Every finding on record at Terrace Health & Rehab Center

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of seven residents (Resident R7, R21, R32, and R81).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood.-Resident R7 had an MDS completed on 5/7/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R7 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R7 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R7 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R21 had an MDS completed on 5/11/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R21 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R21 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R21 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R32 had an MDS completed on 7/16/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R32 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R32 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R32 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R81 had an MDS completed on 7/20/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R81 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R81 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R81 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 7/23/26, at approximately 12:00 p.m. the Resident Nurse Assessment Coordinator Employee E19 confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for four of seven residents.28 Pa. Code: 211.5(f) Clinical records.

Based on a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses: Licensed Practical Nurse (LPN) Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, and Registered Nurse (RN) Employees E13, E14, E15, E16).Review of the facility, Cardiopulmonary Resuscitation CPR dated [DATE], indicated Licensed nurses, respiratory therapists, and van drivers will hold active CPR certification for healthcare providers whose course content and staff performance are validated via a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Courses completed in on-line only format are not acceptable.On [DATE], the facility provided a list of 33 currently employed licensed nurses.Review of the CPR certification cards for LPN Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, and RN Employees E13, E14, E15, E16 indicated the certification was for an online-only CPR class, for non-healthcare providers, that did not include a hands-on session.During an interview on [DATE], at 1:30 p.m. Human Resources Director Employee E17 confirmed the above employees did not have the appropriate CPR certification for licensed nurses.During an interview on [DATE], at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that facility nursing personnel maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 16 of 33 licensed nurses.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of ten residents (Resident R13 and Resident R53). Findings include: Review of facility policy Medication Administration dated 1/15/26, indicated that medications are administered only as prescribed by the provider. Review of Resident R13's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 4/30/26, included diagnoses of type 2 diabetes (disease where the body either doesn't make enough insulin or doesn't use it properly) and chronic kidney disease (long term disease where kidneys slowly lose their ability to filter waste and extra fluid from the body). Review of a physician's order dated 2/28/26, indicated Resident R13 to receive 2 units of insulin lispro subcutaneously twice daily and hold if blood sugar less than 150. Review of Resident R13's medication audit report from 7/1/26, through 7/23/26 revealed the following related to the administration of insulin lispro: 7/3/26: 5:00 p.m. dose administered with blood sugar of 125.7/13/26: 5:00 p.m. dose administered with blood sugar of 132.7/22/26: 5:00 p.m. dose administered with blood sugar of 146. Review of Resident R53's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R53's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 5/14/26, included diagnoses of type 2 diabetes (disease where the body either doesn't make enough insulin or doesn't use it properly) and chronic kidney disease (long term disease where kidneys slowly lose their ability to filter waste and extra fluid from the body). Review of a physician's order dated 1/19/26, indicated Resident R53 to receive 10 units of insulin aspart subcutaneously before meals for blood sugars and hold if blood sugar less than 200. Review of Resident R53's medication audit report from 7/1/26, through 7/23/26 revealed the following related to the administration of insulin aspart: 7/4/26: 8:00 a.m. dose administered with blood sugar of 187; 12:00 p.m. dose administered with blood sugar of 154.7/8/26: 8:00 a.m. dose administered with blood sugar of 138; 12:00 p.m. dose administered with blood sugar of 137.7/11/26: 8:00 a.m. dose administered with blood sugar of 167.7/13/26: 8:00 a.m. dose administered with blood sugar of 154; 12:00 p.m. dose administered with blood sugar of 154.7/14/26: 8:00 a.m. dose administered with blood sugar of 164; 12:00 p.m. dose administered with blood sugar of 158; and 4:00 p.m. dose administered with blood sugar of 139.7/22/26: 8:00 a.m. dose administered with blood sugar of 165. During an interview on 7/23/26, at approximately 11:00 a.m. the Director of Nursing confirmed that the orders for insulin aspart were specifically administered outside of the parameters set in the physician order. During an interview on 7/23/26, at approximately 1:10 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents were free from significant medication errors for two of ten residents. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c) Resident care policies.28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medical supplies were stored and/or disposed of appropriately in one of two medication rooms (Second Floor medication room) and two of two medical supply rooms (Second and Third Floor medical supply rooms). Findings include: Review of the United States Food and Drug Administration prescribing information for Aplisol (sterile, liquid solution of tuberculin purified protein derivative (PPD) used as an intradermal skin test to help healthcare providers detect if a person has been infected with the bacteria that causes tuberculosis) dated November 2013, indicated, Vials in use for more than 30 days should be discarded). Review of the facility policy, Storage and Expiration Dating of Medications and Biologicals dated 1/15/26, indicated, Facility should ensure medications an biological that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. During an observation of the Second Floor supply room on 7/21/26, at 7:06 a.m. the following was noted:(1) Wound vacuum foam with an expiration date of 10/27/24.(1) Wound vacuum foam with an expiration date of 11/2024.(1) Wound vacuum foam with an expiration date of 12/22/24.(1) Wound vacuum foam with an expiration date of 1/2025.(1) Wound vacuum foam with an expiration date of 9/1/25.(2) Wound vacuum foam with an expiration date of 5/10/26,(111) sterile water ampules with an expiration date of 3/21/26(50 count) box glucose test strips with an expiration date of 11/20/25.(9) Luer lock caps with an expiration date of 5/31/26.(4) Connectors with caps with an expiration date of 11/28/25.(1) opened, non-sterile vial adapter.(1) unwrapped normal saline flush.(1) IV catheter with an expiration date of 6/30/25.(1) Transparent dressing with an expiration date of 6/3/26.(88) Collection tubes with an expiration date of 1/31/26. During an observation of the Second Floor medication room refrigerator on 7/21/26, at 7:19 a.m. the following was noted:(1) vial of Aplisol, partially used and undated. During an observation of the Third Floor supply room on 7/21/26, at 7:41 a.m. the following was noted:(75) sterile water ampules with an expiration date of 6/5/26(15) Miralax packets with an expiration date of 03/2025(1) Safety needle with an expiration date of 5/11/26 During an interview on 7/23/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that medications and medical supplies were stored and/or disposed of appropriately in one of two medication rooms (Second Floor medication room) and two of two medical supply rooms (Second and Third Floor medical supply rooms). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1) Management.28 Pa Code: 211.9 (a)(1) Pharmacy Services.28 Pa Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for two of six residents (Resident R4 and R24). Findings include: Review of facility policy Pressure Injury Prevention and Management dated 1/15/26, indicated residents admitted with existing pressure injuries will receive necessary treatment and services consistent with professional standards of practice. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/7/26, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), a stroke and heart fibrillation. Question M0150 was coded 1 yes, resident is at risk of developing pressure ulcers/injuries. Review of a physician order dated 11/20/25, indicated air mattress to bed, check for functioning. Review of a progress note dated 3/5/26, identified Resident R4 had developed a DTI (pressure induced injury with deep purplish tissues) identified by staff on 3/2/26, measuring 2cm x 3.5 cm and the wound Nurse Practitioner indicated, The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Review of the clinical record revealed Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's MDS dated [DATE], indicated diagnoses of dementia, psychotic disturbance, anxiety and cognitive communication deficit. Question M0150 was coded 1 yes, resident is at risk of developing pressure ulcers/injuries. An MDS dated [DATE], Section GG0070 identified Resident R24 was dependent (requires the caregiver to perform all the care) for bed mobility. Review of Resident R24's physician orders dated 11/21/25 indicated bilateral enabler bars for bed mobility and a pressure reduction mattress. Review of a progress note date 5/21/26, indicated that staff had found a pressure ulcer on 5/20/26, and was identified as a new stage III wound measuring 1 cm x 0.8 cm x 0.2 cm with 0% eschar, 60% granulation tissue and 20% slough and the Wound Nurse Practitiner indicated The patient is at increased risk for developing skin breakdown and moisture associated skin damage due to fecal and urinary incontinence, inability to preform self-care. During an interview on 7/21/26, at approximately 11:15 a.m., the Director of Nursing confirmed that the facility failed to make certain Residents R4 and R24 were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Psychiatry Group provided progress notes for continuity of care with each visit for one of two residents reviewed (Resident 39). Findings include: Review of a Minimum Data Set (MDS- periodic review of resident care needs) dated 6/3/26, indicated Resident R39 had a diagnosis of schizophrenia (a serious medical condition involving a breakdown of the relation between thoughts, emotions and behaviors leading to faulty perception, inappropriate actions and feelings and delusions). Review of Resident R39's clinical record identified that he utilizes an outside resource for his mental health care. During an interview on 7/21/26, at approximately 8:10 a.m., Resident R39 stated that he goes to [outpatient therapy] every three months for his care and medication, so he has no issues getting his medication required for his mental health. Review of Resident R39's clinical record did not identify any progress notes or documentation from [outpatient therapy] therapists related to the continuity of care for Resident R39's mental health. Stated he had been at the clinic in January, April and accidentally in May again. During an attempt to get documentation on 7/21/26, at approximately 12:11 p.m., the Director of Nursing stated that she called the clinic and was sent to Medical Record dept and left a message. During a phone conversation with the clinic, on 7/21/26, at approximately 12:15 p.m., the Medical Records staff stated that the facility needed Resident R39 to sign a form allowing the clinic to send over records, although he was a resident of the facility. She stated she would send over the form. During an interview on 7/21/26, at approximately 1:15 p.m., the DON stated she had them fax the form and she would have it signed by resident. During an interview on 7/22/26, at 9:43 a.m., the Assistant Director of Nursing Employee E20 stated the clinic did not send any documentation and that the facility to ensure that the Psychiatry Group provided progress notes for continuity of care with each visit for one of two residents reviewed (Resident 39). 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on emergency preparedness annually to all staff members.Findings include:Review of the United States Code of Federal Regulations S483.73(d)(ii) Emergency Preparedness indicated, The LTC (long-term care) facility must: Provide emergency preparedness training at least annually and Maintain documentation of the training.During an interview on 7/23/26, at approximately 12:46 p.m. the Director of Maintenance Employee E18 confirmed that emergency preparedness training is only provided during new-employee orientation and is not completed annually with each staff member.During an interview on 7/23/26, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on emergency preparedness annually to all staff members.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(3) Staff development.

Based on a review of the food council minutes, resident group meeting information, observation and staff interview, it was determined that the facility failed to serve food that was palatable and attractive.Findings include:Review of three months of food council meeting minutes identified residents stating that the food was tasteless. During the resident group meeting on 8/26/25, at 1:48 p.m., the consensus of the resident's indicated: food trays had hair in them at times, and they question if hair nets are used. Kitchen staff is rude when you call them if they answer the phone and the kitchen staff is rude to the floor staff as well when they call. Rarely get the meal order that is on the menu. The paper on your tray is not accurate often. You get cereal and no milk or milk and no cereal. During an observation of tray line service on 8/27/25 from 11:42 a.m., through 12:40 p.m., the following was observed:When pureed foods were plated, they were all placed in a big glob and the zucchini was very thin and all three items mixed together.18 residents did not receive the cherry cheesecake dessert that was identified for meal posted.15 received plain pudding and three received the alternate pear crisp, although all food slips indicated the cherry dessert.During an interview on 8/27/25, at 2:00 p.m., the Nursing Home Administrator and Corporate Dietary Manager Employee E5 confirmed that the facility failed to serve food that was palatable and attractive.28 Pa. Code 211.6(b) Dietary Services.

Based on observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).Findings include:During an observation of the kitchen on 8/2725, from 11:22 a.m., through 12:45 p.m., the following was observed:A foam glass with liquid and initials SM was observed on food prep table near cooler, Dietary Aide Employee E7 confirmed it was hers.at 11:37 a.m. Dietary Aide Employees E7 and E8 entered the kitchen with their hair not completely covered with hairnet. Dietary [NAME] Employee E9 was wiping down prep areas took rag with gloves into hall, then returned and donned gloves and began placing bread onto pan, left area to get cheese from refrigerator, opened cheese packed in plastic wrap, removed cheese and began making grilled cheeses sandwiches. No handwashing between tasks. Dietary Manager (DM) Employee E6 picked up scoop he dropped onto floor, took it to sink, returned to tray line placed gloves and began serving meals, no hand washing prior to tray line service. Tray line began at 11:43 a.m. was to start at 11:30 a.m. according to schedule. DM Employee E6 removed buns from bag, placed on plate, no handwashing/glove change. Dietary Aide Employee E7 removed bread from package with contaminated gloves as she was performing another task and placed bread slices onto a plate for meat to be placed on by DM Employee E6 Cart delivery posted indicated:2nd floor DR 11:40 a.m , delivery actual time was 11:543rd floor DR 11:50 a.m., actual time left kitchen at 11:582 North was to arrive at noon, actual arrival at 12:103 North was to arrive at 12:10 p.m , actual time left the kitchen at 12:20 p.m.2 South was to arrive at 12:20 p.m., actual time left the kitchen was 12:34 p.m.3 South was to arrive at 12:30 p.m., actual left kitchen at 12:45 p.m. During an interview on 8/27/25, at 2:00 p.m., Corporate Dietary Manager Employee E5 and the Nursing Home Administrator confirmed that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c) Dietary services.

Based on a review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible for six of twelve residents as required (Resident R1, R20, R72, R94, R109, and R502).Based on a review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible for six of twelve residents as required (Resident R1, R20, R72, R94, R109, and R502). Findings include: The facility policy Resident Rights dated 3/28/25, indicated Call light or bell access will be within reach of the resident as one method to communicate needs to staff. Review of Resident R1's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 5/1/23 and revised on 3/31/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 6/21/25 indicated the resident is not capable of using their call light. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/25/25, indicated diagnoses of non-Alzheimer's dementia (loss memory and cognitive functions), malnutrition (imbalance between the nutrients your body needs to function), and psychotic disorder (disconnection from reality symptoms of delusions, hallucinations and disorganized thinking). Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is dependent with all care helper does all of the effort, resident does none of the effort to complete activity or assistance of two or more helpers is required. During an interview on 8/26/25 at approximately10:00 a.m. Resident R72 was unaware of the location of the call light. During an observation with the Nursing Home Administrator (NHA) confirmed on 8/26/25 at approximately 11:00 a.m. Resident R1 call light was on the resident's nightstand next to the resident's bed, out of the reach of the resident. No alternative method was noted to be in place for the resident to communicate needs as per facility policy. Review of Resident R20's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 10/27/22 and revised on 3/13/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 6/13/25 indicated the resident is capable of using their call light. Review of Resident R20's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia, anxiety disorder (feelings of fear, dread or apprehension without an appropriate cause), and malnutrition (imbalance between the nutrients your body needs to function). Review of Section GG: Functional Abilities GG0130, indicated that Resident R20 is dependent with care helper does all of the effort, resident does none of the effort to complete activity or assistance of two or more helpers is required. During an interview on 8/26/25 at 10:50 a.m. Resident R20 was unaware of the location of the call light. During an observation rounds with NHA confirmed on 8/26/25, at approximately 11:00 a.m. Resident R20 call light was on Resident R1's nightstand next to Resident R1's bed, out of reach of Resident R20. Review of Resident R72's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 1/26/23 and revised on 3/13/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 7/27/25 indicated the resident is capable of using their call light. Review of Resident R72's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia, anxiety disorder (feelings of fear, dread or apprehension without an appropriate cause), and hypertension (high blood pressure). Review of Section GG: Functional Abilities GG0130, indicated that Resident R72 is dependent with oral, personal, toileting, and shower hygiene, helper does all of the effort, resident does none of the effort to complete activity or assistance of two or more helpers is required. During an interview on 8/26/25 at approximately 9:30 a.m. Resident R72 was unaware of the location of the call light. During an observation rounds Licensed Practical Nurse (LPN) Employee E2 confirmed on 8/26/25 at approximately 11:10 a.m. Resident R72's call light was wrapped around the call system connection port in the middle of the room, out of reach of Resident R72. Review of Resident R94's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 12/17/24 and revised on 3/13/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 7/3/25 indicated the resident is capable of using their call light. Review of Resident R94's MDS dated [DATE], indicated diagnoses of malnutrition (imbalance between the nutrients your body needs to function), anxiety disorder (feelings of fear, dread or apprehension without an appropriate cause), and renal insufficiency (kidneys have reduced function). Review of Section GG: Functional Abilities GG0130, indicated that Resident R94 is dependent with toileting dressing, and personal hygiene, helper does all of the effort, resident does none of the effort to complete activity or assistance of two or more helpers is required. During an interview on 8/26/25 at approximately 9:30 a.m. Resident R94 was unaware of the location of the call light. During observation rounds with the Employee E2 (LPN) confirmed on 8/26/25 at approximately 11:10 a.m. Resident R94's call light was wrapped around the call system connection port in the middle of the room, out of reach of Resident R94. Review of Resident R109's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 4/22/24 and revised on 3/13/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 7/21/25 indicated the resident is not capable of using their call light. Review of Resident R109's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia (loss memory and cognitive functions), anxiety disorder (feelings of fear, dread or apprehension without an appropriate cause), and diabetes (high blood sugar). Review of Section GG: Functional Abilities GG0130, indicated that Resident R109 is dependent with care helper does all of the effort, resident does none of the effort to complete activity or assistance of two or more helpers is required. During an interview on 8/26/25 at approximately 9:30 a.m. Resident R109 was unaware of the location of the call light. During observation rounds with the LPN Employee E2 confirmed on 8/26/25 at approximately 11:10 a.m. Resident R109's call light was wrapped around the call system connection port in the middle of the room, out of reach of Resident R109. No alternative method was noted to be in place for the resident to communicate needs as per facility policy. During a resident group interview on 8/26/25, at 1:30 p.m., Resident R502 stated her call light is often out of her reach on the floor or behind the bed. R502 stated that she tells the staff to clip it to the bed. Review of Resident R502's clinical record indicated the resident was originally admitted to the facility on [DATE]. Review of the resident's care plan documented interventions initially dated 6/1/23 and revised on 8/24/25 place call bell within reach, remind resident to call for assistance. Review of the resident's bed safety evaluation dated 6/12/25 indicated the resident is capable of using their call light. Review of Resident R502's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia (loss memory and cognitive functions), anxiety disorder (feelings of fear, dread or apprehension without an appropriate cause), and diabetes (high blood sugar). Review of Section GG: Functional Abilities GG0130, indicated that Resident R502 requires assistance with personal hygiene, helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. During an interview on 8/27/25 at 1:30 p.m. the (NHA) confirmed the facility failed to make certain call lights were accessible for six of twelve residents as required (Resident R1, R20, R72, R94, R109, and R502). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Based on interview with therapy staff and resident, clinical record review and staff interview, it was determined facility failed to ensure that residents received proper treatment and assistive device to maintain hearing abilities for one of three residents (Resident R30).Findings include:According to S483.25(a)(2) - Assistive devices to maintain hearing include, but are not limited to, hearing aids, and amplifiers.The facility's responsibility is to assist residents and their representatives in locating and utilizing any available resources (e.g., Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community) for the provision of the services the resident needs. This includes making appointments and arranging transportation to obtain needed services.During an interview on 8/27/25, at 9:01 a.m., Resident R30 call light above her door was illuminated and Therapy Employee E4, entered the room and asked Resident R30 what she needed. Resident R30 stated what I can't hear you, my ears are clogged, can you tell the doctor I need hearing aids.Review of the clinical record indicated that Resident R30 was admitted to the facility on [DATE], with a readmission dated of 7/17/23, diagnoses which included stroke, heart failure and fibrillation. The Minimum Data Set (MDS - periodic assessment of care needs) dated 7/22/25, indicated the diagnoses remained current. Review of an Audiology consult at the facility, dated 12/7/22, indicated impacted hard cerumen in bilateral ears which had to be extracted. That consult indicated follow up for 6-9 months. Review of Resident R30's complete physician orders from 12/5/22, through current indicated an order for [NAME] Otic solution was ordered for her right ear for seven days due to impacted ear wax. An order for audiology as needed was identified. Review of the clinical record did not include a follow up with Audiology from 12/7/22, through current. During an interview on 8/27/25, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to ensure that residents received proper treatment and assistive device to maintain hearing abilities for one of three residents (Resident R30). 28 Pa Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 201.21(c) Use of outside resources 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R2 and R92).Findings include: Review of the facility policy Hemodialysis Care and Monitoring dated 3/28/25, indicates The care of the resident receiving dialysis services will include ongoing communication, coordination and collaboration between the dialysis center and the facility that may include but is not limited to: Telephonic communication, providing pre and post documentation of resident assessment to evaluate the resident response to dialysis and update care plan in collaboration with dialysis recommendations. Medication administration timing, changes and new orders. The facility will provide a copy of the current MAR and pre-evaluation for dialysis from the electronic medical record to the dialysis center. Review of the admission record indicated Resident R2 was initially admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/14/25, indicated diagnoses of end stage renal disease (condition where kidneys lose the ability to remove waste and balance fluids) hypertension (high blood pressure), and bipolar disorder (mental illness with unusual shifts in mood). Review of Resident R2's physician orders dated 8/4/25, indicated dialysis: Tuesday, Thursday, and Saturday at [dialysis center]. Chair time scheduled at 6:05 a.m., pickup time 5-5:30 a.m., and return time 9:30-10:00 a.m. Review of Resident R2's current care plan indicated dialysis: at [dialysis center]. Chair time scheduled at 6:05 a.m., pickup time 5-5:30 a.m., and return time 10:00-10:30 a.m. Review of Resident R2's dialysis communication forms indicated the following:8/5, 8/7, 8/9, 8/12, 8/16, 8/18, 8/21, 8/23, 8/26, and 8/28/25 dialysis communication forms were incomplete. Review of the admission record indicated Resident R92 was initially admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of end stage renal disease (condition where kidneys lose the ability to remove waste and balance fluids) hypertension (high blood pressure), and arthritis. Review of Resident R92's physician orders dated 8/4/25, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Chair time scheduled at 1:00 p.m., pickup time 12-12:30 p.m., and return time 5:30-6:00 p.m. Review of Resident R92's current care plan indicated dialysis: at [dialysis center]. Chair time scheduled at 1:00 p.m., pickup time 12-12:30 p.m., and return time 5:30-6:00 p.m. Review of Resident R92's dialysis communication forms indicated the following:8/4, 8/6, 8/8, 8/11, 8/13, 8/15, 8/18, 8/20, 8/22, 8/25, and 8/27/25 dialysis communication forms were incomplete. During an interview on 8/28/25, at 12:16 p.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R2 and R92). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 11 out of 12 months (October 2024 through August 2025).Findings include: During an interview on 8/26/25, at 9:32 a.m., Corporate Certified Dietary Manager Employee E5 stated that Food Service Director (FSD) Employee E6 is not a Certified Dietary Manager. That the FSD was Serv Safe certified.During an interview on 8/27/25, at 10:25 a.m. the Nursing Home Administrator stated that the Registered Dietitian (RD) was not employed full [NAME] she comes in three times a week. During an interview on 8/27/25, at 2:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that FSD Employee E6 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

Based on observation and staff interviews, it was determined that the facility failed to provide a dining experience that promoted resident dignity for 1 of 5 residents (Resident R62). Findings include:A review of the facility Resident Rights policy dated 3/28/25, indicated that the resident has a right to a dignified existence.A review of the clinical record indicated Resident R62 was admitted to the facility on [DATE] with diagnoses that included epilepsy, intellectual disability, diabetes, and need for assist with personal care. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/6/25, indicated Resident R62 has severely impaired cognition and requires supervision and assistance of one person for eating.During meal observations in the main dining room of the second-floor nursing unit on 8/27/25 at 12:00 p.m., it was revealed that five residents were seated at the dining table including Resident R62. Four residents were served meal trays at 12:05 p.m. and were eating. Resident R62 was sitting at the same table, and was not served his meal until 12:40 p.m.During an interview on 8/27/25, at 12:40 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the facility failed to provide a dignified dining experience for Resident R62, during lunch in the main dining room of the Second-Floor nursing unit. 28 Pa. Code: 201.29(j) Resident rights.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure the comprehensive care plan was implemented related to assisting/cueing a resident for eating for one of five residents (Resident R70). Findings include:Review of facility policy Plan of Care Overview dated 3/28/25, indicated that the facility will provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of each resident. The plan provides guidance to the facility to support the inclusion of the resident in the plan to enable the resident to live with dignity and supports the resident's goals, choices and preferences related to their daily routines.Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE].Review of Resident R 70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/25, indicated diagnoses of diabetes, bilateral cataracts, lung disease, anxiety, cognitive deficit, and dementia and muscle weakness. Section GG0130(Self Care) indicated Eating as requiring supervision/touching assistance.Review of Resident R70's care plan dated 7/11/25, indicated Resident R70 will receive supervision/ touching assistance where helper touches or cues the resident while eating.During an observation on 8/27/25, at 8:40 a.m., Resident R70 was having difficulty eating, when asked Resident R70 stated she was not okay and began shaking. Staff were not in her room cueing/assisting her with her meal. When the tray was removed, only the oatmeal had been eaten.During an interview on 8/27/25, at 8:42 a.m., Nurse Aide (NA) Employee E2 was removing Resident R70's tray and the NA stated, she told me she was done. During an interview on 8/27/25, at 11:40 a.m., The Assistant Director of Nursing (ADON) Employee E3 stated that Resident R70 feeds herself, however, after reviewing the plan of care, ADON Employee E3 confirmed that the facility failed to ensure the comprehensive care plan was implemented related to Resident R70 being assisted with eating. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents (Residents R70).Findings include:Review of the facility policy Routine Resident Care, dated 3/28/25, indicated that the facility will promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs. During an observation on 8/27/25, at 8:40 a.m., Resident R70 was in her room having difficulty eating. Resident had slip indicating a Kennedy cup (assistive aide drinking cup) which was not identified on her tray, there were no staff assisting the resident and she appeared to be having difficulty getting food into her mouth and food was not cut up for her to have the ability to spoon food. Resident was asked if she was ok, she stated No, then began shaking when attempting to scoop food items. Staff indicated that she feeds herself. During a continued observation on 8/27/25, at 9:00 a.m., Nurse Aide (NA) Employee E3 had entered Resident R70's room and came out with an uneaten tray except the oatmeal. When asked what the Resident ate, NA Employee E3 stated she said she was done.Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE].Review of Resident R 70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/25, indicated diagnoses of diabetes, bilateral cataracts, lung disease, anxiety, cognitive deficit, and dementia and muscle weakness. Section GG 0130 (Self-care) indicated eating requiring supervision/touching assistance.Review of Resident R70's care plan dated 7/11/25, indicated Resident R70 will receive supervision/ touching assistance where helper touches or cues the resident while eating.Review of Resident R70's weights indicated weight loss of approximately two pounds per week was identified.During an interview on 8/27/25, at 11:40 a.m., The Assistant Director of Nursing (ADON) stated that Resident R70 feeds herself, however, after reviewing the plan of care, and identified weight loss, the ADON confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five residents (Residents R70). 28 Pa. Code: 211.12(1) Nursing services.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on observations, and staff interview, it was determined that the facility failed to provide a resident adaptive eating equipment and utensils for one out of five residents (Resident R70).Findings Include:Review of the facility policy Assistive Eating Devices dated 3/28/25, indicated the facility will provide assistive eating devices to residents with limited arm mobility, grasp. range of motion as recommended by nursing or therapy to promote independence in drinking and eating to their maximum ability. During an observation on 8/27/25, at 8:40 a.m., Resident R70 was in her room having difficulty eating. Resident had slip indicating a Kennedy cup (assistive drinking cup) which was not identified in her tray, there were no staff assisting the resident and she appeared to be having difficulty getting food into her mouth and food was not cut up for her to have easier ability to spoon food. Resident was asked if she was ok, she stated No, then began shaking when attempting to scoop food items. Staff indicated that she feeds herself.Review of Resident R70's plan of care dated 7/29/25, indicated adaptive equipment: Kennedy cup with hot liquids. During an interview on 8/27/25, 11:40 a.m., the Assistant Director of Nursing Employee E3 confirmed the facility failed to provide a resident adaptive eating equipment and utensils for one out of five residents (Resident R70).Pa Code: 201.14(a) Responsibility of licensee.

Based on a review of facility policy, observations and staff interviews it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. Findings Include: Review of the facility policy Food Storage: Cold Foods last reviewed on 3/25/24, indicated that all time/temperature control for safety foods will be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. All food items will be stored 6 inches above the floor and 18 inches below the sprinkler units. During an initial observation on 9/10/24, at 10:30 a.m., of the dietary department the following was identified: Three staff lunch bags were in the cooler with resident food items. The deep freezer had ice build up on vent pipes with food stored directly under ice dripping onto boxes. Bread stored on shelf on floor of refrigerator. During and interview on 9/10/24, at 11:00 a.m., Dietary Manager Employee E8 confirmed that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policies, facility provided documents, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for one of two residents reviewed (Resident R69). Findings include: Review of the facility policy Abuse, Neglect, Misappropriation last reviewed on 3/25/24, indicated that the facility intent is to prevent the abuse, mistreatment or neglect of residents and to provide guidance to direct care staff to manage concerns or allegations of abuse. Employees will receive abuse preventive training as required as part of the orientation, as needed/indicated and annually thereafter. Accurate and timely reporting of of incidents both alleged and substantiated , will be sent to the officials in accordance with state law; if an alleged violation is verified, appropriate corrective action will be taken by the facility. Review of the clinical record indicated that Resident R69 was admitted to the facility on [DATE], with diagnoses which included kidney disease, compression fractures of spine, cognitive communication deficit, diabetes, lung disease, respiratory failure, falls and obesity. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 8/23/24, indicated the diagnoses remained current. Section C0500 (Brief interview for mental status) indicated a score of 15; which indicated the resident was cognitively intact. Review of a facility provided document dated 9/3/24, indicated that Resident R69 had alleged that Registered Nurse(RN) Employee E6 had verbally abused her when she tried to get her up to get weighed. During an interview on 9/3/24, by the Social Worker Employee E7 indicated that Resident R69 stated that the Unit Manager (RN Employee E6) is rude and has a bad attitude, that she is verbally abusive. The resident stated that she had cried many times over the way the RN Employee E6 speaks to her. Resident R69's Family Member was also interviewed on 9/3/24, as she had witnessed the event, and stated that she agreed with Resident R69's statement and that the Unit Manager(RN Employee E6) used a bad tone. Review of the facility report indicated the facility reported the event and provided re-education to RN Employee E6 for abuse and communication skills on 9/5/24. A Corrective Action was dated 9/5/24, indicated RN Employee E6 was given a written warning but refused to sign. Review of the facility training dated 2/16/24, and again on 6/27/24, indicated that RN Employee E6 had previous abuse training. During an interview during the annual survey on 9/12/24, at 12:15 p.m., with Resident R69 identified that RN Employee E6 had been mean and he does not want her in his room. He stated that she chased a Nurse Aide, who I trusted to help me, out of my room when she was helping me transfer into my chair and left me standing holding on to my bedside table to transfer myself because she was not assigned to provide care for me that day. During an interview on 9/12/24, at 1:25 p.m., the Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse, neglect or misappropriation of property for one of two residents reviewed (Resident R69). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide (NA) Employees E2 and E3). Finding include: Review of the Facility assessment dated [DATE], indicated the facility will provide required in-service training for nurse aides. Review of NA Employees Employees E2 and E3 education records with hire date greater than 12 months revealed the following: NA Employee E2 had a hire date of 4/1/24, with 4.25 hours in-service education between 4/1/23, and 4/1/24. NA Employee E3 had a hire date of 8/9/21, with 7.50 hours in-service education between 8/9/23, and 8/9/24. During an interview on 9/13/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development.

Based on review of facility policy, clinical record review, facility documents and staff interview the facility failed to ensure that residents were free from any significant medication errors, resulting in actual harm by failing to provide [CONDITION(S)] medication, the resident having a [CONDITION(S)] and hospitalized for one of eight residents (Resident CR1). Findings include: Review of the facility policy, Missed Medication Incident, indicated that the facility defines medication error as any physician provider medication that is not administered to the resident as prescribed. Policy also included a procedure to follow for medications not being available to include: checking the emergency box kit for the medications, notifying the physician, contacting the emergency pharmacy, notifying pharmacy, and Director of Nursing (DON). Review of the manufactures guidelines for [MEDICATION(S)] ([MEDICATION(S)]) (Medication used to prevent and control seizures) Highlights of Prescribing Medication - Warning and Precautions indicated that medication should be gradually withdrawn to minimize the potential of increased [CONDITION(S)] activity. Section Discontinuation of [MEDICATION(S)] indicated that a gradual withdraw over one week is recommended. Review of the clinical record admission report indicated that Resident CR1 was admitted on [DATE], with the following diagnoses, pneumonitis (inflammation of the lungs), acute [CONDITION(S)] with [CONDITION(S)] (not enough oxygen in the blood) and [CONDITION(S)] (a central nervous system disorder in which the brain activity becomes abnormal and causes seizures). Review of the clinical record physician orders dated 11/21, indicated Resident CR1 was to receive [MEDICATION(S)] tablet 200 MG, give one tablet via PEG (a flexible tube placed through the abdominal wall and into the stomach allows nutrition fluids and or medications to be put directly into the stomach) tube every morning and at bedtime for seizures. Review of Resident CR1's clinical record progress notes, from 11/18/21 through 11/29/21, indicated that the facility was waiting on [MEDICATION(S)] and that Resident CR1 had missed seventeen doses of the [MEDICATION(S)]. Review of Resident CR1's MAR (Medication Administration Record) dated November 2021, indicated that [MEDICATION(S)] was not administered. Review of the clinical record progress notes failed to indicate that the physician was notified of Resident CR1 not receiving [MEDICATION(S)]. Review of Resident CR1's clinical record progress notes Change in Condition indicated on 11/29/21, resident had a [CONDITION(S)] and was sent out to the hospital. Review of hospital records indicated Resident CR1 was admitted to the hospital on 11/29/21, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It usually lasts between 5 and 30 minutes) state. Review of the Hospital Provider Note MDM/Course dated 11/29/21, indicated Immediately after our initial evaluation patient had another tonic-clinic [CONDITION(S)] ( involve both stiffening and twitching or jerking of a person's muscles) that was witnessed by nursing staff and me (attending physician). Patient was given [MEDICATION(S)] ( injection medication approved by the Food and Drug Administration for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . His medication levels were very low on labs. Patient was given [MEDICATION(S)] ([MEDICATION(S)] is generic name of [MEDICATION(S)]). Review of hospital labs dated 11/29/21, indicated: [MEDICATION(S)] LEVEL - Abnormal; Notable for the following components: [MEDICATION(S)] LEVEL 3.6 (*)(normal levels are 50-100 mcg/ml) All other components within normal limits [MEDICATION(S)] - Abnormal; Notable for the following components: [MEDICATION(S)] LEVEL <2.5 (*)(normal levels are 10.0--20.0 mcg/mL for total [MEDICATION(S)]) All other components within normal limits .0 - 20.0] Review of hospital notes Internal Medicine Admission H&P dated 11/29/21, indicated that blood levels were subtherapeutic for [CONDITION(S)] medication. During a telephone interview on 12/17/21, at 1:22 p.m. with the Quality Director of Pharmacy Employee E1, he/she indicated that [MEDICATION(S)] is a controlled substance, which required additional order forms that are completed by the facility and faxed back to the pharmacy for medication to be dispensed. During the interview it was revealed that the facility requested the medication, the pharmacy returned the additional form for completion but did not receive the re-submission from the facility. During an electronic contact on 12/7/21, at 12:01 p.m. with the DON (Director of Nursing) confirmed that [MEDICATION(S)] was not given as ordered. Review of the clinical record physician orders dated 11/21, indicated Resident CR1 was to receive [MEDICATION(S)] ([MEDICATION(S)] - used to control certain types of seizures) tablet chewable 50 mg Give two tablets via tube (a flexible tube placed through the abdominal wall and into the stomach allows nutrition fluids and or medications to be put directly into the stomach) three times a day. Review of Resident CR1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/17/21, at 2:00 p.m. DON confirmed that [MEDICATION(S)] ([MEDICATION(S)]) was not given the first day of admission for Resident CR1 and the [MEDICATION(S)] was not given as ordered. The facility failed to ensure that Resident CR1 was free from significant medication errors, with [CONDITION(S)] medication not being given, resident experiencing a [CONDITION(S)] at the facility, needing hospitalization and experiencing a second [CONDITION(S)]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/8/21, 12/2/20, and 9/9/19 28 Pa. Code 201.19(b)(1)Management. Previously cited 11/19/21, 6/8/21, 12/2/20, and 9/19/19 28 Pa. Code 201.19 e(1)Management. Previously cited 6/8/21, 12/2/20 and 9/19/19 28 Pa. Code 211.12(d)(1)(5)Nursing services. Previously cited 11/19/21,10/8/21, and 6/8/21

Based on observation, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding wound vac placement and placement of a urinary catheter, resulting in harm of a lower back injury and a urethral tear, which required treatments for two of 17 residents reviewed (Resident R1 and R2). Findings Include: A clinical record review revealed that Resident R1 had been admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment (MDS- a periodic assessment indicating the residents physical and mental needs), dated 5/12/21, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Clinical record review revealed, Resident R1 had developed a Stage 4 pressure ulcer [Stage 4 - pressure ulcer with necrosis (black tissue) of soft tissue through to underlying muscle, tendon, or bone] on his coccyx (tail bone) on 1/28/21. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The wound vac would be placed every Monday, Wednesday, and Friday. After cleansing the area with saline, pat dry, apply one sheet of collagen [wound dressing derived from bovine, [MEDICATION(S)], [MEDICATION(S)] or avian used for partial (superficial) or full thickness (wound with tissue loss that is deep usually obscured by tan, yellow or gray tissue] to the pressure ulcer's wound bed, then [MEDICATION(S)] (a non- adhering dressing infused with Vaseline used to protect the wound bed), then black sponge (sponge that is placed inside of wound which assists the wound in healing by pooling the drainage) for the wound vac. Review of Resident R1's care plan did not include an update regarding the use of the wound vac. During an interview on 5/28/21, at 7:33 a.m. Licensed Practical Nurse (LPN) Employee E7, stated that when she went to change Resident R1's wound vac she found the suction tubing attached to Resident R1's lower back where there had not been a wound. She removed the tubing and observed a reddened, raised area and contacted the Nurse Practitioner to see Resident R1 for a skin evaluation during her rounds. During an observation on 5/28/21, at 7:33 a.m. of the reddened area that had developed, LPN Employee E7 showed the tubing that she had removed, and the nickel sized reddened raised area that had developed. The skin in this area did not have any skin breakdown prior to this incident. The date of application or the staff initials of who placed the wound tubing was not identified. During an interview on 5/28/21, at 9:13 a.m. the Certified Registered Nurse Practitioner (CRNP) Employee E17, confirmed that the wound vac's incorrect placement caused a nickel sized trauma area to develop on Resident R1's lower back, causing actual harm requiring treatment. During the interview on 5/28/21, at 9:13 a.m. the CRNP also indicated that the staff are not trained to apply wound vacs and she was getting in contact with the wound vac company to come to the facility and do an in-service with the nurses. During an interview on 5/28/21, at 3:43 p.m. the Corporate Nurse Employee E4 indicated that she could not provide documentation that the staff had been trained to apply a wound vac. The only information that could be provided was the wound vac pamphlet which does not identify how to apply the wound vac. The facility could not provide a policy and procedure for use of the wound vac. During a clinical record review on 6/1/21, a progress note which was dated 5/28/21, indicated that the CRNP Employee E17 identified the wound as trauma and had ordered a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical record review revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R2 had a readmitted [DATE], which included an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS dated [DATE], indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a progress note dated 4/24/21, indicated that Resident R2 was being transferred from his wheelchair into a shower chair and the resident began to have a bowel movement and had, passed out for approximately 10-15 seconds and the Registered Nurse Employee E1 indicated that he then awoke. After the transfer, Resident R2's urinary catheter had minimal blood tinged urine and Employee E1 stated she removed it due to the catheter not draining. Once removed, Resident R2 began to have a lot of bleeding requiring Employee E1 to apply pressure to his penis. Resident R2 was transferred to his room and placed in bed where Employee E1 had the ambulance called and had inserted another urinary catheter due to Resident R2's abdomen becoming rigid with assessment. Employee E1 then, inserted another larger urinary catheter to attempt to relieve the pressure in the abdomen thinking Resident R2's bladder would rupture. When the balloon for the urinary catheter was blown up, Resident R2 began to pass bright red blood with blood clots, and the resident was transferred to the hospital. During an interview on 6/2/21, at 3:43 p.m. the Corporate Nurse Employee E4, stated that the facility did not feel an investigation into the urethral laceration was necessary as they found nothing needing investigating. Review of the hospital clinical record dated 4/25/21, indicated that the inflation of the balloon in the urethra during the re-insertion of the urinary catheter, caused a urethral laceration requiring treatment and hospitalization . The resident had to be transferred to a higher-level hospital, due to the urethral trauma and the need for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 6/3/21, at 12:12 p.m. Employee E1 confirmed the placement of the urinary catheter at the facility prior to the transfer to the hospital and stated that when she inflated the balloon of the catheter, the resident began passing blood clots and there was no urine return. A review of the transcript of educational information for Employee E1 indicated training was completed via Relias (an online training program) for care of an indwelling catheter, however, the transcript did not include education regarding the placement of urinary catheters. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/19/19, 10/18/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.20(a)(b)(d) Staff development. 28 Pa. Code 201.20(c) Staff development. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 201.29(j) Resident rights. Previously cited 10/18/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 1/27/21, 9/9/19, 10/18/18.

Based on observations, a review of clinical records, facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and to maintain a resident's environment free of potential accident hazards, that increased the risk for injury and actual sustained injuries, requiring treatment from falls causing actual harm for three of 17 residents reviewed (Residents R2, R3, and R4). Findings include: A clinical record review revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses which included, obstructive and reflux [CONDITION(S)] (when urine flow is obstructed which causes urine to back up and injure kidneys) and abnormal posture with contractures of bilateral lower extremities. Resident R2 had a readmitted [DATE], which included an additional diagnosis of a lacerated urethra (urethral [duct that transmits urine from the bladder] trauma which is caused by force). An annual MDS dated [DATE], indicated that the diagnoses remained current. A clinical record review revealed a fall risk observation tool completed on 1/23/21, which indicated Resident R2 was a high risk for falls. Review of incident and accident reports dated from January 2021 through May 2021, indicated that Resident R2 had fallen three times in March 2021. On 3/13/21, Resident R2 had an unwitnessed fall from bed while reaching for something on the floor, sustaining a [CONDITION(S)] and right upper back and right great toe abrasions requiring treatment. On 3/15/21, Resident R2 had an unwitnessed fall from bed reaching for something, sustaining a right arm skin tear requiring treatment. On 3/18/21, Resident R2 had an unwitnessed fall rolling out of bed, sustaining a skin tear to his elbow requiring treatment. The care plan had not been updated following the falls and only indicated that the call bell should be within reach. A clinical record review revealed that Resident R3 had been readmitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] (hereditary disease that causes degeneration of brain cells leading to dementia and uncontrollable movements and degeneration of nerve cells). An annual MDS dated [DATE], indicated the diagnoses remained current. Resident R3 had fallen from bed and sustained a [CONDITION(S)] of her right temple on 1/31/21, requiring treatment and the care plan update indicated the resident was to use the call bell. On 4/20/21, Resident R3 had fallen from a chair and sustained right forehead, right hand, and right knee abrasions, requiring treatments. The care plan update indicated to make certain the resident was wearing appropriate nonskid slippers and to assess for falls. During an observation on 5/27/21, at 10:50 a.m. Resident R3 was observed in a Broda chair (a wheelchair used for positioning for comfort and safety) in her room with the footrest lowered, sliding out of the chair. On 5/30/21, Resident R3 slid from a Broda chair sustaining a left [CONDITION(S)], requiring treatment. The care plan indicated placing a non-slip pad on the Broda chair. During an interview on 6/1/21, at 10:48 a.m. Therapy Manager Employee E2, indicated that Resident R3 slid from the chair and had fallen from the chair due to the staff not placing modified Broda chair lateral supports and pads properly and elevating the footrest as required for Resident R3's safety and specific needs. Therapy Manager Employee E2 stated that, staff have been shown how to place pads and told to keep feet elevated but not the same staff are here all the time. The care plan did not contain resident specific chair-positioning information. During an observation on 6/3/21, at 9:00 a.m. of Resident R3's room, a hard call bell (call bell that is within the handheld remote for the TV) was placed in the resident's room for call use. The resident's hands are contracted, making it impossible for her to use the call bell that was provided. The resident has uncontrollable foot and leg movements and thrashes in the chair. During an interview on 6/3/21, at 9:10 a.m. Nurse Aide Employee E3, confirmed that Resident R3 could not use the call bell in her room, stating the staff must anticipate her needs as she cannot utilize any type of call bell due to contractures and mental state. The care plan did not contain the need for staff to anticipate Resident R3's needs. Nurse Aide Employee E3 stated that, we do not have enough staff to watch the residents and no one cares about that. Meaning not enough staff to provide care by sitting by the bedside to anticipate the care needed by Resident R3. The facility failed to provide the resident with a way to contact staff if she needed assistance, failed to provide supervision since she could not use the call bell, failed to place lateral supports properly, and failed to elevate the footrests to prevent an actual fall which caused an injury to Resident R3. Review of the clinical record revealed that Resident R4 was initially admitted on [DATE], with a history of bilateral above the knee amputations, diabetes, depression, high blood pressure, and muscle weakness. Review of the quarterly MDS dated [DATE], confirmed the medical diagnoses and revealed a BIMS score of 12 (was alert and oriented to time, date, and place and was able to recall 3 words with minimal cueing on interview for his mental status). The MDS also revealed that Resident R4 required the use of a 2 person Hoyer lift (mechanical lift) for transfers. A clinical record review revealed a fall risk observation tool completed on 3/15/21, indicated Resident R4 was a high risk for falls. Review of the care plan revealed fall interventions were placed on 1/6/21 to include: educate resident regarding safety with transfers, complete neuro checks if fall is unwitnessed or head is involved, observe for medication side effects that may increase fall risk, place call bell within reach/remind resident to call for assistance, provide assistive devices as needed, physical therapy/occupational therapy evaluation/treatment. On 1/19/21, the care plan was updated to include fall mats as needed, monitor for pain/discomfort, and administer pain medication as prescribed. Review of incident/accident logs indicated that Resident R4 had 3 falls in March, 8 falls in April, 2 falls in May, and 1 fall in June 2021. Review of an incident report dated 3/15/21, revealed the resident had an unwitnessed fall and stated he hit his head. He was assessed at the facility and sent to the local ER for evaluation and a CT of the head was completed. No cause for the fall given, and the care plan was not updated. On 3/24/21, the resident fell in his room which was unwitnessed, without injuries, and no reason was provided for the fall. The care plan was not updated. On 3/29/21, the resident fell in his room unwitnessed, without injuries, and no cause was reported. The care plan was updated on 3/31/21, to include rearranging the room to ensure personal items are within reach. On 4/1/21, the resident fell in his room unwitnessed, without injuries, and no reason was provided for the fall. The care plan was updated on 4/1/21, to include ensuring the resident's room was free of accident hazards, and assessing risk for falls on admission/readmission, quarterly, and as needed. On 4/2/21, the resident had an unwitnessed fall in his room, without injuries, and no reason provided. The care plan was updated on 4/5/21, to include ensuring the bed locks were engaged, provide adequate lighting at night, and toileting/incontinence programs, or timed voiding schedule as need. On 4/6/21, the resident had an unwitnessed fall in his room, no injuries, and no reason given for the fall provided. The care plan was not updated. On 4/12/21, the resident had an unwitnessed fall in his room, he was sent to the local ER for evaluation and a CT of the brain and cervical spine was completed. The care plan was not updated. On 4/13/21, the resident had an unwitnessed fall in his room, no injuries, and no reason for the fall provided. The care plan was not updated. On 4/21/21, the resident had an unwitnessed fall in his room, no injuries, and no reason for the fall provided. The care plan was not updated. On 4/25/21, the resident had two unwitnessed falls in his room at 5:05 a.m. and 12:40 p.m. no injuries, and no reason for the fall provided. The care plan was not updated. On 5/1/21, the resident had an unwitnessed fall in his room, no injuries, and no reason for the fall provided. The care plan was not updated. On 5/14/21, the resident had an unwitnessed fall in his room, no injuries, and no reason for the fall provided. The care plan was not updated. During an observation on 6/1/21, at 11:18 a.m. Resident R4 was found by State Agent on the floor by his bed, lying on his left side with his left arm under him, yelling for help. The fall mats were in place, and the call bell was on the nightstand out of reach from the resident while on the floor and in bed. The care plan states to place the call bell within reach. Two nurses were observed to be sitting at the nurses' station when Resident R4 was found on the floor and were notified of the resident being on the floor. Resident R4 stated he hurt his back, arm, and hit his head when he fell during evaluation by staff. The care plan was not updated. The facility failed to keep a resident, assessed at high risk for falls, safe from additional falls. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/19/19, 10/18/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.20(a)(b)(d) Staff development. 28 Pa. Code 201.20(c) Staff development. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 201.29(j) Resident rights. Previously cited 10/18/18. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 10/18/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 1/27/21, 9/9/19, 10/18/18.

Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that proper pain management was provided for one of 17 residents (Resident R2), resulting in harm when the resident suffered severe pain during care and attempting to eat. Findings include: Review of the facility Pain Management and Assessment policy last reviewed on 2/26/21, indicated that a thorough assessment by observation and treatment and relief of pain including facial grimaces and guarding and unexplained behaviors will be observed. The basis for pain control includes resident needs. The impact of pain on quality of life with regards to sleep, appetite, and functional abilities are monitored. A clinical record review revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R2 had a readmitted [DATE], which included an additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS dated [DATE], indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 5/28/21, at 9:00 a.m. Resident R2 was observed sitting on his right side in his bed. His face appeared as if he were in pain and he was holding onto the side rail with both hands. He was yelling out and when asked what was wrong, he said, I can't move. During an interview on 5/28/21, at 9:05 a.m. Nurse Aide Employee E3 came into the room to assist and attempted to move Resident R2 and he screamed in pain. During an interview on 5/28/21, Licensed Practical Nurse (LPN) Employee E12 stated she would give him his pain medication of [MEDICATION(S)] 50 mg, which she did. She stated giving him this is like, throwing a pill at an elephant, she stated, this is not enough for him, I've asked for something else but get no response. During an observation on 5/28/21, at 10:00 a.m. LPN Employee E12 was attempting to change Resident R2's multiple (18) pressure ulcer dressings. The Certified Registered Nurse Practitioner entered the room upon hearing the resident yelling out and stated that she would order him a stronger pain medication. During an observation on 6/1/21, at 9:30 a.m. Resident R2 was in bed on his right side, face was grimacing, and he appeared in pain. Review of the clinical record did not include an additional pain medication except for a one-time [MEDICATION(S)] prior to dressing change. The order had fallen off as it had appeared to have been deleted. The two LPN's on the unit were from Agencies and were not given access to the computer system until 8:30 a.m. and had just been getting through medication administration. During an interview on 6/2/21, at 8:00 a.m. LPN Employee E13 contacted House Supervisor to contact Resident R2's physician for pain medication as a prn (as needed) order as once in 24 hours (given only before dressing change) was not helping. LPN stated that Resident R2 was in so much pain and he could not be moved to sit up to eat and confirmed that the facility failed to provide Resident R2 with pain control. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/19/19, 10/18/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.20(a)(b)(d) Staff development. 28 Pa. Code 201.20(c) Staff development. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 201.29(j) Resident rights. Previously cited 10/18/18. 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited 10/18/18. 28 Pa. Code 211.5(f) Clinical records. Previously cited 10/18/18. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 10/18/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 1/27/21, 9/9/19, 10/18/18.

Based on facility policy, clinical and facility record review and staff interview, it was determined that the facility failed to make certain that licensed nurses had the specific competencies and skills necessary to care for residents' with wound vac needs, urinary catheter needs, and use of positioning devices for Broda chairs causing actual harm for three of 17 residents reviewed (Resident R1, R2, and R3). Findings include: During an interview on 6/2/21, at 3:43 p.m. the Registered Nurse Corporate Clinical Specialist Employee E4 indicated that staff have training online through the Relias system and are required to be self-motivated to complete courses annually. The facility was unable to provide documentation of wound vac (a vacuum assisted wound closure which helps the wound heal more quickly) training, urinary catheter insertion training, or proper placement of pads and positioning of residents in a Broda chair (a wheelchair used for positioning and comfort), being completed by staff who had performed the procedures. A clinical record review revealed that Resident R1 had been admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment (MDS- a periodic assessment indicating the residents physical and mental needs), dated 5/12/21, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Clinical record review revealed, Resident R1 had developed a Stage 4 pressure ulcer [Stage 4 - pressure ulcer with necrosis (black tissue) of soft tissue through to underlying muscle, tendon, or bone] on his coccyx (tail bone), on 1/28/21, which required placement of a wound vac. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/28/21, at 7:33 a.m. of the reddened area that had developed, Licensed Practical Nurse (LPN) Employee E7 showed the tubing that she had removed, and the nickel sized reddened raised area that had developed. The skin in this area did not have any skin breakdown prior to this incident. The date of application or the staff initials of who placed the wound tubing was not identified. During an interview on 5/28/21, at 9:13 a.m. the Certified Registered Nurse Practitioner (CRNP) confirmed the wound vac's incorrect placement caused a nickel sized trauma area to develop on Resident R1's lower back causing actual harm requiring treatment. The CRNP stated that she is, going to ask the Wound Vac company to come in to educate facility staff regarding use of the wound vac as staff do not know how to place them properly. A clinical record review revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R2 had a readmitted [DATE], which included additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a progress note dated 4/24/21, indicated that Resident R2 was being transferred from his wheelchair into a shower chair and the resident began to have a bowel movement and had passed out for approximately 10-15 seconds and the Registered Nurse (RN) Employee E1 indicated that he then awoke. After the transfer, Resident R2's urinary catheter had minimal blood tinged urine and the RN Employee E1 stated she removed it due to the catheter not draining. Once removed, Resident R2 began to have a lot of bleeding requiring the RN Employee E1 to apply pressure to his penis. Resident R2 was transferred to his room and placed in bed where RN Employee E1 had the ambulance called and had inserted another urinary catheter due to Resident R2's abdomen becoming rigid with assessment. RN Employee E1 then, inserted another larger urinary catheter to attempt to relieve the pressure in the abdomen thinking Resident R2's bladder would rupture. When the balloon for the urinary catheter was blown up, Resident R2 began to pass bright red blood with blood clots, causing actual harm and the resident was transferred to the hospital During a phone interview on 6/1/21, at 11:50 a.m. RN Employee E1 stated that she and LPN Employee E7 had removed the catheter strap from Resident R2's leg and LPN Employee E7 had deflated the catheter balloon to remove it as Resident R2 had no urine in the catheter and little blood. When the catheter was removed, Resident R2 penis, squirted blood and I had to hold pressure on his penis to stop the bleeding. Once Resident R2 was returned to his room from the shower room, RN Employee E1 stated Resident R2's, abdomen became rigid and I placed a new larger Foley (a urinary catheter) and blew up the balloon and bright red blood clots were coming out. At that time the ambulance came. A review of the hospital clinical record dated 4/25/21, revealed that Resident R2 was admitted after, the facility had attempted to exchange a chronic indwelling Foley catheter and subsequently inflated the balloon in his urethra causing a urethral rupture. The resident was transferred to a higher-level hospital, due to urethral trauma and need for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 6/3/21, at 12:12 p.m. RN Employee E1 confirmed the placement of the urinary catheter at the facility prior to the transfer to the hospital and stated that when she inflated the balloon the resident began passing blood clots, there was no urine return. A review of the transcript of educational information for RN Employee E1, indicated training was completed via Relias (an online training program) for care of indwelling catheter. The transcript did not include education for the insertion of urinary catheters. A clinical record review revealed that Resident R3 had been readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS dated [DATE], indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a record review, it was revealed that Resident R3 had fallen from bed and sustained a [CONDITION(S)] of her right temple on 1/31/21, requiring treatment and the care plan was updated to indicate the resident was to use the call bell. On 4/20/21, Resident R3 had fallen from a chair and sustained right forehead, right hand, and right knee abrasions, requiring treatments. The care plan was updated to indicate staff were to make certain the resident was wearing appropriate non-skid slippers and to assess for falls. On 5/30/21, Resident R3 slid from the Broda chair (a chair used for positioning for comfort and safety) sustaining a left [CONDITION(S)] requiring treatment. The care plan indicated placing a non-slip pad on the Broda chair. During an observation on 5/27/21, at 10:50 a.m. Resident R3 was observed in a Broda chair in her room with the footrest lowered, sliding out of the chair. During an interview on 6/1/21, at 10:48 a.m. Therapy Manager Employee E2 indicated that Resident R3 slid from the chair and had fallen from the chair due to staff not placing modified Broda chair lateral supports and pads properly and elevating the footrest as required for Resident R3's safety and specific needs. Therapy Manager Employee E2 stated that, staff have been shown how to place pads and told to keep feet elevated but the same staff are not here all the time. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/19/19, 10/18/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 201.20(a)(b)(d) Staff development. 28 Pa. Code 201.20(c) Staff development. Previously cited 9/9/19, 10/18/18. 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited 10/18/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/2/20, 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/9/19, 10/18/18. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 1/27/21, 9/9/19, 10/18/18.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to assess, monitor, and provide adequate nutritional interventions to prevent weight loss for one of 18 residents (Resident R1) reviewed. Findings include: The facility policy entitled, "Weight Assessment and Intervention" dated 5/02/11, indicated significant weight loss is defined as 5% change in 30 days or 10% change in six months. If a weight loss of greater than five pounds (lbs.) is noted, the Nurse Aide will report the loss to the Charge Nurse who will notify the Director of Nursing (DON) and the Dietary Manager. If the weight meets the definition of significant loss, the Dietician/Dietary Manager will discuss the recommendations with the Interdisciplinary Team, which includes the physician. A review of the physician's History & Physical dated 1/19/12, indicated Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's note also indicated that Resident R1 was alert, awake, followed commands, and needed assistance with feeding. A review of the Admission Minimum Data Set (MDS - periodic assessment of care needs) assessment dated [DATE], indicated Resident R1 required the extensive assistance of one person for eating. Review of a physician order [REDACTED]. The Nutritional Assessment indicated that Magic Cup added 870 kilocalories (kcal) and 27 grams of protein per day. A review of the Nutritional Assessment completed by the Dietary Services Manager dated 1/24/12, indicated Resident R1 had appropriate height to weight ratio at 65 inches and 123 pounds (lbs.), with severely depleted protein stores, and that Resident R1 required staff assistance for feeding. The Nutritional Assessment interventions for Resident R1 included monitoring the need for additional high calorie protein supplements, weight, skin condition and progress. The Nutritional Assessment goals identified for Resident R1 included increasing by mouth intake to 75% of meals and weight maintenance. A review of the Weight Detail Report dated 3/02/12, indicated Resident R1's weight as follows: 1/18/12 124.0 lbs. 1/19/12 122.6 lbs. 1/24/12 117.4 lbs. (loss of 5.3 % in nine days) 1/30/12 111.6 lbs. 2/01/12 111.6 lbs. (loss of 12.4 lbs or 10% in 17 days). A review of the Weight Detail Report for Resident R1 indicated a weight of 111.6 was obtained and recorded on 1/30/12, at 2:15 p.m. A review of the Dietary Progress Note dated 2/01/12, at 4:00 p.m., the Dietary Services Manager indicated "14 day MDS completed for ARD (Assessment Reference Date- last day of the observation or look-back period) 1/31/12". The 2/01/12, Dietary Progress Notes did not include any interventions for weight loss for Resident R1. A review of the 14 day MDS with the ARD of 1/31/12, indicated a weight for Resident R1 of 112 lbs. During an interview on 3/12/12, at 9:30 a.m., Registered Dietician (RD), Employee E2 confirmed that weight loss interventions for Resident R1 should have been made after the 1/30/12 weight loss was noted. A review of the Weight Detail Report dated 3/02/12, indicated Resident R1 had an average meal intake of 40.7% during the period of 1/18/12 to 2/03/12. During an interview on 3/07/12, at 2:30 p.m., the Charge Nurse, Licensed Practical Nurse, Employee E4, and the DON confirmed that the physician was not notified of Resident R1's significant weight loss prior to 2/03/12. The DON also confirmed that she was not made aware of Resident R1's significant weight loss as the facility policy required. During an interview on 3/12/12, at 9:30 a.m., the RD, Employee E2, confirmed that Resident R1 had a significant weight loss of 10% in a period of 17 days. The RD, Employee E2 confirmed that she was not notified of Resident R1's significant weight loss. During an interview on 3/12/12, at 11:30 a.m., Dietary Services Manager, Employee E3, confirmed that no dietary interventions were made after the 1/20/12, order for Magic Cup supplements and that the physician was not notified by dietary staff of the 10% significant weight loss during the period of 1/18/12 until 2/03/12. Refer to F157 and F327 28 Pa. Code: 211.6(b) Dietary services. 28 Pa. Code: 211.10(c) Resident care policies. Previously cited 9/23/11, 9/21/11, 10/8/10. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 9/21/11, 9/2/11, 6/7/11, 10/8/10. 28 Pa. Code: 211.12(d)(3)Nursing services. Previously cited 9/21/11. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited 12/14/11, 923/11, 9/21/11, 92/11, 6/7/11, 10/8/10.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide sufficient fluid intake to prevent dehydration to one of 18 residents (Resident R1) reviewed. Findings include: The facility policy entitled, "Hydration - Clinical Protocol" dated 5/02/11, indicated the nursing staff and the physician will identify residents with a significant risk for fluid and electrolyte (charged molecules that help regulate metabolism and total body fluid levels) imbalance, such as residents who are not eating or drinking well. The facility policy entitled, "Intake & Output/Food Consumption" dated 5/02/11, indicated that the nursing staff should notify the nursing supervisor if the resident has decreased oral intake and that the supervisor will complete a weekly evaluation summary that includes the average 24 hour oral intake, urine color, skin turgor (elasticity of the skin associated with hydration), [MEDICAL CONDITION] (swelling from excess fluid in the tissues), mucous membrane condition, and document the notification of the physician, any interventions initiated, and the resident's response. A review of the physician's History & Physical dated 1/19/12, indicated Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's note also indicated Resident R1 was alert, awake, followed commands, and needed assistance with feeding. A review of the Admission Minimum Data Set (MDS - periodic assessment of care needs) assessment dated [DATE], indicated Resident R1 required extensive assistance of one person for eating. A review of the Nutritional Assessment completed by the Dietary Services Manager and dated 1/24/12, indicated Resident R1 had fluid requirements of 1680 to 1780 cubic centimeters (cc.) per day, intake adequacy was suboptimal, and that Resident R1 required staff assistance for feeding. The Nutritional goals identified for Resident R1 included encouraging increased hydration. A review of the facility Intake/Output Chart Detail Report for Resident R1 indicated the following intake volumes per 24 hour period: 1/19/12 - 360 cc. 1/20/12 - 480 cc. 1/21/12 - 600 cc. 1/22/12 - 600 cc. 1/23/12 - 330 cc. 1/24/12 - 480 cc. 1/25/12 - 590 cc. 1/26/12 - 600 cc. 1/27/12 - 720 cc. 1/28/12 - 600 cc. 1/29/12 - 480 cc. 1/30/12 - 600 cc. 1/31/12 - 300 cc. 2/01/12 - 240 cc. 2/02/12 - 700 cc. 2/03/12 - 120 cc. A review of the Physician Discharge Summary dated 2/03/12, indicated Resident R1 was evaluated by the physician and was transferred to the hospital due to increased heart rate and respiratory rate and decreased level of consciousness. A review of the physician Hospital Discharge Summary dated 2/07/12, indicated that Resident R1 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED].- blood sodium level is normally 136-146 mmol/L). The Discharge Summary also indicated that Resident R1's change in mental status was due to severe dehydration, that Resident R1, "showed little progress from a mental status standpoint" during the hospitalization and that Resident R1 was eventually discharged to home on hospice services. During an in interview on 3/07/12, at 2:30 p.m., the Director of Nursing (DON) confirmed that the intake records for Resident R1 indicated insufficient fluid intake for the period of 1/18/12 until 2/03/12, that Resident R1 was dependent on staff for assistance with eating and that no interventions were initiated for the inadequate fluid intake. The DON also confirmed that the physician was not notified of Resident R1's insufficient oral intake prior to 2/03/12. Refer to F157 and F325. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 9/23/11. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/23/11, 10/8/10. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/21/11, 9/2/11, 6/7/11, 10/8/10. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/14/11, 9/23/11, 9/21/11, 9/2/11, 6/7/11, 10/8/10.