Every finding on record at Swaim Health Center

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for insulin administration for one of two residents reviewed (Resident 1).Findings include: Review of facility policy, titled IIB14: Injectable Medication Administration, with a last review date of March 31, 2026, revealed in part, Purpose: To administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. Sites for Administration: Subcutaneous: Abdomen (minimally 2 below and left or right of umbilicus for heparins) Upper arm - Fatty tissue over triceps Top of thigh - Fatty tissue over anterolateral thigh. Policy failed to include that insulin administration injection sites should be rotated and that injection site should be documented for each insulin administration to ensure injection sites are rotated. Review of Resident 1's clinical record revealed diagnoses that included Diabetes Mellitus Type II (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 1's physician orders revealed orders for Admelog Solostar 100 units/ml (milliliter) inject 6 units subcutaneously with meals for type II diabetes; do not administer if blood glucose is less than 120 or Resident not eating dated January 23, 2026; and Basaglar KwikPen Subcutaneous Solution Peninjector 100 units/ml (Insulin Glargine) Inject 8 units subcutaneously two times a day dated January 21, 2026. Review of Resident 1's Medication Administration Records from February 2026 through August 2026, revealed the following: February: no administration sites were recorded for his glargine insulin administration twice a day and for his Admelog insulin there were 37 occasions where the box for administration site was documented NA even though his insulin dose was signed as being administered;March: no administration sites were recorded for his glargine insulin administration twice a day and for his Admelog insulin there were 29 occasions where the box for administration site was marked NA even though his insulin dose was signed as being administered;April: no administration sites were recorded for his glargine insulin administration twice a day and for his Admelog insulin there were 40 occasions where the box for administration site was marked NA even though his insulin dose was signed as being administered;May: no administration sites were recorded for his glargine insulin administration twice a day and for his Admelog insulin there were 25 occasions where the box for administration site was marked NA even though his insulin dose was signed as being administered; and forJune, July and August: there were no administration sites recorded for either of Resident 1's ordered insulins. Review of Resident 1's physician order history revealed that his Admelog insulin order was revised on May 27, 2026, by Employee 4 (Registered Nurse) to remove all administration site documentation boxes. During a staff interview with the Nursing Home Administrator (NHA) on August 26, 2026, at 2:35 PM, she indicated that she would expect documentation to include site location of insulin administration. During a final staff interview with the NHA and Director of Nursing (DON) on August 27, 2026, at 10:20 AM, the DON confirmed that nursing staff failed to document insulin administration sites and that this should have been documented for every injection. She further indicated that Employee 4 said she deleted them because she thought it was a duplication. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in one of two nourishment refrigerators (Nursing Nourishment Center) and on the tray service line in the main dining room.Findings Include: Review of facility policy, titled Providing Outside Foods or Beverages to Residents, with a policy review date of March 31, 2026, revealed, in part, 5. All food must be labeled with a received date, residents name, room number when put in the refrigerator. Review of facility policy, titled Employee Sanitary Practices, with a policy review date of March 31, 2026, revealed, in part, 6. Use utensils to handle foods. Observation of Nursing Unit Nourishment Center on August 24, 2026, at 7:15 AM, with Employee 3 (Food Service Director-FSD) and Employee 2 (Assistant Food Service Director-AFSD) revealed a chocolate peanut butter parfait and a quart jar of peach halves in the refrigerator with no names of whom the items belonged, date received, or room number indicated. During a staff interview with Employee 2 and 3 on August 24, 2026, at 7:20 AM, revealed items should have been labeled with the resident's name and dated when received and placed in refrigerator. During a staff interview with the Nursing Home Administrator (NHA) on August 26, 2026, at 8:45 AM, she revealed her expectation was that food items would be dated and labeled with a resident name when placed in Nourishment Center refrigerator. Observation of the tray service line preparation in the main dining room on August 26, 2026, between 8:50 AM and 9:00 AM, revealed the following concerns:1) Employee 5 (Cook) touched the tray rack with gloved hands and then went back to preparing toast. He was observed touching the toast and placing bread in the toaster with the same gloved hands without using any utensil.2) Employee 5 touched the tray rack with the same gloved hands and returned to the serving area and picked up eggs with the same gloved hands without using any serving utensil and placed them on a warming plate.3) Employee 5 touched the tray rack again with the same gloved hands, reached into the warming plate retrieving eggs with his gloved hands without using a serving utensil, and placed the eggs on a plate to be served to residents.4) Employee 5 failed to change gloves or perform hand hygiene during any of these observations.5) Employee 6 (Dietary Aide) entered the serving area from the dining room where she was helping residents during dining. She donned clean gloves, touched the cabinet door under serving prep area and proceeded to use the same gloves to touch toast, butter toast with a knife and placed toast on a plate to be served to residents without using any serving utensil. During a staff interview with Employee 2 on August 26, 2026, at 9:01 AM, he revealed the expectation would be that staff would not touch racks or cupboards and then directly touch food to be served with the same gloves and placed on plates to be served to residents. During an interview with Employee 3 and NHA on August 27, 2026, at 10:30 AM, revealed Employee 3 felt the rack was sanitary as it had been wiped off and sanitized back in kitchen after previous meal service. In addition, Employee 3 indicated that staff would have to go back to the kitchen area to wash their hands when changing gloves, which would delay food service. Observation of tray service line area in main dining room with the NHA and Employee 3 on August 27, 2026, at 11:00 AM, revealed cabinets under the serving area counter with dried debris and areas of painted surface off on the outer surfaces of cabinets. Employee 3 expressed the cabinets cannot be wiped with sanitizer due to material composition as it takes the painted surface off. Discussion took place between the NHA and Employee 3 about the need for a surface that can be properly sanitized. During a staff interview with Employee 3 and NHA on August 27, 2026, at 11:00 AM, revealed their expectation would be that food should be served with utensils as able. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.6(f) Dietary services

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failure to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). This failure placed one additional resident who was identified as at risk for elopement and independent with ambulation in an Immediate Jeopardy situation (Resident 4).Findings include: Review of the facility policy, titled Wandering Management Policy, created February 28, 2022, read, in part, Objective: To prevent wandering that could lead to resident elopement and to identify action steps to be taken in the event of an unauthorized resident absence from the community. Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (a brain condition that gradually affects memory, thinking, and behavior) and Dementia (cognitive and memory changes that disrupt everyday function). Further review of Resident 1's clinical record revealed an assessment, titled Elopement Evaluation, dated November 7, 2025. The assessment indicated that Resident 1 was a risk of elopement. Elopement Risk Note indicated Resident 1 had a wander guard in place. Review of Resident 1's physician orders revealed an order dated September 26, 2025, for behavior monitoring every shift for the following: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care, and wandering. Further review of Resident 1's physician orders revealed an order dated September 30, 2026, for wander guard check site and placement left wrist every shift. Review of Resident 1's plan of care revealed Resident 1 was an elopement risk and wandered related to impaired safety awareness; wandering in others' rooms; and has removed wander guard. Interventions included: if Resident 1 appears to be wandering aimlessly, offer to assist to the bathroom for toileting, offer to walk outside, offer to walk to a quieter area for less stimulation, redirect with snacks or cold soda, redirect with going to look out a window at the wildlife. Further review of Resident 1's plan of care revealed Resident 1 was independent with transfers and ambulation. Review of Resident 1's progress notes revealed a note dated March 17, 2026 at 9:38 PM, that indicated Resident 1 was exit seeking most of the shift. Further review of Resident 1's progress notes revealed a note dated March 27, 2026, at 4:18 PM, that indicated Resident 1 was searching the top of the medication cart for scissors to cut this band off. An additional progress note dated March 29, 2026, at 6:30 PM, indicated Resident 1 was entering other patient rooms and checking doors. Review of the facility provided incident report for Resident 1 indicated under the section titled Incident Description that on March 29, 2026, at 7:19 PM, Resident exited facility without notice. Resident is believed to have exited through admin hallway into small front conference room and proceeded to exit building through a window. Resident was observed by staff outside of building. Resident self-ambulates and has impaired cognition. Wander guard did work when tested by staff. Under the section titled Immediate Action Taken revealed: Resident was taken back inside facility by staff. RN assessment for skin issues, none noted. Resident wander guard in place to left wrist and functioning properly. Review of staff witness statements revealed that Resident 1 was last seen by staff at 7:00 PM ambulating in the hallway by the living room. The witness statements further reported that Resident 1 had been exit seeking for several days, attempting to open doors, looking out windows, and searching the top of nursing carts for scissors to cut off his alarm band. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 6, 2026 at approximately 10:30 AM, the NHA indicated that Resident 1 had exited the unit through an unlocked, unalarmed door at the rear of the activities room and into the administration hallway. From the administration hallway, Resident 1 was able to access the front lobby and front conference room. Resident 1 opened a ground level window and exited the building into the front flower bed. The NHA stated she found Resident 1 in the front flower bed at 7:15 PM and the conference room window was open. Information provided by the facility indicated that there was one additional resident identified as an elopement risk and able to ambulate independently (Resident 4). Review of Resident 4's plan of care revealed Resident 4 is an elopement risk/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness. Review of the clinical record for Resident 4 revealed orders for a wander guard and to check placement every shift and to check function weekly. The facility is located in a wooded area adjacent to a body of water, with a parking area and access road located directly in front of the facility. The NHA was provided with the immediate jeopardy template on April 6, 2026, at 2:30 PM, and an immediate action plan was requested. The facility initiated immediate interventions on March 29, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included the following: Resident 1 was immediately put onto a 1:1 that remained in effect until the provider determined Resident 1 was safe and the windows had been audited mitigated, completed March 31, 2026. The NHA secured the front lobby conference room door on March 29, 2026, at approximately 8:15 PM. Activity room's internal door had a staff member assigned to the door until an audible alarm was installed, completed March 29, 2026 at approximately 10:10 PM. The DON and Registered Nurse (RN) Supervisor conducted an audit on current residents with wander guards to ensure function. No concerns were identified. Completed March 29, 2026, at approximately 8:45 PM. The DON and RN supervisor conducted a healthcare facility audit of doors (internal and external) to verify doors were either secured and/or alarming as to prevent unknown exits by residents. Completed March 29, 2026, at approximately 9:30 PM. The DON conducted an audit on current residents' elopement evaluations and ensured elopement evaluations were up to date with any identified care plan interventions implanted if indicated by the evaluation. Completed March 30, 2026, at approximately 6:00 AM. Director of Environmental Services and the maintenance supervisor conducted an audit of windows in the facility that residents could access to ensure that no windows open greater than six inches and remediation was applied to all windows found to open more than six inches. Completed March 31, 2026 at 12:30 PM. On March 29, 2026, at 9:17 PM, all staff were provided education via email on the conference room door remaining locked when not in use and a screamer alarm being placed on the activity's door. Additional education was provided to facility staff on the requirement to keep the conference room door locked when not in use and an audible alarm installed on the activity room door leading to the administrative hallway with an expectation that staff need to respond immediately. Audits were initiated on March 29, 2026 and will continue to be done three times per week for four weeks and then one time a week for two months to ensure the conference room door is locked when not in use and on the audible alarm to ensure functioning and staff response. Additionally, audit results will be reviewed by the Quality Assurance Performance Committee. During an interview with the NHA on April 6, 2026 at 10:30 AM, the NHA stated that, upon returning to the unit, Resident 1 was immediately placed on 1:1 care and audits were conducted of all facility doors and windows. The NHA also stated that maintenance had installed chains on all the windows in the facility which prevent the windows from being opened more than six inches. Date of compliance March 31, 2026 On April 6, 2026, at 3:46 PM, the facility's immediate action plan was accepted, which included: The facility failed to provide adequate supervision and failed to identify windows in the facility as a potential point of exit. On March 29, 2026 at approximately 7:13 PM, the Resident was found outside by the NHA. The NHA returned Resident to the healthcare center at approximately 7:15 PM. RN assessment performed and revealed no injury. Investigation began immediately and revealed that Resident exited neighborhood through an internal door form the activity resident area and moved to the front lobby to a conference room and likely exited a window at ground level. The investigation determined that the Resident was out of the facility for a period of less than two minutes. Resident was immediately put onto a 1:1 that remained in effect until such time the provider determined the Resident was safe and windows had been audited and mitigated if determined necessary (March 31, 2026 at 6:00 PM).The DON and RN supervisor conducted a healthcare facility audit of doors (internal and external) of the health center to verify door are either secured and/or alarming as to prevent unknown exits by residents from the community on March 29, 2026 at approximately 9:30 PM. The DON and RN supervisor conducted an audit on current residents with wander guards to ensure function on March 29, 2026 at approximately 6:00 AM. The NHA secured the front lobby conference room door on March 29, 2026 at approximately 8:15 PM and going forward it will remain locked when not in use. The maintenance supervisor installed an audible alarm on the activity room door leading to the administrative hallway on March 29, 2026 at approximately 10:10 PM to prevent unknown exits by residents. DES and maintenance supervisor conducted an audit of windows in the healthcare center that residents have the ability to access to ensure that no windows open greater than six inches and if any windows are identified to open more than 6 inches remediation was applied by March 31, 2026 at 12:30 PM.The NHA immediately sent an email to all staff on March 29, 2026 at 9:17 PM. The email included education on the conference door remaining locked when not in use and initial education on the screamer that was placed on the activities door. The NHA and DON provided further education to healthcare staff on: the requirement to keep the conference room door locked when not in use (sign also placed on conference door as staff reminder); that an audible alarm has been installed on the activity room door leading to the administrative hallway to prevent unknown exits by residents and staff are required to respond immediately if alarm sounds this education includes pictures and explanation of audible alarm use; and the elopement policy by March 31, 2026 at approximately 7:00 PM.The NHA or designee will complete random audits on the conference room to ensure it is locked when not in use and on the audible alarm to ensure functioning and staff response to alarm three times a week for four weeks and then one time a week for two months. With audit results forwarded to the Quality Assurance Performance Committee for review and recommendations. During an onsite survey on April 6, 2026, the immediate action plan documents were reviewed. Observations made during a tour of the facility on April 6, 2026, revealed that the conference room in the front lobby was locked and had a sign on the door that read to keep the door locked when not in use, the internal activity room door had an alarm system in place with signage indicating not to use the door and that an alarm would sound if the door was opened, and that all windows throughout the facility had chains in place. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of the education. The Immediate Jeopardy was lifted on April 6, 2026, at 3:46 PM, after ensuring that the immediate action plan had been implemented. The facility failed to implement interventions, supervision, and effective safety measures to prevent Resident 1 from elopement from the facility. This failure placed Resident 1 and one additional resident (Resident 4) in an Immediate Jeopardy situation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of 16 residents reviewed (Residents 5, 22, and 55). Findings include: Review of facility policy, titled Wound Care, with a last review date of August 14, 2024, revealed, in part, 15. Treatments will be performed by personnel in accordance with licensure practice acts. Review of facility policy, titled Intravenous Device Care, with a last review date of August 14, 2024, revealed, in part, 3. Intravenous Care will be documented in the medical record, Electronic Medication Administration Record, and/or Electronic Treatment Administration Record. Section titled PICC Line Care, indicated Intermittent Infusion - Change tubing and needleless connection devices every 24 hours; Dressing Change - Change transparent dressing and caps weekly and PRN [as needed]; and Measure External PICC Catheter Length - Upon insertion and weekly with dressing change. Review of facility policy, titled Change in Medical Condition, last approved December 24, 2024, revealed, [company] facilities shall provide notice of changes in medical condition related to but not limited to CHF [Congestive Heart Failure] .and other care issues in a timely manner meeting the requirements of accrediting agencies and federal and state agencies. Review of Resident 5's clinical record revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and hereditary and idiopathic neuropathy (a group of inherited disorders that affect the peripheral nervous system and a type of nerve damage where the cause remains unknown despite thorough testing, leading to symptoms like numbness, pain, and balance issues). Review of Resident 5's clinical record revealed that she was diagnosed with a diabetic foot ulcer on March 17, 2024. Review of Resident 5's current physician orders revealed an order for Left great toe: twice daily cleanse with wound cleanser; pat dry; apply skin prep to periwound (surrounding skin), and air dry. Cover wound bed with collagen (cut to fit) then calcium alginate (cut to fit). Secure with bordered gauze (island dressing) for wound healing< dated June 23, 2025. Review of order history revealed that this wound care was originally ordered on April 15, 2025. Further review of Resident 5's current physician orders revealed an order for monitor every shift foot cradle, ensure blankets are not tucked, in every shift date May 6, 2025. Review of Resident 5's Treatment Administration Records (TAR) for April 2025 through current revealed the following: April 21 wound care was not signed as completed on 3-11 (evening) shift; May 2 and 8 wound care was not signed as completed on 7-3 (day) shift; May 8 foot cradle check was not signed as completed on 7-3 (day) shift; May 11 foot cradle check was not signed as completed on 11-7 (night) shift; June 2 wound care was not signed as completed on 7-3 (day) shift; June 12, 16, 17, 22, 23, and 29 wound care was not signed as completed on 3-11 (evening) shift; and June 12 and 17 foot cradle check was not signed as completed on 3-11 (evening) shift. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 2, 2025, at 11:35 AM, the DON confirmed she had no additional information to provide. She further confirmed that nursing staff should have provided Resident 5's wound care and foot cradle checks as ordered and should have documented all care accordingly. Review of Resident 22's clinical record revealed diagnoses that included congestive heart failure (chronic condition where the heart is unable to pump blood effectively to meet the body's needs, which can lead to a buildup of fluid in the lungs and other parts of the body) and Parkinson's disease (movement disorder that affects the nervous system and worsens over time). Review of Resident 22's physician orders revealed an order for daily weights in the morning, report a 2 pound weight gain overnight or a 5 pound weight gain in one week to provider to determine if Resident needs additional as-needed lasix (diuretic medication), starting February 27, 2025. Review of Resident 22's May and June 2025 weight documentation revealed that a 2 pound or greater weight gain was recorded overnight on the following dates: May 12th to the 13th, 15th to the 16th, 17th to the 18th, 24th to the 25th, 29th to the 30th; and June 17th to the 18th, and 28th to the 29th. Review of Resident 22's clinical record failed to reveal evidence that the provider was notified of the weight gain per physician orders on the aforementioned dates. During an interview with the DON on July 2, 2025, at 11:52 AM, she revealed that she was unable to provide any additional evidence that the provider was notified of Resident 22's weight gain as ordered. She also revealed the expectation that this should have occurred. Review of Resident 55's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included infection reaction due to left hip prosthesis (artificial devices that replace missing or damaged body parts), unspecified pain, and hypertension (high blood pressure). Further review of Resident 55's clinical record revealed that she had a PICC (peripherally inserted central catheter-a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart used to give medications or liquid nutrition) to receive intravenous antibiotics for the surgical infection of her left hip. Review of Resident 55's current physician orders revealed the following orders: Cefazolin 2 gram intravenous (IV) solution 2 gram in 100 milliliters of normal saline solution (NSS) three times a day; Curos caps use as directed with IV's three times a day; Ultrasite valve CSU100 as directed with dressing change on Saturdays; IV sodium chloride 0.9% solution mini-bag spike and activate each 2 gram vial of cefazolin in 100 ml NSS and infuse over minutes [no minutes specified in order] every 8 hours; Normal Saline flush 10 ml as directed with cefazolin order three times a day; Zyno administration set (tubing) as directed with cefazolin order three times a day; PICC dressing change every week- change PICC line transparent dressing and caps Saturday and as needed if soiled, wet, or loosened; and measure PICC catheter length with every dressing change document length in comment. Review of Resident 55's June 2025 Medication Administration Record (MAR) revealed the following: June 15 at 2:01 PM: cefazolin, Zyno administration set, and saline flush were blank; June 15, at 10:01 PM: saline flush and Zyno administration set were blank; June 20, at 06:01 AM: cefazolin, saline flush, and Zyno administration set were blank; June 24, at 2:01 PM: Curos caps was blank; June 24, at 10:01 PM: cefazolin, IV sodium chloride 0.9% solution mini-bag spike and activate, saline flush, Zyno administration set, Curos caps were blank; June 25, at 2:01 PM: IV sodium chloride 0.9% solution mini-bag spike and activate, and Curos caps were blank; and June 26, at 2:01 PM: cefazolin, IV sodium chloride 0.9% solution mini-bag spike and activate, Zyno administration set, saline flush, and Curos caps were blank. Review of Resident 55's June 2025 TAR revealed that the PICC dressing change was marked N on June 20, 2025, and comment indicated that it was not done since it was due on Saturday; and that the measurement of the PICC line was blank and not signed as completed. In addition, the PICC dressing change entry was signed as completed on June 27, 2025, but the measurement of the PICC line was documented as 0. Review of Resident 55's clinical record progress notes revealed a nurse's note by a Registered Nurse that indicated the PICC line dressing was changed on Saturday, June 21, 2025, but the note failed to include the PICC line measurement. Email communication received from the DON on July 1, 2025, at 5:34 PM, indicated we did change her orders to ensure the dressing change and measurement is on Friday to coincide with it last being done on 06/27/2025. During a staff interview with the NHA and DON on July 2, 2025, at 11:36 AM, the DON confirmed that there were multiple missing entries in Resident 55's MAR and TAR for June 2025 and said there was no additional information to provide. She said that she would expect staff to have administered Resident 55's antibiotic and that it would be documented accordingly. The DON indicated that she could not locate any information in Resident 55's hospital records of the length of her PICC line. She confirmed that staff should have measured residents PICC line on admission and weekly as per facility policy and physician orders. She confirmed that the documentation of the PICC line measurement on June 27, 2025, was recorded as 0 and that would not be an accurate measurement as a PICC should have an external portion to measure. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for two of four residents reviewed for pressure ulcers (Residents 10 and 47). Findings Include: Review of policy, titled Wound Care, last approved December 24, 2024, revealed, Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and provide symptom control as appropriate .Treatments will be performed by personnel in accordance with licensure practice acts. Review of Resident 10's clinical record revealed diagnoses that included chronic pain and muscle weakness. Review of facility wound care tracking revealed that Resident 10 had stage 3 pressure injuries (full-thickness skin loss exposing underlying fat tissue) to both his left and right heels. Review of Resident 10's May 2025 TAR (Treatment Administration Record) revealed a physician order to apply Betadine swabsticks (used to treat or prevent bacterial infections) to both the left and right heels twice daily starting April 1, 2025, and ending May 30, 2025. Further review of Resident 10's May 2025 TAR revealed that it was not documented that this treatment was done on May 10 and 29, 2025, evening shifts. Review of Resident 10's June 2025 TAR revealed a physician order to cleanse the right heel wound with mild soap and water, apply skin prep (used to form a protective film or barrier) to the periwound (tissue surrounding a wound), apply medical grade honey to the wound bed, cover with calcium alginate (absorbs drainage and forms a moist gel), and secure with bordered gauze (absorptive dressing) twice daily starting June 23, 2025. Further review of Resident 10's June 2025 TAR revealed that it was not documented that this treatment was done on June 27 and 30, 2025, evening shifts. Review of Resident 47's clinical record revealed diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way your body metabolizes sugar [glucose], leading to high blood sugar levels) and edema (swelling caused by too much fluid trapped in the body's tissue). Review of facility wound care tracking revealed that Resident 47 had an unstageable pressure injury (type of sore that is characterized by the presence of non-viable tissue which obscures wound bed making it impossible to measure the depth or stage of the ulcer) to his right heel. Review of Resident 47's May 2025 TAR revealed a physician's order to clean the right heel with soap and water, paint with betadine, and cover with bordered gauze each shift starting April 28, 2025, and ending May 5, 2025. Further review of Resident 47's May 2025 TAR revealed that it was not documented that this treatment was done on May 2, 2025 day shift. Review of Resident 47's June 2025 TAR revealed a physician's order to cleanse his right heel with normal saline solution, pat dry, and paint with betadine three times per day, starting June 9, 2025. Further review of Resident 47's June 2025 TAR revealed that it was not documented that this treatment was done on June 10, 2025, at the scheduled 2:00 PM time, and on June 17 and 27, 2025, at the scheduled 8:00 PM time. During an interview with the Nursing Home Administrator on July 2, 2025, at 1:03 PM, she confirmed that they were unable to provide any additional information on this missing wound care documentation for Residents 10 and 47, and that she would expect that wound care would have been documented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 19 residents reviewed (Residents 5, 23, and 47). Findings include: Review of Resident 5's clinical record revealed diagnoses that included diabetes mellitus (chronic condition that affects the way your body metabolizes sugar [glucose], leading to high blood sugar levels) and hereditary and idiopathic neuropathy (a group of inherited disorders that affect the peripheral nervous system and a type of nerve damage where the cause remains unknown despite thorough testing, leading to symptoms like numbness, pain, and balance issues). Review of Resident 5's Comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of October 4, 2024, indicated in Section N. Medications that she was not coded as receiving an anticonvulsant medication during the assessment period. Review of Resident 5's October 2024 Medication Administration Record (MAR) revealed that she had received gabapentin (an anticonvulsant medication used to treat neuropathy) during the assessment period. Email communication received from the Nursing Home Administrator (NHA) on July 2, 2025, at 10:38 AM, indicated that Resident 5's MDS had been corrected. During a staff interview with the NHA and the Director of Nursing (DON) on July 2, 2025, at 11:35 AM, the NHA indicated that she would expect a resident's MDS's to be completed accurately. Review of Resident 23's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 23's Quarterly MDS with the assessment reference date of February 21, 2025, revealed in Section N. Medications that he was coded as receiving a hypnotic medication in the assessment period. Review of Resident 23's February 2025 MAR failed to reveal that he had received a hypnotic medication. Email communication received from the NHA on July 1, 2025, at 4:34 PM, confirmed that Resident 23's MDS had been coded in error and that a correction was completed. During a staff interview with the NHA and the DON on July 2, 2025, at 11:35 AM, the NHA indicated that she would expect a resident's MDS's to be completed accurately. Review of Resident 47's clinical record revealed diagnoses that included type 2 diabetes mellitus and edema (swelling caused by too much fluid trapped in the body's tissue). Resident 47 was admitted to the facility on [DATE]. Review of facility wound care tracking revealed that Resident 47 has an unstageable pressure injury (type of sore that is characterized by the presence of non-viable tissue, which obscures wound bed making it impossible to measure the depth or stage of the ulcer) to his right heel that originated on November 22, 2024. Review of Resident 47's February 12, 2025, quarterly and May 11, 2025 comprehensive MDS assessments revealed that each of them was coded to indicate that he had an unstageable pressure ulcer/injury, but that it was already present upon admission to the facility. Email correspondence received from the NHA on July 1, 2025, at 5:09 PM, confirmed that the aforementioned MDS assessments were coded in error and were being corrected. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of hydration and nutritional status for one of three residents reviewed for nutrition (Resident 10). Findings include: Review of Resident 10's clinical record revealed diagnoses that included chronic pain and muscle weakness. Review of Resident 10's weight documentation revealed that he experienced a significant weight loss of 9.52% between May 1, 2025, and June 2, 2025. Review of dietician progress notes dated June 3, 2025, revealed acknowledgement of the weight loss and a plan to monitor his weight weekly for one month, until July 3, 2025. Review of Resident 10's physician orders revealed an order to weigh weekly on Tuesdays through July 3, starting on June 10, 2025, and ending on July 3, 2025. Review of Resident 10's clinical record failed to reveal that a weight was recorded on June 24, 2025. Review of Resident 10's June 2025 TAR (Treatment Administration Record) revealed a physician's order for an enhanced shake (prepared to provide additional nutritional value) at 10:00 AM, 3:00 PM, and at bedtime daily starting June 10, 2025. Further review of Resident 10's June 2025 TAR revealed that the enhanced shake was not documented as being given on June 13 at 3:00 PM, and on June 13, 22, and 27 at bedtime. During an interview with the Nursing Home Administrator (NHA) on July 2, 2025, at 11:48 AM, she revealed she was not able to provide any additional information on the missing weight documentation for June 24, 2025. She also revealed the expectation that this weight should have been obtained and recorded. During a later interview with the NHA on July 2, 2025, at 1:03 PM, she revealed she was not able to provide any additional information regarding Resident 10's missing enhanced shake documentation, and that she would have expected it to be documented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards during a transfer, resulting in actual harm as evidenced by a skin tear requiring treatment, for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility, and muscle weakness. Review of nursing progress notes entered by Employee 1 (Registered Nurse) dated January 16, 2025, revealed that she was called to Resident 1's bedside to assess a skin tear that was acquired while transferring Resident 1 into bed. Further review of the note revealed, Two aides present, transferring resident d/t [due to] resident dislodging hoyer pad from correct positioning. During transfer right forearm sustained a 9 cm x 11.5 cm long skin tear. Bleeding controlled. Area cleansed. Per ADON [Assistant Director of Nursing], Xeroform, ABD, kling wrap [types of wound dressings] applied. Review of Resident 1's current and active physician orders revealed an order for a transfer status of two assist with a full mechanical lift, effective December 17, 2024. Review of Resident 1's care plan that was in place at the time of the incident on January 16, 2025, revealed a care plan related to his impaired functional status with an intervention of a two-person assist using a hoyer lift for transfers. Review of Employee 2's (Nurse Aide) witness statement obtained by Human Resources on January 20, 2025, revealed, [Employee 3 - Nurse Aide] took resident to room and asked [Employee 2] to assist with the transfer. He noticed the Hoyer Pad was wedged under his bottom so they could not do a Hoyer Lift. [Employee 2] stated they were both on the same page and decided to do a stand/pivot transfer due to safety concerns. [Employee 3] put the Broda [type of wheelchair] next to the bed. [Employee 3] was watching from the opposite side of the bed when [Employee 2] transferred the resident by himself. He put both arms under the resident's armpits and lifted the resident by himself. The resident's arms were on his waist. He heard the resident yell and pivoted him to the bed . When asked why he did it by himself, he stated that it was easier to do that. He also stated that it was safer. When he [the resident] sat down [Employee 3] looked at his arm and saw blood saturated through his sweatshirt. [Employee 2] stated the resident was noncombative. Once in bed, [Employee 3] rolled his sleeve back and saw the skin tear. [Employee 2] went to get the nurse to look at the skin tear. During an interview with Employee 2 on January 27, 2025, at 10:26 AM, he stated that on the date in question, Employee 3 took Resident 1 to his room. She asked Employee 2 for assistance, and he agreed. Once he arrived in the room, they discovered that Resident 1's lift pad was not properly positioned under his bottom. Employee 2 stated that both he and Employee 3 knew that Resident 1 was to be transferred with a lift, but they knew they had to do something else. Employee 2 states that he transferred Resident 1 by himself. During the transfer, Employee 3 was on the other side of the bed, but was paying attention enough to help if needed. Employee 2 stated that he did a stand/pivot transfer with Resident 1's arms around his waist. After he stood Resident 1 up, Resident 1 screamed. Employee 2 stated he then sat Resident 1 down on his bed. That's when they noticed the injury and went to get the nurse. Employee 2 stated that he had never encountered the situation before where a lift pad was not positioned where it was useable, and he just used his best judgement at the time. He acknowledged that he was aware that Resident 1 was to be transferred with a lift. Review of Employee 3's witness statement, obtained by the ADON, Employee 6 (Registered Nurse Unit Manager), and Human Resources on January 20, 2025, revealed, [Employee 3] stated that she had placed the Resident in his room by his bed, between his bed and the roommate's bed. [Employee 3] stated that she went to get [Employee 2] to help her. [Employee 3] stated she walked away, to get gloves on prior to the transfer. [Employee 3] stated as she turned around, [Employee 2] had stood the Resident to transfer him into his bed .[Employee 3] admitted she did not assist with the transfer; however, she watched the transfer occur. She stated [Employee 2] had his arms positioned under the resident's armpits, and the Resident put his arms around [Employee 2's] neck. [Employee 3] stated that the Resident stated ouch as he was placed in a sitting position on his bed. [Employee 3] stated they laid the Resident on his back, when [Employee 3] noted the Resident's right sleeve was saturated with what she assumed was blood. [Employee 3] also stated that she pulled the Resident's sleeve back to see what was wrong with the Resident's right arm .[Employee 3] saw the skin tear on Resident's right forearm and had [Employee 2] go get the Nurse [Employee 3] stated, they told the nurses, that her and [Employee 2] both transferred the Resident. [Employee 3] also admitted that she told a CNA [Certified Nurse Aide], Friday 1/17/25, the real story of what occurred .During the re-enactment of the incident in the Resident's room, [Employee 3] admitted that she stood on the opposite side of the bed and watched [Employee 2] transfer the Resident by himself and did not help nor ask him to stop. [Employee 3] was asked why they were standing and pivoting the Resident instead of using the mechanical lift per care plan. She said the sling was scrunched up under the Resident's bottom. [Employee 3] was asked why they did not stand and fix the sling, she stated, I didn't think of that. Review of wound consult dated January 20, 2025, revealed that Resident 1's right forearm skin tear was assessed on that date, and it was noted that a moderate amount of serosanguinous exudate (wound drainage), and FLACC pain level of 3 (1-10 scale used to assess pain of individuals unable to verbalize pain levels) was present at the time. Orders were given for a wound dressing to be applied twice per day and as-needed. During an interview with the Nursing Home Administrator (NHA) on January 27, 2025, at 10:45 AM, she revealed that she would have expected Employee 2 and 3 to stand Resident 1 and fix his lift pad, or seek assistance from a nurse. During an interview with the Director of Nursing (DON) on January 27, 2025, at 11:40 AM, she revealed that nursing staff were educated in November 2024 about following the care plan, and that failure to do so could rise to the level of neglect. She also revealed that transfer status was specifically reviewed during this training, and staff were instructed to seek help if they have questions about transfer statuses. The facility's corrective action was reviewed during the onsite survey. After the investigation, the facility terminated both Employees 2 and 3. On January 20, 2025, the DON completed a review of incident reports for the previous 30 days to determine negative outcome from failure to follow the Resident's care plan. The finding were negative. On January 20, 2025, a full sweep of all residents was completed to ensure that each had an accurate transfer status noted on their care plan. Review of education dated January 17 - 23, 2025, revealed that nurse aides, licensed staff, and therapy staff were educated on abuse and neglect, and the facility's Transfer of a Resident policy. Ongoing audits were initiated on January 20, 2025, and are to continue three times per week for one month, then weekly for one month, then monthly for three months. The results are to be reviewed at the Quality Assurance and Performance Improvement Committee. Review of the audits revealed they are monitoring if appropriate transfer status was used by staff, and if a mechanical lift was utilized properly, if applicable. Review of the facility's education, audits, and staff interviews revealed no concerns. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of select facility documentation, and staff interviews, it was determined that the facility failed to monitor and utilize equipment in accordance with professional standards for food service safety in the main kitchen and cafe area. Findings include: Observation of the dish machine in the main kitchen on August 12, 2024, at 9:36 AM, revealed the wash cycle temperature was reading 150 degrees Fahrenheit (F- unit of measure) and the rinse cycle temperature was reading 172 degrees F. During an interview with Employee 1 (Food Service Director) on August 12, 2024, at 9:38 AM, he revealed it is possible the machine needs to heat up more for the day before it reaches the minimum acceptable temperatures. Observation of the August 2024 dish machine temperature log on August 12, 2024, at 9:40 AM, revealed the recorded wash cycle temperatures were below the minimum safe temperature of 160 degrees F on August 1-3, 2024, during breakfast; and August 2, 3, and 5, 2024, during lunch. Further observation of the August 2024 dish machine temperature log on August 12, 2024, at 9:40 AM, revealed the recorded rinse cycle temperatures were below the minimum safe temperature of 180 degrees F on August 5 and 11, 2024, during lunch. The temperature log notes if the wash temperature is below 160 F or final rinse below 180 F, notify a manager immediately and record corrective action taken. No corrective action was noted for any of the aforementioned dates. Observation of the dish machine in the main kitchen on August 12, 2024, at 12:57 PM, revealed the wash cycle temperature was reading 142 degrees F and the rinse cycle temperature was reading 175 degrees F. Interview with Employee 2 (Dietary Employee) on August 12, 2024, at 12:58 PM, revealed they are waiting to run the dish machine for the rest of the dishes from lunch since it is not running at the proper temperature. Follow-up interview with Employee 1 on August 12, 2024, at 1:04 PM, revealed he would investigate the issue with the dish machine. Review of the December 2023 kitchen refrigerator and freezer temperature log revealed temperatures failed to be recorded on December 28 and 29, 2023, in the PM; and December 31, 2023, in the AM. Review of the December 2023 ice cream freezer and [NAME] refrigerator temperature log revealed temperatures failed to be recorded on December 28, 20243 in PM; December 30, 2023, in AM and PM; and December 31, 2023, in AM. Review of the February 2024 [NAME] refrigerator and reach in freezer temperature log revealed temperatures failed to be recorded for the [NAME] refrigerator in the PM on February 2, 16, 18, 19, and 29, 2024; the reach in freezer in AM and PM on February 2, 2024; and in PM on February 16, 18, and 29, 2024. Review of the February 2024 kitchen refrigerator and freezer temperature log revealed temperatures failed to be recorded on February 2, 2024, in AM and PM; and February 8, 9, 16 and 29, 2024, in PM. Review of the February 2024 cafe refrigerator and freezer temperature log revealed temperatures failed to be recorded in AM and PM on February 3, 4, 6, 24, 25, and 28, 2024. Review of the May 2024 [NAME] refrigerator and reach in freezer temperature log revealed temperatures failed to be recorded in the PM on May 17 and 24, 2024. Review of the May 2024 kitchen refrigerator and freezer temperature log revealed temperatures failed to be recorded in the PM on May 17 and 24, 2024. Review of the May 2024 dish machine temperature log revealed the recorded wash cycle temperatures were below the minimum safe temperature on May 3 and 4, 2024, during breakfast; and May 5-7, 2024, during lunch; the log failed to reveal wash or rinse cycle temperatures during dinner shift on May 2-14, 22, 28-30, 2024; and failed to reveal corrective action noted for the temperatures outside of acceptable range. Review of the June 2024 [NAME] refrigerator and reach in freezer temperature log revealed temperatures failed to be recorded in the PM on June 7, 29, and 30, 2024; and in AM on June 21, 2024. Review of the June 2024 kitchen refrigerator and freezer temperature log revealed temperatures failed to be recorded in the AM on June 7, 2024, and in the PM on June 21, 2024. Review of the June 2024 cafe refrigerator and freezer temperature log revealed temperatures failed to be recorded in AM and PM on June 22 and 23, 2024. Review of the June 2024 dish machine temperature log revealed the recorded wash cycle temperatures were below the minimum safe temperature on June 20-24 and 26, 2024, during breakfast; June 23-26 and 30, 2024, during lunch; and June 27, 2024 during dinner shift. The log failed to reveal corrective action noted for the temperatures outside of acceptable range. Review of the July 2024 [NAME] refrigerator and reach in freezer temperature log revealed temperatures failed to be recorded in the PM on July 28 and 31, 2024. Review of the July 2024 kitchen refrigerator and freezer temperature log revealed temperatures failed to be recorded in the PM on July 5 and 28, 2024. Review of the July 2024 dish machine temperature log revealed the recorded wash cycle temperatures were below the minimum safe temperature on July 8, 12, 17, 24, 28, and 30, 2024, during breakfast; July 8-10, 12-14, 16, 17, 28, and 29, 2024, during lunch; and July 12, 2024, during dinner shift. The recorded rinse cycle temperature was below the minimum safe temperature on July 28, 2024, during lunch; and the log failed to reveal corrective action noted for the temperatures outside of acceptable range. Review of select facility invoice dated August 12, 2024, revealed the dish machine was in need of repair and was fixed that evening. Interview with the Nursing Home Administrator on August 14, 2024, at 12:17 PM, revealed her expectation for kitchen equipment to be utilized and monitored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on facility policy review, record review, and staff interview, it was determined that the facility failed to ensure residents with limited mobility received appropriate services and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 42). Findings include: Review of facility policy, titled Restorative Care Program, last reviewed August 15, 2023, read, in part, Presbyterian Senior Living facilities will provide restorative services which prevent, slow functional decline and/or maintain the resident highest practicable level functioning in accordance with state and federal regulations. Matrix Care Point of Care will be assigned for Nurse Aid documentation to include the program and the minutes the program is performed. Review of Resident 42's clinical record revealed diagnoses that included chronic pain (pain that lasts more than three months or beyond normal healing time), anxiety (a feeling of worry, nervousness, or unease), and left above the knee amputation. Review of Resident 42's care plan revealed she has restorative nursing programs in place for active range of motion to upper and lower extremities and dressing and grooming at 7:00 AM and 3:00 PM, daily. Review of Resident 42's point of care documentation failed to reveal minutes or tolerance documented for her restorative programs at 7:00 AM on July 4, 19, 24, and 31, 2024. Review of Resident 42's point of care documentation failed to reveal minutes or tolerance documented for her restorative programs at 3:00 PM on July 16, 2024; and August 1 and 13, 2024. Review of Resident 42's point of care documentation failed to reveal minutes or tolerance documented for her restorative programs at both 7:00 AM and 3:00 PM on July 21, 2024, and August 2, 2024. Interview with the Director of Nursing on August 14, 2024, at 2:02 PM, revealed she was unable to locate documentation to indicate Resident 42's restorative program was implemented or that she had refused it on the aforementioned dates. No further information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon timely for two of five residents reviewed for unnecessary medications (Residents 5 and 42). Findings include: Review of facility policy, titled Medication Regimen Review, last reviewed August 15, 2023, read, in part, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The findings are phoned, faxed, or e-mailed within 24 hours to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record. The prescriber is notified if needed. Review of facility policy, titled Documentation and Communicating of Consultant Pharmacists Recommendations, last reviewed August 15, 2023, read, in part, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to the recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. Review of Resident 5's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), anxiety (a feeling of worry, nervousness, or unease), and osteoarthritis (a condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness). Review of Resident 5's clinical record revealed a Medication Regimen Review (MRR) document dated May 27, 2024, that stated Resident is receiving Bisphosphonate (medication). Please consider the addition of a calcium supplement and/or vitamin D supplement to medication regimen. The physician was noted to agree with the recommendation and wrote an order for Calcium 500 mg + Vitamin D 500 IU twice daily, and signed and dated June 27, 2024. Further review of Resident 5's MRR document revealed the notation that the medication was ordered on July 12, 2024. During an email correspondence with the Director of Nursing (DON) on August 14, 2024, at 9:45 AM, she revealed they did not receive the pharmacy recommendation from the pharmacist until around June 10, 2024, at that time it was provided to their Medical Director (MD) for completion. The MD did not return the MRR to the DON until July 12, 2024, and the DON put the order in herself. She further revealed verbal education was provided to the MD at that time about the importance of timeliness of completion and return of MRR's. Interview with the DON on August 14, 2024, at 12:13 PM, revealed pharmacy sends their MRR's over in an email and sometimes they are secured, and the facility is unable to open them which delays the process, or pharmacy sends them over late. She further revealed the facility is working on a better process for timely delivery and responses to MRR's. Review of Resident 42's clinical record revealed diagnoses that included chronic pain (pain that lasts more than three months or beyond normal healing time), anxiety, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 42's clinical record revealed a MRR dated November 30, 2023, noting that Resident 42's lorazepam (medication for anxiety) was due for an assessment related to the regulations for a gradual dose reduction, and that if there is no dosage reduction indicated, please provide the clinical rationale. The rationale for no dosage reduction was provided and signed by the physician on January 4, 2024. Email correspondence with the DON on August 14, 2024, at 12:16 PM, she revealed the response from the physician was delayed because the facility did not receive the aforementioned MRR from pharmacy until December 20, 2023. 28 Pa. Code 211.2(d)(3) Physician services 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review, observations, facility policy review, and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards to promote healing and prevent infection of pressure ulcers for one of two residents reviewed for pressure ulcers (Resident 103). Findings include: Review of Facility policy, titled Wound Care, last approved on May 31, 2023, revealed it stated the facility's policy was, Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate. Review of Resident 103's clinical record on October 10, 2023, at approximately 1:30 PM, revealed diagnoses that included stage 4 pressure injury of the sacrum (wound of the skin caused by pressure over a bony prominence that extends to the through the skin to the bone and other connective tissue) and osteomyelitis (infection of the bone). During wound dressing change observations on October 12, 2023, at approximately 10:05 AM, Employee 1 was observed removing a pair of scissors from Employee 1's scrub pants pocket and placing them in a pink tub with treatment supplies. Further observations revealed Employee 1 did not clean the scissors prior to placing them with treatment supplies. Observations at approximately 10:17 AM, revealed Employee 1 used the scissors to cut foam multiple times to insert the foam into Resident 103's wound bed. During a staff interview on October 12, 2023, at approximately 12:30 PM, Director of Nursing revealed it was the facility's expectation that Employee 1 would have cleaned the scissors prior to utilizing them to cut the foam. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of facility investigation reports, and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions for one of three residents reviewed (Resident 1). Findings include: A review of Resident 1's clinical record revealed diagnoses that included osteoporosis (decreased bone density and softening of the bone), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and was hospice status (end of life). Further review of Resident 1's admission record indicated she was admitted on [DATE]. Review of Resident 1's Quarterly MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated May 17, 2023, indicated a BIMS (brief interview of mental status) scored a 3, indicating severely impaired cognitive status. Review of section G0110-B (functional mobility describing how a resident move between surfaces including to or from a bed, chair, or wheelchair) of the MDS assessment indicated a performance level of 3-Extensive assistance and a support level of 2-two-person assistance, meaning that Resident 1 receives two-person assistance when transferring between surfaces. A review of Resident 1's Fall Risk Evaluation, with a date of July 5, 2023, revealed a score of 14, which indicates the Resident is at high risk for falls. A review of Resident 1's care plan, effective August 6, 2023, revealed a triggered focus area for risk of falls related to impaired vision and ambulatory dysfunction. Review of Resident 1's incident report dated August 8, 2023, at approximately 8:00 AM, for an injury of unknown origin, indicated Resident 1 had a x-ray completed August 8, 2023, of her left hip due to complaints of pain to left hip and swelling that began on August 6, 2023, between 4:00 PM and 5:00 PM. Final x-ray results were reported to the facility in the afternoon on August 8, 2023, which showed a final impression to be an acute displaced/angulated fracture of the left hip, left femur with an acute intertrochanteric fracture of the proximal femur with varus angulation deformity at the fracture site, and there was no other fracture seen in the remaining shaft of the femur distally to the knee. During the facility interview with Employee 7 (Nurse Aide) on August 8, 2023, Employee 7 revealed that she was assigned to Resident 1 on August 6, 2023, during day shift. Employee 7 stated that she provided AM care/hygiene and transferred Resident 1 from the bed to the wheelchair using a gait belt. Employee 7 revealed that she transferred Resident 1 from the wheelchair to the bed after lunch using a gait belt. Employee 7 stated that when she was trained, she was informed Resident 1 was a one-person assist transfer. When asked if Resident 1 had pain or anything out of the ordinary happen during transfer, Employee 7 replied, no, she gave me no indication of anything out of the ordinary. During a telephone interview with Employee 7 on August 16, 2023, at 12:30 PM, it was verified that Employee 7 was assigned to Resident 1 on August 6, 2023, during the day shift. Employee 7 was asked how Resident 1 was transferred, she replied, I'm aware now that she is a 2 assist for transfers but wasn't aware at that time, I believe I mistakenly looked at the roommates transfer status. Employee 7 was ask to describe the transfer technique for Resident 1 on August 6, 2023, she replied, the wheelchair was placed beside the bed and locked, the footrest was moved, a gait belt was applied, I told resident on the count of 3 you are going to stand, then resident pivoted until she sat on the edge of the bed, I placed my hand on the resident's back to lower her into bed and raised her legs onto the bed. Employee 7 stated the Resident gave her no indication of pain. Employee 7 added that Resident 1 made her usual comment, what did you do that for?, and Employee 7 stated that she reminded the Resident, remember you're going to lie down and take a nap. Employee 7 said she removed the Resident's socks and then her pants, at which time the Resident said she was cold. Employee 7 said she performed incontinence care and covered the Resident. Employee 7 said, she never yelled or screamed, there was indication of pain even during incontinence care. During an interview with the Assistant Director of Nursing and Nursing Home Administrator on August 17, 2023, both agreed that the care plan should be followed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa Code: 211.10 (c)(d) Resident care policies

Based on review of facility policy, clinical record review, investigation document review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide a two-person transfer and use of a device as per care planned for one out of three sampled residents (Resident 1). Findings include: A review of the facility policy, titled Abuse Neglect or Exploitation last reviewed October 22, 2022, indicated that neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress to the resident despite knowledge that the care and services are required. A review of Resident 1's clinical record revealed diagnoses that included osteoporosis (decreased bone density and softening of the bone), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and was hospice Statins (end of life). Further review of Resident 1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident 1's Quarterly MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated May 17, 2023, indicated a BIMS (brief interview of mental status) score of 3, indicating severely impaired cognitive status. Review of section G0110-B (functional mobility describing how a resident move between surfaces including to or from a bed, chair, or wheelchair) of the MDS assessment indicated a performance level of 3-Extensive assistance and a support level of 2-two-person assistance, meaning that Resident 1 received two-person assistance when transferring between surfaces. Review of Resident 1's care plan, effective August 6, 2023, indicated to provide transfer assistance of two-persons, using a gait belt and walker. Review of Resident 1's physician order, effective August 6, 2023, indicated transfer assistance of two-persons from bed to wheelchair/wheelchair to bed, and to utilize a rolling walker. Review of Resident 1's incident report dated August 8, 2023, at approximately 8:00 AM, indicated that Resident 1 had an x-ray completed August 8, 2023, of her left hip due to complaints of pain to left hip and swelling that began on August 6, 2023, between 4:00 PM and 5:00 PM. Final x-ray results were reported to facility in the afternoon on August 8, 2023, which showed a final impression to be an acute displaced/angulated fracture of the left hip, left femur with an acute intertrochanteric fracture of the proximal femur with varus angulation deformity at the fracture site, and there was no other fracture seen in the remaining shaft of the femur distally to the knee. Based on the results of the x-ray, the facility began an internal investigation to determine how Resident 1 sustained the injury. Employee 1 (Nurse Aide) was interviewed by the facility on August 8, 2023, at 1:00 PM. Employee 2 was assigned to Resident 1 on the evening shift of August 6, 2023. Employee 1 stated that she entered the room around 4:00 PM (Nursing Home Administrator [NHA] informed this writer that facility video reveals that it was closer to 5:00 PM) and Resident 1 was sleeping. Employee 1 stated he attempted to raise the head of the bed and Resident 1 responded, my hip is killing me. Employee 1 also stated that the last time he was assigned to Resident 1, the Resident did not have any hip pain. The facility interview with Employee 2 (Licensed Practical Nurse) on August 8, 2023, at 1:00 PM, revealed she had provided Resident 1 with medications and wound care on August 5, 2023, and August 6, 2023, on day shift. Employee 2 documented that she did not assist with any other direct care or any transfers for Resident 1. Employee 2 documented that the Hospice nurse pushed Resident 1 back to her room after lunch, and informed Employee 2 that Resident 1 was sitting in her room and doing good, then the Hospice nurse left. The facility interview with Employee 3 (Licensed Practical Nurse) on August 8, 2023, at 1:30 PM, revealed that she worked 6:00 PM until 6:00 AM, and began her shift on August 6, 2023. Employee 3 stated that Employee 4 informed her that Resident 1 was having pain and, after being informed the second time, she contacted the Registered Nurse to assess the Resident. There was no trauma observed. Employee 3 added that Resident 1 usually yells with any movement. The facility interview with Employee 4 (Registered Nurse) on August 8, 2023, at 1:00 PM, revealed Employee 4 worked the night shift August 6, 2023, into August 7, 2023. Documentation revealed she was called to Resident 1's room by Employee 3 due to the Resident having pain. Resident 1 told Employee 4 that she was having back pain, but Employee 3 said no, she's having left hip pain. Resident 1 informed Employee 4 that she broke my back a couple weeks ago. Employee 4 said no trauma was observed, but Resident 1 wouldn't let me do much with ROM [range of motion)]. During the facility interview with Employee 5 (Nurse Aide) on August 8, 2023, at 1:00 PM, Employee 5 revealed that she provided PM care and every 2-hour checks/changes and position changes On Saturday evening August 5, 2023. Employee 5 documented that Resident 1 was transferred to bed during the shift with 2 Employee persons and use of the walker. Resident 1 had no complaints of pain. The facility interview with Employee 6 (Registered Nurse) on August 8, 2023, he stated that staff made him aware that Resident 1 had a lump on her left hip. Employee 6 assessed Resident 1, who stated he was resting comfortable at the time. The assessment revealed there did appear to be an abnormality of the left hip and Employee 6 notified the PA-C (Physician Assistant-Contracted), when she arrived shortly after the assessment. It was determined that the hospice nurse would be in the building, and she would also assess the Resident. Hospice assessed Resident 1 and it was decided the staff would monitor the Resident for the next 24-hours. The family of the Resident was notified, and they decided to have an x-ray performed for the purpose of re-evaluating the Resident's pain medication. The x-ray was scheduled for August 8, 2023. A review of the documentation by the PA-C on August 8, 2023, stated the following assessment and plan: Resident 1 was seen this AM at the request of nursing staff for left hip discomfort. Resident is usually bedbound and does not usually bear weight and there has been no reported falls or injuries. Resident is confused per baseline, unable to give much info at the time of visit. Resident does appear to have pain when touching the left hip area. Musculoskeletal Assessment: limited range of motion, rotated in bed, leaning to right side, left hip exam reveals no ecchymosis; tender upon palpation; no range of motion of either lower extremity; knee without swelling and no range of motion. Plan: left hip pain; Questionable left hip pain without reported injury, consider arthritic flare versus acute bony injury but without reports of fall/injury, this is less likely; it was discussed with staff that id hospice\family approves we can obtain x-ray versus treating with pain meds that she already has and re-assess later afternoon/tomorrow depending on how things go. Will monitor closely. During the facility interview with Employee 7 (Nurse Aide) on August 8, 2023, Employee 7 revealed that she was assigned to Resident 1 on August 6, 2023, during day shift. Employee 7 stated that she provided AM care/hygiene and transferred Resident 1 from the bed to the wheelchair using a gait belt. Employee 7 revealed that she transferred Resident 1 from the wheelchair to the bed after lunch using a gait belt. Employee 7 stated that when she was trained, she was informed Resident 1 was a one-person assist transfer. When ask if Resident 1 had pain or anything out of the ordinary happen during transfer, Employee 7 replied, no, she gave me no indication of anything out of the ordinary. During a telephone interview with Employee 7 on August 16, 2023, at 12:30 PM, it was verified that Employee 7 was assigned to Resident 1 on August 6, 2023, during the day shift. Employee 7 was asked how Resident 1 was transferred, she replied, I'm aware now that she is a 2 assist for transfers but wasn't aware at that time, I believe I mistakenly looked at the roommates transfer status. Employee 7 was ask to describe the transfer technique for Resident 1 on August 6, 2023, she replied, the wheelchair was placed beside the bed and locked, the footrest was moved, a gait belt was applied, I told resident on the count of 3 you are going to stand, then resident pivoted until she sat on the edge of the bed, I placed my hand on the resident's back to lower her into bed and raised her legs onto the bed. Employee 7 stated the Resident gave her no indication of pain. Employee 7 added that Resident 1 made her usual comment, what did you do that for? and Employee 7 stated that she reminded the Resident, remember you're going to lie down and take a nap. Employee 7 said she removed the Resident's socks and then her pants, at which time the Resident said she was cold. Employee 7 said she performed incontinence care and covered the Resident. Employee 7 said, she never yelled or screamed, there was indication of pain even during incontinence care. The facility did report to the appropriate authorities and followed their policy pertaining to abuse and neglect. During an interview on August 17, 2023, at 12:30 PM, the Assistant Director of Nursing (DON) and NHA confirmed that the facility failed to ensure that Resident 1 was free from neglect, because Employee 7 failed to provide two-person transfer assistance with a walker, which may have caused harm. 28. Pa Code 201.14(a) Responsibility of licensee 28. Pa Code 201.18(b)(1)(3) Management 28. Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to review and revise the resident care plan to reflect the resident's current status for one of 21 residents reviewed (Resident 13). Findings Include: Review of Resident 13's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 13's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 13's current care plan revealed a code status of full code, with a start date of June 3, 2021. In an email correspondence from the Nursing Home Administrator (NHA) on October 20, 2021, at 5:27 PM she stated that Resident 13 was originally a full code upon admission but then Resident 13 changed to a DNR on June 11, 2021. During an interview with the NHA on October 21, 2021, at 1:45 PM she stated that the care plan should have been updated when Resident 13's code status changed. During an interview with Resident 13 on October 18, 2021, at 11:30 AM she stated that she wears bilateral hearing aides but one was being repaired and one was lost. Review of Resident 13's most recent quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated August 3, 2021, revealed in section B, Resident 13 has minimal difficulty hearing with hearing aides. Review of Resident 13's current care plan revealed no mention of Resident 13 wearing hearing aides. In an email correspondence from the NHA on October 20, 2021, at 5:27 PM she stated that Resident 13's hearing aides were not on the care plan since one is currently missing and the other one is out for repair. She stated the care plan will be updated when the hearing aides are returned. During an interview with the Director of Nursing on October 21, 2021, at 1:45 PM she stated that the care plan should have been updated to reflect the current status of Resident 13's hearing aides. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 21 residents reviewed (Resident 21). Findings include: Review of Resident 21's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on October 18, 2021, at 11:10 AM revealed a pacemaker monitor at Resident 21's bedside. Review of Resident 21's current orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 21's current care plan on October 20, 2021 at 9:30 AM revealed that the presence of Resident 21's pacemaker and considerations related to its use were not included in her plan of care. During an interview with the Nursing Home Administrator and Director of Nursing on October 21, 2021 at 1:46 PM they revealed the expectation that information regarding Resident 21's pacemaker should have been included in her plan of care. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility documentation and personnel records and interviews with staff, it was determined that the facility failed to ensure that nursing staff maintained active certifications for two nurse aides in the facility. Findings include: Review of documentation submitted by the facility on February 25, 2021, revealed that Nurse Aide 2's (NA 2) certification had expired on February 21, 2021. Employee worked on February 22, 2021 and February 23, 2021 prior to being placed on administrative leave on February 24, 2021. Interview with the Nursing Home Administrator on [DATE], revealed that NA 2 was on administrative leave from February 24, 2021 to [DATE]. Employee returned to work on [DATE] after her recertification was complete. Review of documentation submitted by the facility on [DATE], revealed that Nurse Aide 3's (NA 3) certification had expired on [DATE]. The facility identified the expired certification on [DATE] and placed employee on administrative leave. Review of NA 3's timecard revealed employee worked at the facility as a Certified Nurse Aide from [DATE] until [DATE] with an expired certification. Interview with the Nursing Home Administrator on [DATE] revealed NA 3 worked with an expired nurse aide certification from [DATE] to [DATE]. Employee was sent home on [DATE] on administrative leave until employee became recertified. Employee returned to work on [DATE]. 28 Pa Code 201.19 Personnel Policies and Procedures.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 residents reviewed (Residents 2 and 25). Findings include: Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility incident reports revealed that Resident 2 had a fall which resulted in a [CONDITION(S)] and wrist on October 20, 2020. Review of Resident 2's December 28, 2020 quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the MDS was coded to indicate that Resident 2 experienced a fall with major injury since the time the last most recent applicable MDS was completed. Review of MDS submissions revealed that the most recent applicable MDS was completed with a reference date of October 23, 2020 (date of readmission from hospital following repair of fractures). Review of facility incident reports for Resident 2 failed to reveal any additional falls with major injury that had occurred between October 23, 2020 and December 28, 2020. Review of Resident 25's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 25's August 28, 2021 quarterly MDS revealed that it was coded that at the time of the assessment Resident 25 had one stage 3 pressure ulcer/injury (injuries that occur on the skin surface due to prolonged pressure which limits blood flow. Stage 3 involves full thickness of the skin and may extend into the tissue layer below the skin). Further review revealed that the assessment was coded to indicate that the pressure ulcer/injury was acquired prior to Resident 25's admission to the facility. Review of Resident 25's clinical record revealed an admitted [DATE]. Review of Resident 25's skin evaluation record revealed that at the time of the August 28, 2021 assessment resident was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the RNAC (Registered Nurse Assessment Coordinator) on October 21, 2021, at 8:52 AM she confirmed that the aforementioned MDS assessments were coded incorrectly. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to secure the personal privacy and confidentiality of the residents' medical information for one of seven residents observed during medication administration (Resident 5). Findings Include: Review of facility policy titled IIA2: Medication Administration-General Guidelines dated 2020, revealed .privacy is maintained always for all resident information (e.g. MAR) by closing the MAR book/covering the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 19, 2021, at 9:01 AM Licensed Practical Nurse (LPN) 1 was observed preparing and then administering medications to Resident 5. Upon entering Resident 5's room, LPN 1 left the computer screen open with Resident 5's medication orders displayed on the screen. During an interview with LPN 1 on October 19, 2021, at 9:16 AM he stated that he should have closed the computer screen when walking away from the computer. On October 21, 2021, at 1:44 PM the Nursing Home Administrator and Director of Nursing stated that the computer screen with Resident 5's information displayed should not have been left open. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident the right to formulate an advance directive or living will for one of nineteen residents reviewed (Resident 52). Findings include: Review of the facility's undated policy titled Advanced Directives defines an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care that relates to the provision of health care when the individual is incapacitated. Further review of the policy defines an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The POLST/MOLST/DMOST form is NOT an advance directive. Further review reveals, if the resident does not have an advance directive, facility staff must inform the resident or resident representative of their right to establish one as set forth in the laws of the State and provide assistance if the resident wishes to execute one or more directive(s). Facility staff must document in the resident's medical record these discussions and any advance directive(s) that the resident executes. Review of Resident 52's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This status refers to not receiving any resuscitation efforts in the event of an emergency. Review of 52's clinical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 52's clinical record revealed that an advance directive was not present and no documentation related to the facility staff informing the resident or resident representative of their right to establish an advance directive was present. 28 Pa. code 201.8 (b)(2) Management. 28 Pa. code 201.29(a) Resident Rights.

Based on observations and interviews, the facility failed to ensure the resident's environment was free of accident hazards and harm, for six of 71 residents, (Residents 4, 5, 6, 7, 8 and 9), identified as cognitively impaired, when the physical therapy room was left unlocked and unattended with an unlocked [MEDICATION NAME] (a device used to store therapeutic steam packs in 160-165 degree Fahrenheit (F) temperature), holding hot steaming water, measuring 161.4 degrees Fahrenheit (F), placing the residents at risk for harm and the residents at the facility in Immediate Jeopardy. Findings include: An observation on (MONTH) 25, (YEAR), at 9:44 a.m. revealed both entry doors of the therapy room, located between the North and West resident care units, were unlocked. A [MEDICATION NAME] was in the therapy room, turned on, and full of fluid and steam packs (sealed cloth pad containing a filler that is used for therapeutic treatment). The [MEDICATION NAME] had a lid with a handle, which was easy to open. The [MEDICATION NAME] used by the facility measures 33 inches tall and 20 inches wide making it easy for anyone sitting in a wheelchair to lift the lid, lean into the area of steam and hot water with their head, or reach into the hot water with their hand(s). A chain and lock was hanging on the side of the unit and was not in use. Review of the [MEDICATION NAME] user manual, page 4 stated the following: Warning, the water in the [MEDICATION NAME] is approximately 71 degrees Celsius (metric unit of measurement) (160 degrees F), and the water scalding temperature is approximately 49 degrees Celsius (120 degrees F). During an interview with the Director of Nursing (DON) on (MONTH) 25, (YEAR), at 9:45 a.m. she stated that the physical therapist was in the therapy room earlier today to evaluate two newly admitted residents. The DON stated, when the therapy room is unoccupied by staff, the doors should be locked. Verification that the physical therapist left the facility was made by lack of physical presence, and a review of the therapist's punch time for hours worked on (MONTH) 25, (YEAR). The therapist arrived at the facility at 5:25 a.m. and left the facility at 8:08 a.m. Observations on (MONTH) 25, (YEAR), at 9:50 a.m. revealed that residents on the South, North, and West resident care units had access to the unlocked doors in the therapy room simply by pushing down on the lever handles of the doors to open them. Review of the Admission MDS (minimum data set- periodic assessment of resident needs) Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 11, (YEAR), for Resident 4 revealed a BIMS (brief interview of mental status) of 4, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 4 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of her upper and lower extremities. Review of the Admission MDS Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 21, (YEAR), for Resident 5 revealed a BIMS of 0, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 5 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of upper and lower extremities. Review of the Quarterly MDS Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 6, (YEAR), for Resident 6 revealed a BIMS of 4, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 6 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of upper and lower extremities. Review of the Annual MDS Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 27, (YEAR), for Resident 7 revealed a BIMS of 3, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 7 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of upper and lower extremities. Review of the Quarterly MDS Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 1, (YEAR), for Resident 8 revealed a BIMS of 3, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 8 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of upper and lower extremities. Review of the Quarterly MDS Section C. Cognitive Patterns, Subsection C0500, dated (MONTH) 28, (YEAR), for Resident 9 revealed a BIMS of 3, indicating severe cognitive impairment. Review of Section G, Functional Status, Subsection E. Locomotion on unit, and F. Locomotion off unit, revealed Resident 9 was self-sufficient once in the wheelchair, and Subsection G0400. Functional Limitation in Range of Motion was coded with no impairment and had full range of motion of upper and lower extremities. The Director of Therapy was contacted by the DON and requested to come into the facility immediately to answer questions regarding the unlocked therapy room and [MEDICATION NAME]. The Director of Therapy arrived at the facility at 10:34 a.m. The fluid temperature inside the [MEDICATION NAME] was 161.4 degrees F. (The time required for a 3rd degree burn to occur at 155 degrees F. is one second) as measured by the Director of Therapy. The Director of Therapy stated that the lock and chain hanging on the side of the [MEDICATION NAME] is never used. During an interview with the DON and Director of Therapy on (MONTH) 25, (YEAR), at 10:34 a.m. the surveyor requested the facility's policy for safety and storage of the [MEDICATION NAME]. The facility did not have a policy. The Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy was identified on (MONTH) 25, (YEAR), at 1:20 p.m. A request for an immediate plan of action was made to the NHA. An acceptable plan of action was submitted on (MONTH) 25, (YEAR), at 3:56 p.m. and included the following plan to resolve the Immediate Jeopardy status: A. Residents who were in the therapy department this morning, (MONTH) 25, (YEAR), have had skin checks completed with no areas [MEDICAL CONDITION], Residents 10 and 11. B. Current residents who are independently mobile and cognitively impaired that could have accessed the therapy department today have received skin checks with no areas [MEDICAL CONDITION]. An audit has been completed by doing a full house sweep to identify any areas that are not secured that could be a burn hazard. None were identified. C. Staff currently working in the facility have been educated that the [MEDICATION NAME] is to be locked, always, when not being accessed, and the therapy room door must be locked always, when therapy staff are not present in the room. All other staff will be educated, prior to the start of their shift, that the [MEDICATION NAME] is to be locked when not being accessed and the therapy room doors must be locked always when therapy staff are not present in the room. D. A daily audit will be completed for one week and then weekly for 11 weeks to ensure that the [MEDICATION NAME] is locked and that the therapy department is locked when there are no staff members present in the room. Audits will be forwarded to the Quality Assurance Committee for review and further recommendations. E. A policy obtained from the contracted therapy service on (MONTH) 25, (YEAR), reflects a monthly cleaning schedule form for the [MEDICATION NAME]. This policy will be revised to reflect specifics per the manufacturer's recommendations to include cleaning the [MEDICATION NAME] every 2-weeks and monitoring temperatures to maintain 160-165 degrees F. F. A policy will be developed to address cleaning the [MEDICATION NAME] pack covers specific to infection control with an audit tool to be implemented for this activity. Audit tool will be reviewed by the therapy director and forwarded to QAPI for review and further recommendations. During an interview with the Nursing Home Administrator on (MONTH) 25, (YEAR), at 1:25 p.m. she confirmed that the therapy room doors should be locked when therapy staff are not present in the room, that the [MEDICATION NAME] should be locked always when not in use, and that a cleaning schedule and temperature checks per manufacturer's guidelines should be followed. An onsite visit was conducted on (MONTH) 26, (YEAR), at 9:15 a.m. to review and observe that the plan of action was implemented. An observation of the therapy room on (MONTH) 26, (YEAR), at 9:30 a.m. revealed that the [MEDICATION NAME] was secured with a chain and lock. The NHA revealed and provided audits that are being completed daily, to assure when the therapy room is unoccupied that both doors are secured. Review of education revealed all staff were educated on the importance of keeping the therapy room doors secured. The Immediate Jeopardy was lifted on (MONTH) 26, (YEAR), at 9:45 a.m. and the NHA was informed. Observation during initial tour on (MONTH) 25, (YEAR), at 7:30 a.m. revealed an unlocked wound care cart in the hall of the North Wing resident care unit. Every drawer was accessible by pulling on them. Inside the top drawer were a pair of scissors and a hemostat, also called a [MEDICATION NAME] clamp or arterial forceps, (a surgical tool used in many surgical procedures to control bleeding). During an interview with the Director of Nursing (DON) on (MONTH) 25, (YEAR), at 7:35 a.m. she was asked, do you know why this cart is here and unlocked? to which she replied, I don't know why it is here or unlocked. The sharps (scissors and hemostat) were shown located in the top drawer. The DON locked the cart and transferred it to a secured room behind the nurse's station. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/26/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/26/18, 2/13/17, 2/2/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 2/2/17. 28 Pa. Code 201.18(d) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/26/18, 2/13/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/26/18, 4/10/17, 2/13/17.

Based on clinical record review and interview with the staff, the facility failed to ensure that insulin was administered following the, Medication Administration policy which resulted in a resident receiving 63 units of insulin, more than the physician ordered dose of insulin, resulting in the resident requiring frequent monitoring, the administering of medication for low blood sugar, and not feeling well for one of 6 residents reviewed Resident (1). Findings include: Review of the, Medication Administration policy, (utilized to provide licensed nursing staff instruction and direction regarding how to prepare and administer resident's medication) dated 2014, revealed that the procedure for administering medications included verifying the (medication) order, checking the medication administration sheet, preparing the medication accurately and to practice the 6 rights throughout the medication pass, which includes the right medication and the right dose. Review of Resident 4's clinical record revealed medical [DIAGNOSES REDACTED]. Review of Resident 4's, Medication, Treatment and Task Administration Record, (a form utilized to indicate what medications and times a resident was to receive medication) dated July 2016 - August 2016, revealed that Resident 4 was to receive 7 units of Humalog insulin (a fast acting medication given by injection, used to treat Diabetes). Review of an Interdisciplinary Progress Note (notes kept in the resident's record regarding the care a resident is provided) dated July 17, 2016, at 8:37 a.m. revealed that Licensed Practical Nurse (LPN) 3 reported that the resident received 70 units of Humalog insulin (10 times the prescribed dose). An interview with the Nursing Home Administrator on July 27, 2016, at 4:00 p.m. and a review of a facility Incident/Accident Report (a form utilized by the facility to document, investigate and determine the cause of an incident or accident) dated July 27, 2016, confirmed that LPN 3 administered the incorrect dose of Humalog insulin to Resident R4. Further review of the, Interdisciplinary Progress Note dated July 17, 2016, at 8:46 a.m. and 10:27 a.m., revealed that Resident 4's physician was notified of the medication error and an order was received to monitor Resident 4's blood sugar (the amount of glucose in the blood by inserting a needle into the finger to withdraw a small amount of blood) every 30 minutes until 12:00 p.m. and that the resident was given [MEDICATION NAME] (a medication given by injection to raise very low blood sugar). Review of the, Medication, Treatment and Task Administration Record dated July 2016 - August 2016, revealed that Resident R4 received 6 additional blood sugar checks between 9:00 a.m. and 12:00 p.m., as well as an additional injection of medication ([MEDICATION NAME]) at 9:51 a.m. In an interview with Resident 4 on July 27, 2016, at 4:30 p.m. the resident stated that following the administration of the incorrect dose of Humalog insulin he/she had, jitters, shakes, sweat like crazy. The resident also stated, every half hour they kept sticking me with needles. I didn't too much care for it. An interview with the Director of Nursing on July 27, 2016, at 6:40 p.m. confirmed that LPN 3 failed to follow the facility's, Medication Administration policy. The facility failed to ensure that insulin was administered following the, Medication Administration policy which resulted in Resident 4 receiving 63 units of insulin, more than the physician ordered dose of insulin, resulting in Resident 4 requiring frequent monitoring, the administering of medication for low blood sugar, and Resident 4 not feeling well. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/26/15. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 2/24/16, 10/1/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/24/16, 12/16/15, 10/1/15.

Based on review of clinical records, facility policy and incident reports and interviews with the residents and the staff, it was determined that the facility failed to ensure that there were no significant medication errors for one of 6 residents reviewed (Resident 4). Findings include: Review of the, Medication Administration policy, (utilized to provide licensed nursing staff instruction and direction regarding how to prepare and administer resident's medications) dated 2014, revealed that the procedure for administering medications included verifying the (medication) order, checking the medication administration sheet, preparing the medication accurately and to practice the, 6 rights throughout the medication pass, which includes the right medication and the right dose. Review of Resident 4's clinical record revealed medical [DIAGNOSES REDACTED]. Review of Resident 4's, Medication, Treatment and Task Administration Record, (a form utilized to indicate what medications and times a resident is to receive medication) dated July 2016 - August 2016, revealed that Resident 4 was to receive 7 units of Humalog insulin (a fast acting medication given by injection, used to treat diabetes). Review of an, Interdisciplinary Progress Note (notes kept in the resident's record regarding the care a resident is provided) dated July 17, 2016, at 8:37 a.m. revealed that Licensed Practical Nurse (LPN) 3 reported that the resident received 70 units of Humalog insulin (10 times the prescribed dose). An interview with the Nursing Home Administrator on July 27, 2016, at 4:00 p.m. and a review of a facility, Incident/Accident Report (a form utilized by the facility to document, investigate and determine the cause of an incident or accident) dated July 27, 2016, confirmed that LPN 3 administered the incorrect dose of Humalog insulin to Resident R4. Further review of the, Interdisciplinary Progress Note dated July 17, 2016, at 8:46 a.m. and 10:27 a.m., revealed that Resident 4's physician was notified of the medication error and an order was received to monitor Resident 4's blood sugar (the amount of glucose in the blood by inserting a needle into the finger to withdraw a small amount of blood) every 30 minutes until 12:00 p.m. and that the resident was given [MEDICATION NAME] (a medication given by injection to raise very low blood sugar). Review of the, Medication, Treatment and Task Administration Record dated July 2016 - August 2016, revealed that Resident R4 received 6 additional blood sugar checks between 9:00 a.m. and 12:00 p.m., as well as an additional injection of medication ([MEDICATION NAME]) at 9:51 a.m. In an interview with Resident 4 on July 27, 2016, at 4:30 p.m. the resident stated that following the administration of the incorrect dose of Humalog insulin he/she had, jitters, shakes, sweat like crazy. The resident also stated, every half hour they kept sticking me with needles. I didn't too much care for it. An interview with the Director of Nursing on July 27, 2016, at 6:40 p.m. confirmed that LPN 3 failed to follow the facility's, Medication Administration policy, resulting in a significant medication error. The facility failed to ensure that insulin was administered following the, Medication Administration policy which resulted in Resident 4 receiving 63 units of insulin, more than the physician ordered dose of insulin, resulting in Resident 4 requiring frequent monitoring, the administering of medication for low blood sugar and Resident 4 not feeling well. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/24/16, 12/16/15, 10/1/15.

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to accurately assess, timely identify, and provide the necessary care and services to provide interventions and timely treatments following a change of condition for 1 of fifteen residents reviewed (Resident 10). Findings include: Review of the facility policy on Fall Management, reviewed [DATE], revealed that any fall that involves a potential/actual head injury will include follow-up neurological checks, which will be documented on the Neurological Assessment Flow Sheet. Review of the facility policy for Neurological Evaluation, reviewed [DATE], revealed that any resident with the potential of a head trauma injury or having an acute change in level of consciousness, will receive 72 hours of neurological evaluation (check of ability to open eyes, obey simple commands, and flaccidity) following notification of the physician. The neurological assessments are to be done every fifteen minutes for the first hour, every hour for the next three hours, every two hours for the next four hours, every four hours for the next sixteen hours and every eight hours for the next forty-eight hours. Review of the facility's two Incident/Accident Report forms, dated [DATE], revealed that Resident 10 had two unwitnessed falls that evening, the first at 7:55 p.m. and the second at 9:35 p.m. Neuro checks were initiated after the first fall and are documented one time on the neurological flow sheet at 8:00 p.m. on [DATE]. The second fall occurred at 9:35 p.m. and at that time, Resident 10 was also found on the floor in his room but was unable to say what happened. A pressure pad alarm was placed on the chair and bed. A new neurological flow sheet was started at 9:35 p.m. on [DATE]. No entries were made for the next two scheduled checks. Review of nurses' notes dated [DATE], at 6:12 a.m., state that Licensed Practical Nurse 1 (LPN 1) gave Resident 10 an [MEDICATION NAME] (0.5mg) at 12:13 a.m. for anxiety and restlessness. He had increased wandering and would not stay in the bed or in the recliner and had a very unsteady gait. He was also given a whirlpool bath and then brought to the nursing desk where he fell asleep and had been sleeping since 12:13 a.m. The neurological flow sheet indicates that neuro checks were done at 2:20 a.m., 4:20 a.m., 6:20 a.m. and 8:20 a.m. The entry for 8:20 a.m. indicates a change in eye opening response from a 4 (spontaneous opening) to a 2 (opens to pain not applied to face), in verbal response from a 4 (confused but able to answer questions) to a 1 (no response), and in motor response from a 6 (obeys request for movement) to a 1 (flaccid/no response). A nurses' note dated [DATE], at 12:07 p.m., states that Registered Nurse 1 (RN 1) was asked to see Resident 10 as he was less responsive than usual. He was in his bed, does not open his eyes to verbal or tactile stimuli and does not open his eyes to sternal rub. The nurses' note indicates that the on-call doctor was paged at this point. A nurses' note dated [DATE], at 12:35 p.m., indicates that Resident 10 was transported to the Holy Spirit Hospital via EMS. Review of the Radiology and Diagnostic report for CT of brain from Holy Spirit Hospital dated [DATE], indicates a large subdural hematoma (collection of blood on the surface of the brain). Resident 10 was admitted to Holy Spirit Hospital for comfort care and he expired on [DATE]. The death certificate indicates immediate cause subdural hematoma. Interview on [DATE], at 1:30 p.m. with the Executive Director (ED), revealed that the facility staff did not follow proper process and procedures to provide the appropriate care to Resident 10. She also indicated that through the facility's investigation, it was discovered that the neuro checks transcribed on [DATE], for the times 4:20 a.m. and 6:20 a.m.were transcribed without actually having been done. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited: [DATE] and [DATE] 28 Pa. Code 211.5(f) Clinical record Previously cited: [DATE] 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.11(a)(c)(d) Resident care plan Previously cited: [DATE] and [DATE] 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited: [DATE] and [DATE] 28 Pa Code 211.12(c) Nursing services