mental status, abnormal vital signs, and admission to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that the residents were free of significant medication errors for two of 10 residents (Resident O1 and Resident E10) as evidenced by no administration of an anticoagulant medication to Resident O1 for a total of 40 days, which resulted in Resident O1 experiencing breathing difficulties and requiring transfer to the hospital and admission with a [DIAGNOSES REDACTED]. This resulted in an Immediate Jeopardy situation for the residents health and safety. Findings include: Review of the facility policy titled, Admission/Readmission, undated, revealed that the nursing staff are to place medication orders into the computer system and perform medication reconciliation of hospital discharge records (a process to check that the orders from the hospital match the current orders at the facility). Further review of the facility policy stated that during the morning meeting the Unit Manager and the Director of Nursing would go over the new admission charts and the readmission charts for medication reconciliation. Review of Resident O1's clinical record revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Review of Resident O1's physician's orders at the time of admission revealed an order for [REDACTED]. Further review of Resident O1's admission physician's orders revealed that the Xarelto 20 milligrams was to be held (not to be given) starting on January 29, 2017, in preparation for a scheduled colonoscopy on February 1, 2017. Review of the resident's discharge orders from the hospital after the colonoscopy dated February 1, 2017, revealed that Resident O1 was to resume Xarelto 20 milligrams one time a day. Review of Resident O1's February 2017 physician's orders revealed that the anticoagulant medication Xarelto was not transcribed in the February 2017 physician's orders as instructed on the discharge orders from the hospital on February 1, 2017. Review of Resident O1's February and March 2017 Medication Administration Record [REDACTED]. Review of Resident O1's nursing notes dated March 12, 2017, at 1:39 p.m. indicated that the resident complained of, shortness of breath and the resident's pulse/oxygen meter registered the oxygen level in her blood stream as 82% on room air. Nursing documentation further revealed that with, three liters of oxygen administered the resident's pulse/oxygen level only rose to 85-89%. The resident's physician was notified and an order was obtained to transfer Resident O1 to the emergency room for treatment and evaluation. Further review of the nursing notes dated March 13, 2017, at 1:14 a.m. revealed that the resident was admitted to the hospital's intensive care unit on March 13, 2017, with a [DIAGNOSES REDACTED]. The embolism prevents blood and nourishment from getting to a specific area of the lungs. This may lead to the death of lung tissue in this area. Damage to the lungs may make it difficult for the lungs to work properly. In severe cases, a [MEDICAL CONDITION] embolism can lead to death). A review of the hospital documentation dated March 12, 2017, confirmed that the resident was admitted to the hospital with [REDACTED]. an anticoagulant. During an interview on May 2, 2017, at 2:00 p.m. the Nursing Home Administrator was unable to produce evidence of a facility investigation into why the anticoagulant medication was not administered to Resident O1 from February 1, 2017, to March 12, 2017. The Nursing Home Administrator indicated that the facility was unable to locate and produce a medication error report or any investigation into this significant medication error. The Nursing Home Administrator confirmed during interview that the Quality Assurance committee did not review this significant medication error during the April and May 2017 committee meetings. An interview conducted with the resident's physician on May 3, 2017, at approximately 9:15 a.m. revealed that the medication error was identified for Resident O1 when she returned from the hospital. The medication error report was never brought to the physician for completion. The facility failed to ensure that Resident O1 was administered the anticoagulant medication Xeralto for a period of 40 days which placed this resident in harm as evidenced by the resident experiencing respiratory discomfort, requiring transfer to the hospital and being diagnosed with [REDACTED]. Review of Resident E10's clinical record revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a nursing note dated March 19, 2017, that stated the family visited the resident and asked why the resident was not on [MEDICATION NAME] (an anticoagulant medication). The note further stated that the Certified Registered Nurse Practitioner (CRNP) was notified that [MEDICATION NAME] needed to be started due to a review of the resident's hospital discharge records. Review of Resident E10's hospital discharge records dated February 28, 2017, indicated to continue the medication [MEDICATION NAME] 2.5 milligrams to be given daily on Wednesdays and Fridays only. Review of Resident E10's March 2017 Medication Administration Record [REDACTED]. An interview conducted with the Nursing Home Administrator on May 3, 2017, at approximately 3:30 p.m. revealed that the facility was unable to locate the medication error report or an investigation into this significant medication error. Further interview with the Nursing Home Administrator confirmed that the Quality Assurance committee did not review this error during the April and May 2017 committee meetings. An interview conducted with the facility's Medical Director on May 3, 2017, at approximately 10:15 a.m. revealed that the medication errors were discussed with the Director of Nursing and an audit was conducted but the Director of Nursing was unable to produce the documented evidence of this audit. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on May 3, 2017, at 1:32 p.m. for failing to provide anticoagulant medications for a period of 40 days to Resident O1 which resulted in the resident requiring hospitalization and a [DIAGNOSES REDACTED]. safety in Immediate Jeopardy. A corrective action plan was requested on May 3, 2017, at 1:32 p.m. to immediately put systems in place to ensure that all current, newly admitted and readmitted residents' medications orders were reviewed and reconciled. The facility provided a corrective action plan on May 3, 2017, at 3:25 p.m. which indicated: * Resident O1 and Resident E10 were to be assessed by their physicians; * Resident O1 and Resident E10's medications were to be reviewed and investigations into their significant medication errors were to be completed; * all licensed nursing staff were to review all current resident hospital discharge summaries and to complete their medication reconciliation; * all nursing staff were to be in-serviced on the review of new residents' admission and residents' readmission medication orders and medication reconciliation and the review of the facility policy and procedure on admission medication orders. The Immediate Jeopardy was removed on May 6, 2017, at 11:33 a.m. following confirmation that the corrective action plan was implemented. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/18/16, 07/01/16, 02/16/16 28 Pa. Code 201.14(c) Responsibility of licensee Previously cited 11/18/16 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 02/16/16, 04/20/16, 07/01/16, 11/18/16 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/18/16, 02/16/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/13/17, 11/18/16, 04/20/16, 02/16/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 04/13/17, 11/18/16, 07/01/16, 04/20/16, 02/16/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 04/13/17, 11/18/16, 07/01/16, 02/16/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 04/13/17, 03/01/17, 11/18/16, 07/01/16, 04/20/16, 02/16/16

Based on a review of the Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, clinical record review and staff interviews, it was determined that the facility failed to meet professional standards of quality, by failing to properly assess and notify the physician of a change in the resident's condition for one of three residents reviewed, which resulted in actual harm to Resident CL1. Findings include: Review of the Pennsylvania Code, Title 49 Professional and Vocational Standards, Chapter 21.145(a) states that the LPN (Licensed Practical Nurse) is prepared to function as a member of the health-care team by exercising sound nursing judgement in nursing situations. Chapter 21.145(b) further states the LPN administers medication and carries out therapeutic treatment ordered for the patient. Chapter 21.11 (a) the registered 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 the following functions: (4) carries out nursing care actions which promote, maintain and restore the well-being of individuals and (6) evaluates the effectiveness of the quality of nursing care provided. (b) The registered nurse is fully responsible for all actions as a licensed nurse and accountable to clients for the quality of care delivered. Review of Resident CL1's hospital discharge summary dated [DATE], revealed that the resident had been newly diagnosed with [REDACTED]. interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine). Further review of the hospital's discharge summary revealed that the medication [MEDICATION NAME] (a medication used in the treatment of [REDACTED]. Further review of the hospital discharge summary indicated that after consultation with hematology/oncology the patient was recommended for a gamma knife treatment (advanced [MEDICAL CONDITION] treatment used with small to medium [DIAGNOSES REDACTED]s) to be done outpatient. The discharge summary also indicated that the resident was waiting for nursing facility placement as he was significantly weak. Review of the hematology/oncology consult report dated [DATE], revealed that the resident did have [MEDICAL CONDITION] (irregular and rapid heartbeat) with a rapid ventricular response (the lower chamber of the heart, beats too fast) while in the hospital. Review of Resident CL1's closed record revealed that the resident was admitted to the facility on [DATE], at 4:40 p.m. The resident did not complain of pain or other discomfort. The resident was alert and oriented. Review of the physician's admission orders [REDACTED]. Review of Resident CL1's closed record revealed that a nursing note completed by Licensed Nurse, Employee E6, dated [DATE], at 10:43 p.m. noted that at, 16:40 (4:40 p.m.) Resident arrived to facility and this nurse received an admission packet. Resident was resting comfortably in bed. At 18:00 (6:00 p.m.) this nurse went in to do full body assessment and was asked to return after resident was done with his supper. Resident asked this nurse to heat up his grilled cheese sandwich, which this nurse did. This nurse informed resident that his grilled cheese sandwich was hot so to be very careful. At 18:30 (6:30 p.m.) resident c/o (complained of) indigestion, this nurse went to check med list to see if resident had an order for [REDACTED]. Checked pulse and it was 88. Resident was talking and in no distress when this nurse left the room. Further review of Resident CL1's closed clinical record revealed a nurses' note completed by Licensed Nurse, Employee E7, dated [DATE], indicating that, After dinner, resident c/o (complained of) chest pain. [MEDICATION NAME] 15cc (cubic centimeters) po (by mouth) given with some relief obtained, but resident continued to c/o (complain of) chest pain and burning in chest like I have indigestion. Supervisor called to room to evaluate resident. Interview conducted on [DATE], at 2:50 p.m. with Licensed Nurse, Employee E7, who administered the antacid medication to the resident on [DATE], confirmed that she had given the resident 15 cc of [MEDICATION NAME] without a physician's orders [REDACTED].>Review of Resident CL1's admission orders [REDACTED]. Review of the entire clinical record revealed that there was no documented evidence that the resident's attending physician was notified of the resident's complaints of chest pain. Further there was no evidence that the resident was administered the medication [MEDICATION NAME] 0.4 milligrams sublingual (under tongue) as ordered by the physician to be administered whenever necessary for chest pain. Interview with Employee E6 on [DATE], at 2:30 p.m. confirmed that she was assigned to Resident CL1. She had been employed for three months and this was her first admission and Employee E7 was trying to assist her as best she could. She confirmed that the resident was complaining of indigestion and had never told her that he had chest pain. She did confirm she had given the resident 15 milliliters of [MEDICATION NAME]. Review of a nursing note dated [DATE], at 9:47 p.m. documented by the Nursing Supervisor, Employee E4, revealed that, at approximately 18:35 (6:35 p.m.) I was called to resident's room to assess his complaint of acid reflux at the insistence of his wife his v/v (vital signs) were stable but (the resident) had a complaint of the abdominal discomfort and acid indigestion. Resident was propped up in the bed and appeared highly anxious and the licensed nurse was present and took the vitals (signs) that were WNL (within normal limits) pulse was elevated I asked if there was an antacid in his orders we both left and I made rounds. The resident went to the other unit and returned with his wife at his side. Further review of the nursing note revealed that Employee 4, observed, resident slumped on his right side with the head of his bed in the high fowlers (the head of the bed is in an upright position at a 90 degree angle) his eyes were glazed over and he was not responsive and he had no palpable pulses and gasping breaths applied O2 (oxygen) NRB (non-rebreather mask, a device is used to deliver high flow rates and high concentrations of oxygen) @ (at) 15 lpm (liters per minute). Resident was DNR/DNI (Do Not Resuscitate/Do Not Intubate) as per the order from the hospital. The resident had no breaths and no pulse apical (pulse felt at the heart) or radial (pulse felt at the wrist) at 19:10 (7:10 p.m.) informed family and received orders to pronounce. An interview with Nursing Supervisor, Employee E4, on [DATE], at approximately 1:45 p.m. confirmed that he did not call the attending physician to notify the physician that the resident had complained of indigestion, chest pain and symptoms of anxiety. Employee E4 stated that the physician was not notified because he felt the resident had indigestion after eating a large meal. A second interview conducted with Nursing Supervisor Employee E4 on [DATE], at approximately 3:30 p.m. revealed that when asked why emergency 911 services were not initiated for Resident CL1, Employee E4 responded that he did not ask the resident if he wanted to go to the hospital. Additionally neither did the resident or his wife request for the resident to return to the hospital. Employee E4 stated he was the only one who met with the wife and told her that her husband had died . Resident CL1 had been admitted to the facility on [DATE], at 4:40 p.m. and on [DATE], at 7:10 p.m. Nursing Supervisor Employee E4 observed Resident CL1 with no breaths and no pulse. The facility failed to provide services according to accepted standards of clinical practice for a newly admitted resident with [DIAGNOSES REDACTED]. Refer to F157 and F309. 42 CFR 483.20(k)(3)(i) Services Provided Meet Professional Standards Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records and interviews with residents and facility staff, it was determined that the facility failed to identify, assess, provide treatment and implement preventative measures for new pressure ulcers, resulting in actual harm to one of three residents reviewed. (Resident C16) Findings include: Review of Resident C16 ' s clinical record revealed that the resident had the following (but not limited to) Diagnosis: [REDACTED]. Review of the Resident C16 ' s Activity of Daily Living (ADL) sheets dated December 1, 2015 to December 8, 2015 revealed that the resident was total dependence or extensive assist with dressing (meaning a staff member was needed to get the resident dressed/undressed due to his physical condition). Review of the Resident C16 ' s Skin Assessment completed on December 1 and December 4, 2015 there were no skin issues identified. A nursing note dated December 8, 2015 stated the following DTI (deep tissue injury) noted on left forth toe 1.2 cm (centimeter) x 1.5 cm area. Light tan in center and dark brown around outer aspect. The left posterior foot (back of foot on the inside) 3.1 cm x 2.4 cm, black in color; Right posterior foot (back of foot on the inside) 6.0 cm x 6.5 cm, black in color. Interview with Resident C16 on December 17, 2015 at approximately 11:00 a.m. revealed that the resident was fitted for new shoes, through the therapy department, and the consultant ordered him a size 9 ½ shoe. The resident states that he wore a 10 ½ shoe size and the shoes were too tight when they arrived. Further investigation revealed that the resident voiced that the shoes were too small but the staff continued to place them on his feet. An interview was conducted with the Director of Nursing on December 17, 2015 at approximately 1:30 p.m. that revealed that the nurse believed that the new areas identified were caused by the new shoes not fitting properly. An additional interview was conducted with Employee E4 which revealed that due the Resident C16 being diabetic a consultant, that specialized in foot ware for diabetics, measured the residents foot but could not verify if the resident was asked his shoe size. There was no documented evidence stating that the nursing assistants notified nursing licensed staff of any redness or discoloration while performing ADL ' s before December 8, 2015. Further review of the clinical record revealed the resident was seen on December 14, 2015 by the wound specialist and stated a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure wound of the left, distal plantar (back of foot on the inside) measuring 2.3 cm x 2.5 cm x not measurable centimeters, 50% thick adherent (sticking to) black necrotic (death of) tissue (eschar) and 50% thick adherent devitalized (no strength) necrotic tissue. Stage II (partial thickness skin loss involving the outer layers of the skin) pressure wound of the left, fifth toe measuring .8 cm [MEDICAL CONDITION] cm x not measurable cm. Unstageable (due to necrosis (dead tissue)) of the right, plantar foot measuring 4.5 cm x 6 cm x not measurable cm with thick adherent black necrotic tissue (eschar) 100%. Arterial wound result (from an inadequate blood supply) of the left, posterior (back) ankle measuring 2.4 cm x 1.8 cm x not measurable cm. with thick adherent devitalized necrotic tissue 100%. An interview was conducted with the Nursing Home Administrator and Director of Nursing on December 17, 2015 at approximately 2:30 p.m. revealed that due to the extensive dressing need of the resident it would be expected that the nursing assistants would report redness or any suspicious discoloration of the residents ' feet. It was revealed that these pressure ulcers could have been detected earlier by monitoring the proper shoe fitting and sizing and staff reporting them immediately to the nursing supervisor. The facility failed to accurately assess and monitor the resident ' s skin to prevent pressure ulcer, and/or timely identify development of a pressure ulcer for Resident C16 who was at risk for skin breakdown which resulted in an actual harm to the resident. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 11/06/2015 28 Pa. Code: 211.5 (f) Clinical records. Previously cited 3/18/15, 6/1/15, 10/22/2015 28 PA Code: 211.10(d) Resident care policies Previously cited 1/23/14, 04/25/2014 28 Pa. Code: 211.12 (c) and (d)(1)(5) Nursing services. Previously cited 3/18/2015, 6/01/15, 10/22/2015, 11/06/2015, 11/24/2015

Based on closed clinical record review, facility documentation review, acute hospital documentation review, facility policy and procedures and staff interviews, it was determined that the facility delayed notification to the physician of a significant change in a residents' condition requiring physician intervention and a subsequent transfer to an acute hospital, resulting in actual harm to the resident (Resident R1) for one of five residents reviewed. Findings include: Review of facility policy and procedure entitled, Notification of Physician, revised date February 6, 2015, documented that the facility was to notify the physician of a resident's change in condition in a timely manner. Procedure Step 1 documented that for any change in condition resident would have a licensed registered nurse assessment completed and physician would be notified. Review of facility policy and procedure entitled, Change in Condition, reviewed date [DATE], documented that a licensed registered nurse would assess a resident any time there was a change in condition. Procedure Steps 2 & 3 documented that the registered nurse supervisor would complete a resident assessment and the physician and/or Certified Registered Nurse Practitioner would be notified of the assessment and change in condition. Finally Procedure Step 6 included for family notification of the change in condition as soon as possible. Review of facility policy and procedure entitled, Notification to Resident/Families/Responsible Party, revised date [DATE], documented for Procedure Steps 1 & 2 that notification would be made when there was a significant change in a resident's physical, mental or psychosocial status and if the responsible party could not be reached a secondary name was given, the secondary party was to be notified by the nursing staff. Review of facility policy and procedure entitled, Advance Directives, under category, Discussion with Resident/Responsible Party Concerning Code Status, reviewed date [DATE], Procedure Steps 6 & 7 documented for those residents who have a Do Not Resuscitate (DNR) order experience a significant change in condition, a physician determination must be obtained for transfer to the acute hospital and the hospital transfer sheet must reflect DNR order and state Advance Directives are present, and attach a copy of the Advance Directive. Review of closed clinical record for Resident R1 revealed [DIAGNOSES REDACTED]. Readmission orders [REDACTED]. Review of [DATE] physician orders [REDACTED]. Review of nursing notes, dated [DATE] at 6:15 a.m. documented by nurse supervisor, Employee E4, was called to resident's room, found resident sitting in chair not responding to voice or touch. Pupils pinpoint and non-reactive, unable to hear heartbeat or obtain pulse, respirations ,[DATE] per minute, oxygen saturation 57% on 4 liters of oxygen. Resident transferred to bed using hoyer lift, oxygen raised to 5 liters per minute, [MEDICATION NAME] treatment given. Still unable to obtain blood pressure or pulse, respirations remain ,[DATE] per minute, oxygen saturation ,[DATE]%. Pupils remain pinpoint and non-reactive. Left message for responsible family member. Review of nursing note, dated [DATE] at 7:00 a.m., documented by licensed nurse, Employee E3, was called by nurse aide to resident's room due to resident being non-responsive. Employee E3 further documented could not get pulse or blood pressure on resident and pulse oxygen saturation rate was not reading at time. Duo-nebulizer treatment given and pulse oxygen saturation rate measured 57%, oxygen up to 5 liters per minute, very long periods of apnea, resident's face, hands and lower extremities very pale white unable to get vitals to stabilize, registered nurse notified. Review of nursing note, dated [DATE] at 8:15 a.m., documented by nurse supervisor, Employee E4, revealed that Employee E4 assessed resident secondary to verbal shift to shift report from registered nurse and nurse aide that resident was non-responsive. Employee E4 further documented that resident was in bed respirations even, 18 beats per minute, oxygen saturation at 95% oxygen at 5 liters per minute titrated to 4 liters per minute secondary to history of [MEDICAL CONDITION]. Resident non-responsive , flaccid extremities, scattered rhonchi throughout bilateral lung fields. Pupils 2 mm, non-reactive to light eyes with upward gaze, moving left to right nut not tracking/fixing. Does not respond to tactile/verbal stimuli. Spoke with resident's responsible family member and updated responsible family member on resident's condition and status. Responsible family member wants resident sent to hospital. Called attending physician and obtained verbal telephone order to send resident to emergency room for evaluation and treatment. Paperwork prepared. Review of emergency department records, dated [DATE] at 9:25 a.m., documented that Resident R1 presented via ambulance after being found unresponsive by nursing home staff at 6:00 a.m. and remained unresponsive after onset of symptoms; and was transported to the hospital for evaluation at 9:00 a.m., totalling approximately 3 hours after onset of symptoms. Emergency department documented that they were unable to obtain history regarding resident other than history provided by emergency medical services. Emergency department documented on [DATE] at 9:25 a.m. that as per emergency medical services they believed the resident was a Do Not Resuscitate (DNR)/no code but there was no clear documentation or paperwork with the resident's records from the nursing home. Resident was treated with non-invasive ventilator support and was admitted to intermediate intensive care unit with chief complaint and [DIAGNOSES REDACTED]. Facility nurse note, dated [DATE] at 2:36 p.m., documented that hospital called facility and reported that resident had expired. Review of resident's Transition of Care Form, dated [DATE] at 8:17 a.m., accompanied by Director of Nursing, on [DATE] at 10:00 a.m., confirmed that a facility unit clerk had completed the form and had documented that the resident's code status was full code; and that there were no notifications to the attending physician or the family. In addition, Director of Nursing reported that this form would have traveled with the resident and ambulance personnel to the hospital and included a copy of the Medication Administration Record, [REDACTED]. Interview with Administrator, on [DATE] at 10:15 a.m., confirmed that licensed staff failed to provide documentation of the of the arrival time of the ambulance but review of facility video surveillance of [DATE] showed the emergency medical service arriving at facility at 8:25 a.m., and exiting at 8:35 a.m. Interview with the Administrator and Director of Nursing, on [DATE] at approximately 3:00 p.m., confirmed that licensed staff should have notified the physician immediately of the medical change in resident's condition, on [DATE]. In addition, licensed staff should have notified the resident's secondary emergency contact person of a change in resident's condition, when efforts to notify the resident's spouse/primary emergency contact were not successful. Facility failed to consult with the attending physician to address the resident's continued medical deteriorated condition resulting in actual harm to Resident R1. Facility also failed to provide consistent and accurate information regarding resident's code status to emergency medical services resulting in a transfer of information to the acute hospital emergency department that was conflicted and delayed until the arrival of family. 28 Pa. Code: 201.14(a) responsibility of licensee 28 Pa. Code: 201.18(a)(e)(1)(3) Management 28 Pa. Code: 01.18(b)(1)(3) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited [DATE], [DATE] and [DATE] 28 Pa. Code: 211.5(g) Clinical records 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE] and [DATE] 28 Pa. Code: 211.12(d)(3) Nursing services

Based on observations, clinical record review, staff interview, and facility policy review it was determined the facility failed to timely identify and ensure care and services in place for one one of two resident reviewed with pressure ulcers (Resident A19). Findings Include: Review of the facility policy and procedure titled "Skin Review" revised on June 3, 2013 revealed it's policy to identify skin issues in a timely manner with accurate documentation and implementation of facility skin policy and procedure. Review of Resident A19's Quarterly Minimum Data Set (MDS- periodic assessment of resident status and care needs) dated June 4, 2014 revealed that the resident was severely impaired for decision making, dependent on staff for bed mobility, transfer, for locomotion on the unit and was at risk for developing pressure ulcers. Review of Resident A19's physician orders dated May 7, 2014 included [DIAGNOSES REDACTED]. Review of Resident A19's care plan dated July 2, 2014 for skin care, included approaches of comfort care, for staff to conduct systematic skin inspection per facility protocol and to pay attention to each extremity. Observation of Resident A19 during wound and incontinence care by licensed Employees E4 and E5 on July 21, 2014 at 12:10 p.m. revealed a blackened area on the resident's left heel. Licensed nurse Employee E4 provided care to the resident whileicensed nurse Employee E5 assisted during the procedures. During the wound and incontinence care staff repositioned the resident on her right side and a blackened area was observed on the resident's left heel. During the observation Employee E4 did not apply any treatment to a blackened area on the resident's left heel. During an interview immediately following the observation on July 21, 2014 at 1 p.m. licensed nurse Employee E 4 was asked what the blackened area on the resident's left heel was. The interview revealed that the blackened area was a new pressure area that had not been previously identified by the facility staff. Review of facility pressure ulcer documentation dated July 21, 2014 revealed that the resident had developed a facility acquired unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (separation of dead tissue from living tissue) or eschar (dry scab, dead tissue in thewound bed). The wound measured 2 centimeters x 1.8 centimeters x undetermined depth) with bluish purple color around half of wound. Review of the physician's fax report dated July 21, 2014 revealed that the resident had a pressure ulcer measuring 2 centimeters x 1.8 centimeters, hard brownish /black eschar (dead tissue) with bluish pink around 1/2 of the wound. The fax report revealed a verbal telephone order to cleanse the resident's left heel with normal saline, to apply skin prep and be completed every shift until healed. Interview with Employee E4 at 1 p.m. revealed that the resident was seen during wound round that morning and this new area was not identified, until it was brought to the attention of the facility by the surveyor. Interview with the Director of Nursing on July 22, 2014 at 2: 30 p.m. confirmed that the left heel pressure ulcer was a newly identified pressure ulcer area, identified on July 21, 2013 after observation of wound/incontinence care. The facility failed to timely identify and ensure necessary care and services were in place to prevent new pressure ulcers from developing on Resident A19's left heel who was at risk for developing pressure ulcers . 28 Pa. Code 201.14 (a) Responsibility of licensee 4/25/14, 1/23/14, 9/26/13 28 PA Code 201.18(b)(1) Management Previously cited 4/25/14, 1/23/2014; 9/26/2013 28 PA Code 201.18(e)(1) Management Previously cited 4/25/14 28 PA Code 211.5(f) Clinical records Previously cited 4/25/14,3/25/2014; 1/23/2014; 9/26/2013 28 PA Code: 211.10(d) Resident care policies Previously cited 4/25/14, 1/23/14, 9/26/13

Based on observations, clinical record review, staff interview, and facility policy review it was determined the facility failed to provide interventions to prevent the development of pressure wounds and failed to implement proper infection control measures in the treatment of [REDACTED]. Findings Include: Review of the facility policy and procedure titled "Skin Review" revised on June 3, 2013 revealed a Skin Review Form will be reviewed by the RN Supervisor/Unit Manager for completion, accuracy and need for changes of plan of care. Review of Resident E13 [DIAGNOSES REDACTED]. Review of Resident E13 progress notes revealed an entry dated March 25, 2014 at 4:18 a.m. that the resident was found on the floor in front of the recliner. The resident was unable to state the level of pain but stated " it hurts right here " . The hips were out of alignment with the left side higher than the right side. An X-ray order was received. Progress notes dated March 25, 2013 at 6:52 a.m. revealed that the x-ray of the left hip showed a [MEDICAL CONDITION] (thigh bone). Review of the significant change Minimum Data Set (MDS- periodic assessment of resident needs) dated March 27, 2014 revealed the resident was a total assist of two with transfers and Activities of Daily Living. Further review of Resident E13s pressure ulcer report dated April 14, 2014 revealed a facility acquired right heel deep tissue injury (a prolonged pressure or positioning within a short period of time that compromises tissue and creates a wound deep in the dermis that initially presents superficially) measuring 3.5 centimeters by 3.0 centimeters . Review of the physician orders dated April 14, 2014 ordered Heel EZ boot (Eliminates pressure on the heel for treatment and prevention of deep tissue injuries or pressure ulcers); to keep heels off loaded (not directly lying on the bed) and skin prep ( a protective skin over wounds) to heel blister twice a day until healed. Review of Resident E13's care plan for pressure ulcer risk reviewed March 31, 2014 post a left [MEDICAL CONDITION] listed no new interventions for pressure relief. Review of the care plan updated April 14, 2014 after the onset of the right heel deep tissue injury listed interventions of heel EZ boot and skin prep as ordered by the physician. There were no interventions added after the left [MEDICAL CONDITION] until the development of a deep tissue injury to the right heel resulting in actural harm to Resident E13. Interview with licensed nurse Employee E2 on April 24, 2014 at 11:30 a.m. confirmed there were no interventions in place prior to the development of the deep tissue injury on the right heel on April 14, 2014. Review of Resident E18 demographic sheet revealed the resident was admitted to the facility on [DATE]. Review of the resident admission assessment revealed there were no wounds to the resident's heels at the time of admission. Review of Resident E18's admission Minimum Data Set (MDS- assessment of resident care needs and status) dated January 17, 2014 revealed the resident had a Brief Interview for Mental Status score of three which indicates severe cognitive impairment. Further review of the MDS revealed the resident is a total assist of two with transfers and most of the ADLs. Review of Resident E18 admission nursing review sheet indicated the resident was admitted [DATE] and had no pressure ulcer on the right lateral (outside) heel. Progress notes dated February 9, 2014 at 2:51 p.m. stated observed stage 3 pressure ulcer on right lateral (outside) heel (ulcer involving full thickness skin loss involving damage to or necrosis of subcutaneous tissue (dead tissue) measuring 2.2 centimeters by 1.9 centimeters. Review of Resident E18's pressure ulcer documentation dated February 11, 2014 revealed a facility acquired, stage 3 pressure ulcer measuring 1.2 centimeters long by 1.9 centimeters wide and 0.1 centimeters deep with 75% granulation (connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) 25% slough ( yellow or white tissue that adheres to the ulcer bed in strings or thick clumps that is cast off from the surface of the skin). Review of Resident E18's plan of care revealed the resident was at risk had a pressure ulcer on the lateral heel and is at risk for further skin breakdown with a start date of January 10, 2014. Intervention listed as intitiated April 21, 2014 (not January 10, 2014) included low air loss mattress, body pillow and heel boots. Resident E18'a interventions for pressure sore prevention of the right heel were not timely implemented at the onset of the stage 3 right lateral heel pressure ulcer observed February 9, 2014 and implemented April 21, 2014 resulting in actual harm to Resident E18. Interview with licensed nurse Employee E6 revealed that the facility was unable to provide evidence that there were interventions in place to prevent pressure ulcers to the heels before the development of the stage three pressure ulcer on February 9, 2014. Review of facility policy for Dressing Change-Clean Technique, revised February 17, 2014, indicated that a clean dressing technique is used to provide an appropriate and safe environment conducive to wound healing. Further review revealed that staff should gather needed supplies and place on a clean surface with a trash bag available for waste. Additionally, the policy indicated that staff should wash hands, don gloves then remove dressing and place in trash bag. Staff should then remove gloves and discard in trash bag, then wash hands and don a new pair of gloves. Review of Resident A20's admission nursing assessment, dated February 26, 2014, revealed a right lateral plantar (side of foot) deep tissue injury (A prolonged pressure or positioning within a short period of time that compromises tissue and creates a deep wound in the skin that initially presents superficially as a purple localized area of discolored intact skin due to damage of underlying soft tissue from pressure) measuring 1.5 centimeters by 1.3 centimeters. Review of Resident A20's physician orders dated February 27, 2014, for skin prep (protective barrier) to the resident's right lateral plantar deep tissue injury two times a day and heal boots at hours of sleep. The oder for heel boots was changed to when in bed on March 3, 2014. Review of wound report, dated April 21, 2014, revealed that the deep tissue injury measured 1.8 centimeters by 1.0 centimeter. Observation of licensed nurse Employee E7, on April 24, 2014 at 1:30 p.m. during treatment of [REDACTED]. Employee E7 then took out the individual bags of supplies and placed those on the bedside table. The employee removed Resident A20's sock and then with the same gloves placed normal saline solution on the wound and rubbed up with the gauze over the wound. Employee E7 applied the skin prep and then blew on the skin prep to dry it. The employee then touched the wound with her gloved thumb and then touched it with her pinkie finger to determine if the skin prep was dry. The employee then replaced the resident's sock, removed her gloves which she placed in the trash bag and put all the individual bags of supplies back into the big bag. Employee E7 did not wash her hands at that point. The employee then took that bag along with the trash bag out of the room, placed the treatment bag on the nurses station counter, then went to the soiled utility room where she placed the trash bag and then washed her hands. Review of Resident G14's quarterly Minimum Data Set (MDS - periodic assessment of resident needs and status) dated March 7, 2014, revealed a Stage 3 pressure ulcer on left hip measuring 1.2 centimeters by 1.1 centimeters by 0.1 centimeters. Review of Resident G14's physician's orders signed April 10, 2014 revealed an order, originally dated February 24, 2014 for Iodosorb Gel to be applied topically to left hip wound bed after cleansing with normal saline solution and use of a 4 x 4 gauze pad, then cover with bordered foam dressing daily and as needed. During wound observation of licensed staff, Employee E9, on April 23, 2014 at 10:15 a.m. revealed during treatment to Resident G14's left hip, Employee E9 placed the bag containing all the individually bagged treatment supplies and two towels on the resident's bedside table which had not been cleaned prior to the placement of supplies and towels. Doning a pair of gloves Employee E9 loosened the tape on the left side of resident's brief, removed the soiled dressing and placed it into a trash bag laying on the bed. Employee E9 then removed gloves placing them into the trash bag. Employee E9 then put on another pair of gloves without washing hands and then preceeded to place normal saline solution on the wound and rubbed back and forth with the gauze over the wound. The employee then closed Resident G14's brief, placed dirty linen into the plastic bag, removed her gloves placing them into the trash bag and put unused supplies and iodosorb gel into bag containing treatment supplies. Resident G14 requested a tissue; Employee E9 obtained a paper towel from the bathroom and handed it to the resident. Employee E9 did not wash her hands at this point. The employee then took the bag of treatment supplies along with the bag of trash and dirty linen out of the room and went to the soiled utility room where she placed the bag of treatment supplies on the counter, placed bag of trash in trash receptacle and linen in linen hamper and then washed her hands. The employee picked up bag of treatment supplies and placed on counter at nurses' station. Observations of Residents A20 and G14 revealed that the residents were not afforded infection control techniques while staff were providing wound care to the residents 28 Pa. Code 201.14 (a) Responsibility of licensee 1/23/14, 9/26/13 28 PA Code 201.18(b)(1) Management Previously cited 1/23/2014; 9/26/2013 28 PA Code 201.18(e)(1) Management 28 PA Code 211.5(f) Clinical records Previously cited 3/25/2014; 1/23/2014; 9/26/2013 28 PA Code: 211.10(d) Resident care policies Previously cited 1/23/14, 9/26/13 28 Pa. Code: 211.11(a) Resident care plan 28 PA Code: 211.12(c) Nursing services Previously cited 1/23/14, 3.14.14 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 3/25/2014; 9/26/2013

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to manage and consult with the physician regarding a resident's pain levels, assist a resident in obtaining a follow-up procedure resulting in actual harm to one of 24 residents ( Resident H5) and failed to develop alternative interventions for monitoring a wound and follow up physician orders [REDACTED].. (Resident H5, L4 and CL1) Findings include: Review of the history and physical for resident H5 dated April 24, 2012, revealed [DIAGNOSES REDACTED]. cells for nourishment), [MEDICAL CONDITION] (stroke) and [MEDICAL CONDITION] (softening of the bone). On March 2, 2012 at approximately 1:30 p.m. nursing notes stated a nursing employee who cared for Resident H5 reported to the licensed nurse that the resident was having extreme pain. The resident progress notes dated March 2, 2012 at 3:42 p.m. revealed that the resident was having extreme right ankle pain and was yelling out "Please make this pain go away". The certified registered nurse practitioner (CRNP) was notified and an x-ray was ordered. The resident progress notes of that date at 4:41 p.m. revealed a [MEDICAL CONDITION] and fibula (both lower leg bones) with slight ankle eversion (turning outward). The resident was transferred to the hospital and returned at midnight with a soft cast in place. Review of the hospital discharge instruction sheet revealed directions to obtain an orthopedic consult. Medication orders dated March 2, 2012 included [MEDICATION NAME] (form of [MEDICATION NAME]) for pain. The CRNP's note of March 5, 2012 indicated that the resident would not be going out for an orthopedic consult secondary to being a poor surgical risk. The CRNP had a phone discussion wth the POA who agreeded to this plan and expressed that he wanted the resident kept comfortable. Review of advance care planning dated January 17, 2012 revealed that extraordinary measures were not in place and that surgery would be for extreme symptom management only. Resident H5's progress notes of March 7, 2012 at 3:15 p.m.and 5:50 p.m. indicated that the resident continued to have pain and consistent low meal intake. Weights were discontinued on March 14, 2012. Resident progress notes of March 21, 2012 at 6:00 a.m.revealed that the resident was found on the floor in front of the bed. The resident had pulled the cast off and multiple necrotic areas were identified on the right foot and heel. Measurements dated March 22, 2012 revealed: right outer foot 2 centimeters wide by 2 centimeters long; no stage indicated, right little toe 0.5centimeters wide by 0.5 centimeters long; no stage indicated, right great toe 1.0 centimeter wide by 0.3 centimeters long; no stage indicated, right inner foot 2.0 centimeters wide by 1.0 centimeter long; no stage indicated, right heel 3.0 centimeters wide by 3.0 centimeters long; no stage indicated, right great toe 1.2 centimeters wide by 4.0 centimeters long; no stage indicated, and right outer foot above heel 1.0 centimeter wide by 1.0 centimeter long; no stage indicated. Resident progress note of March 21, 2012 at 3.45 p.m.indicates that there is a large amount of purulent drainage showing through the skin of the right heel. The CRNP note of March 21, 2012 stated that Resident H5 had necrotic and unstageable pressure areas. The right foot was noted to be curved medially and no splint was reapplied secondary to skin and self removal issues. Regarding pain, the CRNP wrote that Roxonal and [MEDICATION NAME] were being used and that pain seemed to be adequately controlled at times but with movement of the right lower extremitiy the pain increased drastically. The note further stated wound care and physical therapy would be consulted. Interview with the Physical therapist Employee E7 on May 8, 2012 at 10:00 a.m. revealed that the consult was for possible appropriate cast application for immobility but was unable to make any suggestions. She stated that it was out of her scope of practice, as a therapist takes direction from the physician. A wound consult was obtained from the wound physician on March 23, 2012 for Resident H5. Nurses notes dated March 23, 2012 at 4:20 p.m. stated that the physician recommended a vascular consult. When asked for the consult written by this physician, the DON stated that one was not written but that this doctor talked directly to the CRNP. The CRNP called the POA and confirmed that the goal was to keep the resident comfortable. The splint was discontinued on March 26, 2012 and a heel boot used for the right foot. A screen completed by the speech therapist on March 29, 2012 at 12:30 p.m. revealed that oral intakes flucuated but were frequently refused or the resident only took a small amount. On April 4, 2012 the resident progress notes indicated that a mass identified as part of the leg bone was noted at the opening of the right outer wound and movement of the bone was seen when the leg was moved. The resident had increased pain with any movement. The resident progress notes on April 6, 2012 at 1:30 p.m. revealed that moderate amount of purulent drainage was noted during a dressing change to foot wounds . April 8, 2012 note revealed that the resident had increased pain on movement and a moderate amount of purulent drainage with odor was noted. The resident frequently refused the heel boot which was providing the only stabilization of the leg. Resident progress note for April 11, 2012 at 3:27 p.m. revealed that mutiple times throughout the day, despite pain medication administration, the resident expressed that she wanted a doctor to fix her foot and that she wanted to die. There was a large amount of purulent drainage with a foul odor from the right outer ankle. An order was received from the CRNP to consult hospice for pain and wound management. On April 17, 2012 6:00 p.m.the hospice wound nurse evaluated the wounds and pain levels. At 8:00 p.m. the facility received a verbal telephone order from the physician to transfer the resident to the hospital as a direct admit. The resident's right leg was amputated above the knee. The resident's condition stablized and she returned to the facility April 20, 2012. The facility failed to modify the pain treatment plan in consultation with the physician when despite medication administration, orally and topically, the resident continued to experience severe pain resulting in actual harm and hospitalization to resident H5. Review of Resident L4's April 2012 physician orders [REDACTED]. Review of alteration in skin report dated April 19, 2012 revealed that an open area was noted on resident's buttocks. The report indicated that the resident refused to have wound measurements taken. A second alteration in skin report dated April 26, 2012 revealed that the area was still present on the resident's buttocks but that the resident again refused to have wound measurements taken. Review of the resident's current care plan revealed that there were no interventions in place for non-compliance with wound measurements. Interview with the Director of Nursing on May 8, 2012 at 2:30 p.m. revealed that the resident was not care planned for non-compliance with wound measurements but was care planned for non-compliance in other areas. The only intervention in place was to reapproach the resident when he was non-compliant. There was no evidence of attempts to reapproach the resident for measurement and description of the wound on his buttocks. The interview with the Director of Nursing confirmed that there were no other interventions in place. Review of Resident CL1's physician's progress note dated February 3, 2012 revealed that staff asked the attending physician to see Resident CL1 and noted a hard moveable mass on the lower outer quadrant of right breast. Physician ordered a mammogram to be performed on the right breast to rule [MEDICAL CONDITION]. The mammogram was performed on February 21, 2012. On February 21, 2012 a Physician Report/Orders Form was faxed to physician requesting an order for [REDACTED]. physician's orders [REDACTED]. Review of Resident CL1 ' s nurses' note on February 22, 2012 revealed that a call was placed to the resident's son regarding the Breast Imaging Center ' s request that an ultrasound should be performed, awaiting son's consent. Review of Resident CL1 's nurses' note on March 8, 2012 at 6:00 p.m. revealed resident being discharged from facility to home and a copy of the letter from Breast Imaging related to mammogram was sent with son and he was instructed by facility to notify the resident's physician. During an interview with Director of Nursing on May 10, 2012 at about 11:30 a.m. it was confirmed that there was no appointment scheduled for Resident CL1's ultrasound of right breast as per the physician's orders [REDACTED]. F309 483.25 QUALITY OF CARE Previously cited 4/11/2011; 6/29/2010 28 Pa. Code 211.5(f) Clinical records Previously cited 4/11/2011 Pa. Code 211.10(c) Resident care policies Previously cited 4/11/2011; 6/29/2010 Pa. Code 211,12(d)(1)(3)(5) Nursing services Previously cited 4/11/2011; 6/29/2010