Every finding on record at The Pines at Philadelphia Rehab and Healthcare CTR

Based on review of facility policy, resident and staff interviews, observation, and clinical record review, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities for one of two resident's reviewed for hearing (Resident 7).Findings include:Review of the facility policy titled, Care of Hearing Aids last revised 02/2026 states under procedure, Bring equipment to the bedside and tell resident what you are doing to do. Remove the ear mold from the receiver. Wahs the ear mold with soap and water. Use a pipe cleaner to thoroughly dry the cannula. When the ear mold is copletley dry, snap it back onto the receiver. Gently clean the resident's ear. Insert hearing aid. Assist the resident to adjust the control to a desired level. Record the following in the medical record. Procedure, resident's response to hearing aid (if tone and amplification are satisfactory).Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/4/26 included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), malignant neoplasm of the prostate (prostate cancer), unspecified dementia, unspecified severity, without behavioral disturbance (memory impairment), low back pain (back pain), and thyrotoxicosis without thyrotoxic crisis or storm (overactive thyroid). The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Section B: Hearing indicated that Resident R7 has moderate difficulty hearing. Under Hearing Aids, it was incorrectly coded that Resident R7 does not use a hearing aid or other hearing appliance to assist with hearing.Review of the initial and most recent comprehensive care plan dated, 4/29/26, did not include goals and/or interventions related to the use of hearing aids. There was no physician order either with in the clinical record for nursing staff assist and monitor of the hearing aids.A review of the admission Nursing Evaluation dated April 28, 2026, revealed that upon admission Resident R7 wore glasses and bilateral hearing aids.On 5/27/2026, at 10:42 a.m., an telephone interview was conducted with the daughter of Resident R7. She reported that Resident R7 is generally able to understand and communicate; however, his ability to do so depends on whether his hearing aids are charged and being worn. She stated that Resident R7 does not like to wear his hearing aids, but without them he is unable to hear adequately. The daughter further reported that nursing staff frequently place the resident's hearing aids out of his reach. She/he stated that staff often place the hearing aids on the overbed tray table and then move the tray table away from the resident, preventing him from independently accessing and using his hearing aids.On 5/27/2026, at 12:40 p.m., an observation of Resident R7 was conducted. Resident R7 was observed lying in bed sleeping. The resident's hearing aids were observed at the bedside; however, they were not connected to the charging device and were not charging at the time of the observation.On 5/27/2026, at 2:45 p.m., an interview was conducted with Resident R7's representative at the resident's bedside. The representative reported that he/she had just arrived and observed that the resident's hearing aids were located across the room and were not within the resident's reach. The representative stated that this was consistent with previous concerns that staff frequently place the resident's hearing aids in locations that are inaccessible to the resident.During the same interview on 5/27/2026, at 2:45 p.m., Regional Registered Nurse, Employee E8, confirmed that Resident R7 did not have a care plan or physician order directing nursing staff to assist the resident with wearing, maintaining, or ensuring the charging of his hearing aids. Employee E8 further confirmed that, as of that day, the facility had implemented a physician order and updated the resident's care plan to address the use, maintenance, and charging of the resident's hearing aids.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services to assist a resident in maintaining or improving bowel and bladder continence to the extent possible for one of two sampled residents reviewed for continence care. (Resident R7)Findings:Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated May 4, 2026 included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), malignant neoplasm of the prostate (prostate cancer), unspecified dementia, unspecified severity, without behavioral disturbance (memory impairment), low back pain (back pain), and thyrotoxicosis without thyrotoxic crisis or storm (overactive thyroid). The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Section B: Hearing indicated that Resident R7 has moderate difficulty hearing. Under Hearing Aids, it was incorrectly coded that Resident R7 does not use a hearing aid or other hearing appliance to assist with hearing.Review of the physician orders Resident R7 was prescribed Lasix 20 mg (furosemide) which is a loop diuretic, commonly called a water pill. It helps the body get rid of excess fluid by increasing urine production.A review of the comprehensive care plan, most recently reviewed on April 29, 2026, revealed that it did not include goals and/or interventions related to maintaining bowel and bladder continence, including toileting assistance and continence management interventions.The comprehensive care plan only identified a focus area indicating that Resident R7 required moderate assistance from two staff members for scoot-pivot transfers. The associated goals stated that Resident R7 would perform bed mobility with supervision and transfer with supervision. The care plan did not address the resident's bowel or bladder continence status, toileting needs, scheduled toileting program, continence management, or staff assistance required to maintain continence to the extent possible.On May 26, 2026, at 9:40 a.m., Resident R7 was observed lying sideways in bed unclothed and without bed linens. Fecal matter was observed on the resident's buttocks and side. During the observation, Certified Nursing Assistant (CNA), Employee E5, entered the room, spoke with Resident R7, and reported that the resident had finished having a bowel movement, wanted to get dressed, and wanted assistance transferring to his chair. Fecal matter was also observed on Resident R7's toilet. At 9:46 a.m., the toilet remained visibly soiled with fecal matter. Licensed Nurse, Employee E3, who was present during the observation, confirmed that the toilet was dirty and stated that she was unsure where the assigned CNA was or why Resident R7 had been left unclothed, without bed linens, and with fecal matter remaining on his buttocks. Employee E3 stated that she would ensure the resident received assistance.On May 26, 2026, at 10:21 a.m., an interview was conducted with Licensed Practical Nurse (LPN), Employee E3, who identified herself as Resident R7's assigned nurse. Employee E3 reported that Resident R7 speaks limited English and exhibits behaviors that affect his continence care. Employee E3 stated that the resident will at times urinate on himself and in his bed and then use the call bell requesting staff assistance for cleanup. Employee E3 further reported that the resident frequently removes his incontinence briefs, which contributes to challenges in managing his urinary continence and personal hygiene needs.On May 27, 2026, at 9:28 a.m., an interview was conducted with Physical Therapist, Employee E6, while Resident R7 was participating in a therapy session. Resident R7 was observed to be appropriately dressed and compliant with therapy. Employee E6 reported that Resident R7 was unable to ambulate and was receiving physical therapy to improve lower extremity strength and transfer abilities. When asked whether Resident R7 exhibited noncompliant behaviors or whether Employee E6 had observed the resident intentionally urinating on himself or his surroundings, Employee E6 stated no. Employee E6 further reported that throughout therapy sessions, Resident R7 had been compliant and cooperative with all therapeutic interventions.On May 27, 2026, at 2:35 p.m., an interview was conducted with Resident R7 and his daughter, who identified herself as the resident's Power of Attorney (POA). Due to the resident's hearing impairment and communication difficulties, the daughter assisted with interpretation. When asked to describe the events of May 26, 2026, Resident R7 reported that after breakfast, at approximately 9:30 a.m. to 10:00 a.m., he activated the call bell approximately five times. Resident R7 was unable to recall how long it took for staff to respond; however, he/she reported that by the time assistance arrived, he/she had already had a bowel movement and required assistance with toileting and hygiene. Resident R7 stated that Certified Nursing Assistant (CNA), Employee E9, informed him/her that he/she needed to use the toilet. According to Resident R7, CNA Employee E9 transferred him/her to the toilet, removed his/her brief, and then left him/her seated on the toilet. Resident R7 reported that CNA Employee E9 provided wet paper towels and instructed him/her to clean himself. Resident R7 stated that he was unable to perform toileting hygiene independently. Resident R7 further reported that CNA Employee E9 left the bathroom area, leaving him/her seated on the toilet for approximately ten minutes.Resident R7 stated that while waiting for assistance, his/her back began to hurt. Due to the pain and the presence of fecal matter, he/she removed his shirt and used it to cover his wheelchair, which had become soiled with fecal matter. Resident R7 reported that he/she then transferred himself from the toilet to the wheelchair, wheeled himself back to his bed, transferred himself into bed, and remained unclothed until staff returned to provide assistance.Resident R7 further reported that this was not the first occurrence and stated that a similar incident had occurred again today, during which he/she was left on the toilet and instructed to clean himself/herself using wet paper towels despite being unable to do so independently. Resident R7 also reported that the toilet was unsteady and that the toilet seat moved when in use, causing him to fear falling during transfers and toileting.Resident R7 reported that staff believed he intentionally urinated or had bowel movements on himself; however, he denied doing so intentionally. Resident R7 stated that due to his/her hearing impairment, his call bell requests were not always answered promptly and that by the time assistance arrived, he/she often no longer needed toileting assistance and instead required incontinence care and changing.The resident's daughter reported that Resident R7 has a history of enlarged testicles, benign prostatic hyperplasia (enlarged prostate), and prostate cancer, which make urination difficult. She stated that the resident is unable to effectively use a standard urinal and prefers to use a cup for urination. The daughter further reported that the resident is unable to urinate while seated on the toilet due to his enlarged prostate and that when staff place him on the toilet for extended periods, he may urinate on himself because he is unable to void effectively in that position.On May 28, 2026, at 8:34 a.m., an interview was conducted with the Director of Nursing, who reported that the facility had investigated concerns related to Resident R7's activities of daily living and determined that the resident may be more appropriately accommodated through the use of a female urinal due to his individual needs. The Director of Nursing further confirmed that Resident R7 did not have a care plan addressing his toileting preferences, including his preference for using a cup rather than a standard male urinal, nor did the care plan include interventions related to refusal behaviors, toileting assistance, or individualized continence management strategies.On May 28, 2026, at 11:15 a.m., Occupational Therapist, Employee E7, reported that Resident R7 required set-up and supervision for upper body self-care and moderate assistance for lower body self-care. Employee E7 stated that the resident required assistance with toileting hygiene, clothing management, and thorough cleansing following bowel movements. Employee E7 further reported that the resident was frequently observed with a wet brief and/or fecal matter during therapy sessions and required staff assistance to wipe himself following toileting. Employee E7 stated that the resident could stand for less than one minute while holding onto grab bars and that family training conducted on May 15, 2026, included instruction regarding the resident's need for assistance with self-care, dressing, and toileting. Employee E7 reported that the resident required assistance with these tasks prior to admission due to a history of falls, chronic pain, back surgery, and limitations related to knee and back pain.Employee E7 further reported that during family training on May 15, 2026, the resident's daughter stated that the resident preferred using a cup rather than a urinal. Employee E7 indicated that the resident's toileting needs may be better addressed through modification of the urinal or use of a preferred toileting device and stated that additional interventions would be discussed and implemented moving forward.On May 28, 2026, at 2:45 p.m., an interview was conducted with the Director of Nursing and the Administrator. During the interview, both confirmed that the facility had not implemented individualized interventions to address Resident R7's toileting needs and preferences, including his preferred method of urination, toileting assistance needs, and behaviors impacting continence care. The Director of Nursing and Administrator acknowledged that the facility failed to provide the necessary treatment and services to assist Resident R7 in maintaining bowel and bladder continence to the extent possible.28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record reviews, review of facility investigations and grievance logs, it was determined that the facility failed to report allegation for neglect and misappropriation for two of 18 residents reviewed (Resident R19 and R51).Finding include: Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated September of 2024 revealed that Misappropriation of resident property is defined as means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Further review revealed that Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is a policy of this facility that abuse allegations including abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of resident property are reported per federal and state law, in addition local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. If an incident or allegation is considered reportable the administrator or designee will make an initial report to the state agency. Follow up investigation will be submitted to the state agency within five working days Review of facility grievances logs dated June 30, 2025, revealed that resident R 19 stated that money was taken from his nightstand, he noticed that cash was missing but didn't know exactly when the money was taken. Review of the facility documented valuable agreement dated May 23, 2025, revealed that the resident has $6.00 in a wallet and wished to keep the money with him. Review of facility interview with resident R 19 stated that he noticed that the money was missing on June 30, 2025. Resident R19 confirmed he was aware that the drawer has a lock, he was not sure if he locked it. Review of the facility investigation included a review of facility security recorded taped footage of resident R19's hallway at time of suspected theft, and interviews with all staff that had access to the resident's room and five residents residing on the same nursing unit. Interview with NHA employee E1 on July 16,2025 at 12:58 PM confirmed that the incident was thoroughly investigated and a perpetrator was identified and terminated. Employee E1 confirmed that the incident was not reported. 28 Pa. Code 201.14(a) responsibility of Licensee No Notes Review of facility grievance log revealed grievance report for Resident R51, dated June 12, 2025, reporting that “Resident reported to SSD that on June 12, 2025 during first shift 2 girls (Black girl with [NAME] Mouse shirt and Spanish girl) were changing her diaper. While changing her diaper the black girl said, “Don’t pull that.” Then the Spanish girl yanked out her biliary drain (a thin, flexible tube that is used to drain bile). Resident stated that she then had to go to the hospital and while at the hospital they had to recut her to put another biliary drain in.” Review of Resident R51's clinical record revealed that resident was admitted to facility on April 20, 2025, with diagnosis of, but not limited to, Acute Cholecystitis (inflammation of the gallbladder that occurs due to impaired emptying of the gallbladder). Review of Resident R51’s MDS (Minimum Data Set) dated May 21, 2025, revealed that resident has a BIMS (Brief Interview for Mental Status) of 15, indicating resident is cognitively intact. Review of Resident R51’s hospital records dated June 12, 2025, revealed resident had dislodged cholecystostomy tube (Biliary drain) and that resident was sent to IR (interventional radiology) to have drain replaced. Interview with Employee E2 on Director of Nursing on July 15, 2025, at 1:20pm confirmed that the facility failed to report the Resident R51’s allegation of neglect received for June 12, 2025.

Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed pain medication to meet the needs of one of four residents reviewed for pain management (Resident R64). Findings include: Review of facility policy titled Pharmacy Services, revised 2019, revealed pharmacy services are available to residents 24 hours a day, seven days a week. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. Review of Resident 64's clinical record revealed Resident R64 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (loss of muscle mass and strength), chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems), and chronic pain syndrome (condition where pain persists for more than 3 months and significantly impacts a person's physical, mental, and emotional well-being). Review of facility documentation, dated June 17, 2025, revealed Resident R64 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on July 14, 2025 at 10:46 a.m. with Resident R64 revealed Resident R64 has not received his/her scheduled Xtampza ER (extended-release of oxycodone, indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate) since admission. Resident R64 stated he/her takes this scheduled medication at home. Further interview on July 14, 2025 at 10:50 a.m. revealed Resident R64 stated he/she had a pain level of 8.5 (pain level scale of 1-10 with 1 being the least pain and 10 being the most pain) in his/her lower back throughout leg and pain in head. Review of Resident R64's physicians orders, dated July 11, 2025, revealed the physician prescribed Xtampza ER oral capsule 9 mg- one capsule by mouth every 12 hours related to pain. The order had a start date for the medication to be given on July 11, 2025 at 9:00 p.m. Review of Resident R64's MAR (medication administration record) revealed physician order for Xtampza was not given at the scheduled administration times as ordered by physician:-July 11th at 9:00 p.m.-July 12, 2025 at 9:00 a.m. and 9:00 p.m.-July 13, 2025 at 9:00 a.m. and 9:00 p.m.-July 14, 2025 9:00 a.m. Interview on July 15, 2025 at 12:08 p.m. with Employee E2, Director of Nursing, confirmed Resident R64 did not receive his/her scheduled pain medication due to delay in delivery from pharmacy. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services28 Pa. Code 211.9 (f)(2) Pharmacy services

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to provide necessary services to maintain adequate grooming for dependent residents for three of 13 residents reviewed (Resident R11, R22 and R95). Findings include: A review of the Bath(Bed/Shower) policy last updated November 30, 2018, indicated A bath is given to cleanse the skin and refresh the patient. Use whatever bath method is suitable to each patient, however, a bed bath is to be used only if it is impossible to bathe the patient in the tub or shower. Review of admission record indicated Resident R11 was admitted to the facility on [DATE], with a diagnosis of fracture of lower end of right femur, fracture of upper end of right tibia, aftercare following joint surgery, difficulty in walking , presence of right artificial knee joints. Review of Resident R11's Admission Minimum Data Set (MDS - a periodic assessment of care needs) dated September 5, 2024, revealed the resident required assistance with personal hygiene with substantial/maximal assistance. A review of Resident R11s care plan dated August 30, 2024, revealed the resident requires the assistance with activity of daily living (ADL), functions-partial/moderate assist with UB self-care, maximal to total assist with LB self-care and toileting of one staff with bathing/showering and dressing. Observations on September 10 , 2024, at 2:48 p.m., revealed Resident R11 had long facial hair on her chin, cheeks, and long nails. When asked if Resident R11 desires to be shaved the reply indicated I feel like people think I'm a man and I would love to get a shave and cut my nails. This observation was confirmed by the Director of Nursing, Employee E2. Review of admission record indicated Resident R95 was admitted to the facility on [DATE], with a diagnosis of difficulty in walking, reduced mobility, chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breath). A review of Resident R95s care plan dated September 4, 2024, revealed the resident requires the limited assistance with activity of daily living (ADL), set up/supervision with UB self-care. Observations on September 10, 2024, at 11:59 a.m., revealed that Resident R95 had long nails, facial hair, and had not received a shower since his admission. The resident expressed a desire to be shaved, and it was noted that his scheduled shower days were Tuesday and Friday. Resident R95 should have received a shower on Friday, September 6, 2024. A review of the shower task records showed no indication of whether the shower was provided or if Resident R95 had refused it. Director of Nursing, Employee E3 confirmed the observations. Review of admission record indicated Resident R22 was admitted to the facility on [DATE], with a diagnosis of sequelae of cerebral infarction (long term effects after a stroke), muscle weakness, difficulty in walking, need for assistance with personal care, muscle wasting and atrophy. A review of Resident R22s care plan dated July 19, 2024, revealed the resident requires the assistance with activity of daily living (ADL). Review of Resident 22's Admission Minimum Data Set (MDS) - a periodic assessment of care needs) dated August 5, 2024, revealed the resident is dependent for with personal hygiene, showers, toileting with substantial/maximal assistance. Observations on September 10, 2024, at 02:28 p.m., revealed that Resident R22 had long nails, facial hair and wanted to them to be cut and be shaved. Nursing aid, Employee E12 confirmed the observations. 28 Pa. Code 211.12 (d)(1) (5) Nursing Services

Based on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for three of three personnel files reviewed related to skills competencies evaluations (Employees E8, E9, E10). Findings include: The facility policy titled Staff Training Policy last updated January 2024, revealed The facility is committed to providing high-quality care and services to its residents. To achieve this goal, the facility recognizes the importance of ongoing staff training and development. It further stated Competency Validation: Employees will be assessed for competency in their specific job duties and responsibilities. Review of Employee E8's personnel file revealed that the employee was agency employee worked on June 28, 2024, hired, as a registered licensed nurse. Review of Employee E9's personnel file revealed that the employee was agency employee worked on August 26, 2024, hired, as a nursing aid licensed nurse. Review of Employee E10's personnel file revealed that the employee was agency employee worked on September 9, 2024, hired, as a licensed nurse. On September 12, 2024, at 10:41 a.m. an interview with Human Resource Director, Employee E4 and Director of Nursing, Employee E2 confirmed that agency staff including registered nurse, Employee E8, nursing aid licensed nurse, Employee E9, and license nurse, Employee E10 are not being evaluated on their competency to ensure nursing employees possess the required skills to properly care for resident's needs and are oriented to the facility practices. 28 Pa. Code 201.19(7) Personnel records 28 Pa. Code 201.20(b) Staff development

Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for two of two residents reviewed (Resident R11, and Resident R38). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Admission Minimum Data Set (MDS - a periodic assessment of care needs) dated September 5, 2024, indicated the diagnoses of fracture and orthopedic aftercare and a BIMS score of 15 - cognition intact. Review of Resident R11's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that she signed the document on admission on August 30, 2024. Review of admission record indicated Resident R38 admitted to the facility on [DATE]. Review of Resident R38's Admission Minimum Data Set (MDS - a periodic assessment of care needs) dated August 26, 2024, indicated a BIMS score of 15 - cognition intact. Review of Resident R38's Binding Arbitration Agreement indicated she signed it on admission on August 26, 2024. Interview on September 12, 2024, at 9:15 a.m. with the Nursing Home Administrator confirmed that that The Arbitration Agreement was found to limit all residents to a 10-day period to revoke the agreement, instead of the standard 30 days. During an interview on September 12, 2024, at 12:49 p.m., Resident R11 revealed that they were unaware of the arbitration agreement. When asked if they understood the procedures, Resident R11 responded, I have never heard anything about it; I don't know what it is. During an interview on September 12, 2024, at 12:55 p.m., Resident R38 stated that they were not aware of the arbitration agreement. When asked if they understood the procedures, Resident R38 responded, Upon admission, I remember someone came and had me sign something, but I don't know what the arbitration procedure is. During an interview with the Admissions Director, Employee E5, on September 12, 2024, at 1:10 p.m., it was revealed that she is responsible for educating all residents about the arbitration agreement. However, she was unaware of the 30-day revocation rights, stating that this aspect had never been addressed in any of her educational sessions with residents. Employee E5 remarked, I don't educate them about the 30-day revocation right. I've been here for a year, and I haven't learned everything yet. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident timely received the necessary behavioral health care to attain or maintain the highest practicable mental and psychosocial well-being for one of 13 residents sampled (Resident 38). Findings include: Review of admission record indicated Resident R38 admitted to the facility on [DATE].with diagnoses including anxiety. The Social Service assessment dated [DATE], revealed that Resident R28 had been experiencing feelings of being down, depressed, or hopeless for 7 to 11 days, which accounts for half or more of the days during that period. Resident 38's clinical record indicated a progress noted documented by the physician on August 22, 2024, that resident R38 has a diagnosis of anxiety. A further progress note, documented by Psychologist Employee E4 on August 27, 2024, revealed that Resident R38 exhibited anxiety about the future of her marriage. On September 10, 2024, at 12:18 p.m., an interview was conducted with Resident R38, who was observed crying. The resident shared, I have really bad anxiety, and changing roommates has made it worse. My first roommate was coughing and had COVID, so I was exposed and had to change rooms. My second roommate didn't like that I needed my TV and light on because that's the only way I can fall asleep. Now my current roommate is moving out today, and I don't want to deal with another roommate. On September 12, 2024, at 10:17 a.m. a telephone interview was held with nurse practitioner, Employee E11 who prescribed Mirtazapine 7.5 mg give one table by mouth at bedtime for insomnia on September 4, 2024. It was confirmed that there was no treatment provided to address anxiety during the day. On September 12, 2024, at 10:32 p.m., Resident R38 was interviewed regarding her new roommate. During the interview, Resident R38 shared that when she experiences anxiety, she becomes aware of it through symptoms of trichotillomania, a mental health condition characterized by the recurrent, irresistible urge to pull out hair from the scalp, eyebrows, eyelashes, or other parts of the body. R38 pointed to her head, where a large portion of hair was missing from the top. She further reported that coloring helps her calm down. Further record review did not indicate any intervention that were develop to help the resident to cope with anxiety. During an interview with the Director of Nursing and the Nursing Home Administrator on September 12, 2024, at approximately 4:15 p.m., they were unable to provide evidence that Resident R38 had received any interventions to address her anxiety needs. Additionally, no documentation was available regarding services provided to manage the resident's behaviors or to promote her highest practicable physical, mental, and psychosocial well-being. 28 Pa. Code: 201.29 (a)(b)(c) Resident Rights

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food stored in the refrigerator, freezer and resident's room was stored by professional standards for food service safety. Findings include: Review of facility policy Labeling and Dating System Protocol undated, revealed that All fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has Purveyor shipping label ot it. Make sure to not date over or cover up the manufacture's expiration date on the product. It further, specifies Refrigerated items opened: mayo, garlic, dressings, salsa 30 days; cheese sliced or shredded opened 1 week from open date; Deli Meat opened unsliced 7 days; Deli meat opened sliced 3 days; Beef , Pork Poultry raw 3 days. An initial tour of the Food Service Department conducted on [DATE], at 10:35 a.m. with Food Service Director, Employee E6, revealed the following: Observation in the main walking refrigerator had open catchup expired [DATE], 2 cheeses without labels one was shredded bag of open cheese and the second was block of open cheese, pastrami, opened beef bologna labeled, opened Italian sausages labeled as received date of [DATE] no expiration date. Opened raw pork lion with expiration date of [DATE], with no label. In the main freezer opened home fries not labeled, veggies burgers opened not labeled. At the serving table of the prep line the spices such as soy sauce-received date [DATE], syrup received date [DATE], teriyaki sauce received date [DATE] and no expiration dates. Vegetable oil opened not labeled, yellow food coloring received date [DATE], spices paprika, garlic received date [DATE], rosemary expired [DATE], paper, sesame, oregano only received date of [DATE]. An interview on [DATE], at 10:35 a.m., with Food Service Director, Employee E21, confirmed the above findings. On [DATE], at 2:28, 2024 an interview was held with Resident R22 who had opened salsa, nacho cheese, ranch, two opened pickled pickles jar without labeling nor refrigeration. Nursing aid, Employee E12 confirmed the observations. 28 Pa. Code 201.14 (a) Responsibility of Licensee.

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that physician orders were recorded completely and accurately for two of 16 records reviewed (Residents R96 and R145). Findings include: Review of clinical documentation for resident 96 revealed that he was admitted to the facility on [DATE]th, 2024 with diagnoses including, but not limited to, anemia, malnutrition, and dependence on renal dialysis. Continued review revealed an order for ProSource Nocarb 30mL two times a day for hemodialysis. No route of administration was recorded. Interview with employee E2, the director of nursing, on September 11, 2024, at 1:30 p.m. revealed that a complete physician order was to include the appropriate route of administration and confirmed the absence of such for this order. Review of clinical documentation for resident R145 revealed that he was admitted to the facility on [DATE], with diagnoses including, but not limited to, methicillin resistant staphylococcus aureus (MRSA, a bacteria which is resistant to treatment by penicillin and its derivatives), and long term use of antibiotics. Continued review revealed an order for Vancoycin HCL Intravenous Solution Reconstituted 1 GM .Use 1 gram intravenously two times a day for IV ABT (antibiotic), ordered on September 7, 2024. Interview with employee E2, the director of nursing, on September 10, 2024, at 11:20 a.m. revealed that a complete physician order was to include an appropriate diagnosis for the medication, and confirmed that IV ABT was the class of drug, not the reason for its use. 28 Pa. Code 211.12(c) Nursing service 28 Pa. Code 211.12(d)(1) Nursing service 28 Pa. Code 211.12(d)(2) Nursing service 28 Pa. Code 211.12 (d)(5) Nursing service

Based on review of clinical records, review of facility policy and procedure, review of facility documentation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough injury of unknown origin investigation regarding a hip fracture for one of 3 residents reviewed. (Resident CL1). Findings include: Review of facility policy, Abuse Prevention, date last revised February 25, 2022, revealed that It is the policy of Pines of Philadelphia does not tolerate any form of resident abuse, neglect , or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse, neglect, exploitation, misappropriation of property, and injuries of unknown origin in compliance with State and Federal regulations and the mission and philosophy of this facility. Review of facility policy, Incident and accident , dated last approved March 2019, revealed under Protocol .2. A thorough investigation and follow-up will be completed within five working days. A summary of the accident/incident will be documented. 3.The event may be an accident or a situation that could result in an accident. Accidents/incident may include, but are not limited to, the following: fall/suspected falls, explained or unexplained bruises/skin tears, medication errors, elopement, resident/patient to resident/patient abuse, self-inflicted injury, injuries of unknown origin, injury to resident/patient during handling. 4.All accidents/incidents, where there is suspected mistreatment, neglect, abuse, or injuries of unknown origin will be reported to the Administrator and Director of Nursing immediately. Reports to other officials will be made in accordance with the Elder Justice Act and applicable state law. Follow Abuse Policy and Procedure. A review of clinical record of Resident CL1 revealed admission on November 3, 2023 with the following diagnosis: rhabdomyolysis (a rare muscle injury where muscles break down and release toxic components into your blood and kidneys), dementia, hyperlipidemia, disorder of the skin and subcutaneous tissue, difficulty in walking, muscle wasting and atrophy, muscle weakness, lack of coordination, history of falling. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the Resident CL1's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated November 9, 2023, indicated a BIMS (Brief Interview of Mental Status) severe impaired. Review of clinical record indicated Resident CL1 had an unwitnessed fall on November 4, 2023 with nursing assessment dated , November 4, 2023 indicating complain of pain level 2 progress note on November 4, 2023 at 11:41 p.m. revealed pt complaint of pain from lower left portion of back, 4x4 bruise noted .MD contacted and acknowledged. Neuro checks were initiated and completed and Resident CL1 had no further pain documented. Further review of the record indicated CL1 started complaining of pain on: November 12, 2023, at 8:53 PM for pain level of 5 Acetaminophen administered with being ineffective November 13, 2023 at 1:42 AM for pain level of 7 Acetaminophen administered with being ineffective November 13, 2023 at 8:37 AM for pain level of 10 Acetaminophen administered with being effective November 13, 2023 at 4:14 PM for pain level 8 Acetaminophen administered with being effective November 13, 2023 at 8:49 PM for pain level 6 Acetaminophen administered with being effective November 14, 2023 at 9:00 a.m. pain level 5 MeloxiCNA 7.5 mg table was administered November 14, 2023 at 8:53 p.m. for pain level 4 Acetaminophen administered with being unknown result of effectiveness Based on the CL1 interview which occurred on November 14, 2023, at 11:59 a.m. CL1 had a pain level 10. There was no documented evidence that CL1 was assessed and treated for pain management on November 14, 2023, from 9:00 a.m. to 8:53 p.m. Based on the nursing progress notes dated November 14, 2023, at approximately 16:30 p.m. it noted patient presented in bed on left side at start of shift x-tray tech arrived approx. 16:30 to obtain Xray of back but patient refused. Another nurse from C- unit arrived to help with interpretation, patient was agreeable but then patient refused while yelling no while guarding left side. Patient yelled each time attempt was made to reposition him off his left side. An interview with the Director of Nursing on December 12, 2023, at approximately 10:00 a.m. confirmed that CL1 was without pain medication for a period of approximately 12 hours before being transfer to the local hospital for evaluation and was diagnosed with a hip fracture. On December 12, 2023, at 10:30 a.m. an interview with the Director of Nursing, Employee E2 revealed that facility did not interview the following Certified Nurse Assistant, (CNA), and License Practice Nurse (LPN)s for the days when CL1 started experiencing pain based on the assignment sheets: 11/12/23 shift 7-3 CNA, Employee E5 was not interviewed. 11/12/23 shift 3-11 CNA, Employee E6 was not interviewed. 11/12/23 shift 11-7 CNA Employee E6 was not interviewed 11/12/23 shift 11-7 LPN Employee E4 was not interviewed. 11/13/23 shift 7-3 CNA Employee E3 was not interviewed. 11/13/23 shift 3-11 CNA Employee E6 , CNA and LPN, Employee E8 were not interviewed. 11/13/23 shift 11-7 CNA, Employee E9 and LPN, Employee E4 were not interviewed. 11/14/23 shift 7-3 CNA Employee E9 was not interviewed. 11/14/23 shift 3-11 CNA Employee E10 was not interviewed. 11/14/23 shift 11-7 CNA Employee E10 and LPN Employee E11 were not interviewed. It was further revealed that facility did not conclude the investigation with the decision which was documented as they were waiting for the resident to return to the facility. Facility did not review the cameras to determine if CL1 could have experience any unwitnessed fall between November 12, 2023 and November 14, 2023 when he was transferred to the hospital. On December 12, 2023, at 2:30 p.m. an interview was held with Administrator, Employee E1 and the Director of Nursing, Employee E2 confirming that facility did not conduct complete and thorough injury of unknown origin investigation for CL1 which resulted in hip fracture. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a Resident Council meeting, resident interviews, review of facility policy and procedures, it was determined that the facility failed to ensure that grievance forms were available and accessible to residents' on the nursing units for five of 14 sample residents reviewed (Residents R201, R197, R2, R23, R4). Findings include: A review of facility policy Resident Grievance , revised November 2023 revealed: A resident may file an anonymous grievance by filling out a grievance form and placing it in the secured anonymous grievance box located near the social services office. On November 15, 2023, at 10:03 a.m. a tour of the facility was conducted with the Nursing Home Administrator, Employee E1 and Social Worker, Employee E10 revealed that grievance forms were not available to residents to make anonymous grievances. During the Resident Council meeting on November 15, 2023, at 1:15 p.m. Residents R201, R197, R2, R23, R4, who were alert and oriented reported that they did not know how to report grievances nor had seen the grievance forms. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation, review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure a resident received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers and continue treatments to prevent new from forming for one of 14 resident records reviewed. (Resident R20). Finding include: Review of the facility's policy titled Skin-Pressure Ulcers updated on January 15, 2023, states the facility has a systemic approach to a zero tolerance of pressure ulcers. The degree of risk is high for all patients, as determined by this patient population. Individual risk factors will be noted on the Nursing Admission Assessment to direct specific preventative treatments. Individual modalities will be incorporated in the care plan but will always include basic skin care, nurses will perform a thorough skin assessment on admission and once a week and will report any new or acquired stage of ulcer formation or impaired skin integrity. Review of Resident R20's admission nursing evaluation dated October 13, 2023, indicated the resident's admitting diagnosis was idiopathic peripheral autonomic neuropathy (damaged peripheral nerves) and type two diabetes (increased levels of blood sugar), and the general condition of the skin was documented intact without presence of wounds, ulcers, or skin discoloration. On admission, Resident R20 was at risk for skin breakdown related to his decrease mobility, chronic pain and deconditioning. The goal was the resident not to develop any skin impairments. Interventions included to keep the skin clean and dry and provide a well-balanced diet dated, October 13, 2023. Review of the nursing skin assessment dated , October 16, 2023, documented Resident R20 with discoloration to the left heal and complained of pain. Two weeks later, the next nursing skin assessment dated [DATE], documented Resident R20 continuing pain and discoloration to the left heel and indicated the area needed Attention. No further documented evidence was found regarding the left heel until the pintail wound care consult dated November 8, 2023. Review of the initial wound care consult dated November 8, 2023, diagnosed Resident R20's with pressure ulcers on now both of his heels. The physician staged the pressure ulcers as a deep tissue injury (DTI- depth unknown), that measured, 2.5 cm. x 3. cm. x -on the right heel and 5. cm x 5. cm. x - on the left. The same day Resident R20 was diagnosed with his pressure ulcers, his care plan was updated on November 8, 2023 to included new intervention (skin prep to heels and heel boots in bed). Interview with Resident R20 on November 16, 2023, at 10:05 a.m. stated he complained to nursing his heels were hurting but they didn't do anything. I saw the wound doctor and now I use heel boots (protects and off loads the heels in bed). Interview with the Director of Nursing on November 16, 2023, at 12:00 p.m. stated when the third shift nurse completed the skin assessments (October 16 and 30, 2023) it was not communicated to the rest of the staff the resident had pain and discoloration to the heels. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12. (d)(1)(2)(3)(5) Nursing services

Based on observations, clinical record, and staff interview, it was determined that the facility failed to ensure that the resident received enteral feedings as prescribed and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of one resident sampled (Resident 17). Findings include: Review of Resident 17's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, of respiratory failure, dysphagia following cerebral infarction (stroke), oropharyngeal phase; hemiplegia (weakness of one entire side of the body) and hemiparesis (most severe form complete paralysis) following unspecified cerebrovascular disease affecting left dominant side, paroxysmal atrial fibrillation, neuromuscular dysfunction of bladder. Resident 17 required a percutaneous endoscopic gastrostomy (PEG tube) also known as G-tube (gastrostomy tube is a medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements). Review of Resident R17's November 8, 2023 physician orders revealed an order for every shift for GI rest related to dysphagia following cerebral infarction Jevity 1.5 via peg tube at 50 ml/hr x 20 hrs total feeding 1000 ml (up at 6pm, down 2pm). Auto flush 150ml q4 hrs (6x/day). Observations of the resident's tube feeding pump on November 14, 2023, at 9:58 a.m. revealed feed bag had no identifying details on the bag , to include the name of the enteral feeding formula and rate of delivery to ensure that the resident was receiving the enteral feeding as prescribed. License nurse, Unit Manager, Employee E3 confirmed the observation and reported that it should have been labeled with the name of its content, rate given and every shift a nurse should have monitored it. On November 14, 2023, at 10:02 a.m. an interview with License nurse, Employee E6 who was the nurse assigned to the resident reported that the feed was placed during the November 13, 2023, evening shift at 6 p.m. and Employee E6 didn't realized it was not labeled. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide to ensure that one of 19 residents reviewed was properly access for pain and provided effective pain management. (Residents R190). Findings include: The facility policy entitled, Pain Management last reviewed February 2023, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. An interview was held with Resident R190 on November 14, 2023, at 11:59 a.m. with his grandson by resident's bedside. Resident R190 reported that he had severe pain level 10 on his left side of the back going into his left tight. Grandson asked the license nurse, Employee E4 who was assigned to care for the Resident R190 if resident received Celebrex (anti-inflammatory medication) which was ordered yesterday November 13, 2023. Employee E4 reported that the physician had order Melaxican and it was administered to the resident today between 9:00AM -10AM. Review of Resident's R190 November 2023 physician orders revealed an order dated November 3, 2023 for Acetaminophen Table 325 milligrams (mg) give 2 tablets by mouth every 4 hours as needed for pain. Review of Resident 190's November 2023 Medication Administration Record, revealed that the resident was administered Acetaminophen Table 325 mg 2 table every 4 hours on the following dates and times: November 12, 2023, at 8:53 PM for pain level of 5 Acetaminophen administered with being ineffective November 13, 2023 at 1:42 AM for pain level of 7 Acetaminophen administered with being ineffective November 13, 2023 at 8:37 AM for pain level of 10 Acetaminophen administered with being effective November 13, 2023 at 4:14 PM for pain level 8 Acetaminophen administered with being effective November 13, 2023 at 8:49 PM for pain level 6 Acetaminophen administered with being effective November 14, 2023 at 9:00 a.m. pain level 5 Meloxican 7.5 mg table was administered November 14, 2023 at 8:53 p.m. for pain level 4 Acetaminophen administered with being unknown result of effectiveness Based on the Resident 190 interview which occurred on November 14, 2023, at 11:59 a.m. Resident R190 had a pain level 10. There was no documented evidence that Resident R190 was assessed and treated for pain management on November 14, 2023 from 9:00 a.m. to 8:53 p.m. Based on the nursing progress notes dated November 14, 2023, at approximately 16:30 p.m. it noted patient presented in bed on left side at start of shift x-tray tech arrived approx. 16:30 to obtain Xray of back but patient refused. Another nurse from C- unit arrived to help with interpretation, patient was agreeable but then patient refused while yelling no while guarding left side. Patient yelled each time attempt was made to reposition him off his left side. An interview with the Director of Nursing on November 15, 2023, at approximately 10:00 a.m. confirmed that License nurse Employee E4 had no record that she provided pain medication after she administered Meloxican at 9:00 a.m. and the next pain medication was given at 8:53 p.m. on November 14, 2023. Resident was without pain medication for a period of approximately 12 hours before being transfer to the local hospital for evaluation and was diagnosed with a hip fracture. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of clinical record and review of facility policy, it was determined that the facility failed to ensure residents who require dialysis treatments and prescribed medication received such services, consistent with professional standards of practice for one of 14 resident clinical records reviewed (Resident R11). Finding includes: Review of the facility's Hemodialysis policy updated on January 15, 2023, revealed the purpose of hemodialysis is to maintain venous access, hemodynamic, fluid volume, temperature, nutrition and prevent injury or infection. The policy further states, all patient observations, interventions, etc. will be recorded in the patient record. Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE], with physician orders for the resident be taken to the dialysis center for dialysis every Monday, Wednesday, and Friday starting at 6:00 a.m. Review of Resident R11's October 2023 and November 2023 electronic medication administration record (eMAR) revealed the resident's scheduled 9:00 a.m. medications on his dialysis days were coded as not given due to dialysis as follows: Amiodarone for atrial fibrillation (risk of stroke due to irregular heartbeat) 200 milligrams (mg) was not given on October 25, 27, 30, and November 1, 2023; Aspirin 81 mg was not given on October 25, 27, 30, and November 1, 2023; Bumetanide 2 mg was not given at 9:00 a.m. on October 25, 27, 30, and November 1, 2023. Keppra 500 mg of was not given at 9:00 a.m. on October 25, 30, and November 1, 2023; 45 ml Lactulose oral solution given for the resident's diagnosis of gastrointestinal hemorrhage was not given on October 25, 27, 30, 2023. and 8.6-50 mg. Senna-Docusate Sodium was not given at 9:00 a.m. on October 30, and November 1, 2023. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff interview, it was determined that the facility failed to post daily nurse staffing data on each nursing unit on November 15, 20023, on both nursing floors of the facility. (First floor and Second Floor) Finding include: Observations on November 15, 20023, at 10:03 a.m. on the first-floor receptionist desk did not reveal that the staffing information was posted in a prominent place readily accessible to residents and visitors. An interview on November 15, 20023, at 10:03 a.m. with the Nursing Home Administrator, confirmed that the staffing information was not posted for the current date. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale failed to provide the duration of a hypnotic medication for two of five residents reviewed (Resident R3 and Resident R87). Findings include: Review of Resident R3's October 2023 physician orders included an order dated October 30, 2023, for Zolpidem Tartrate Oral Table 10 milligrams (anti-psychotropic medication) 1 tablet by mouth every 24 hours as needed for sleep related to insomnia. Review of Resident R3's clinical record revealed a note to the attending physician/prescriber from the consultant pharmacist dated October 30 2023, with a recommendation to evaluate the use of prn (as needed) Zolpidem pm. The note indicated that per CMS regulation effective 11-28-2017 all PRN (as needed) psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior. To extend the PRN order past the 14 days, the prescriber must document the rationale in the medical record and indicate the duration of the PRN order. Review of the physician, not dated, indicated to disagree and insomnia chronic. Further review of the clinical record failed to indicate the duration or end date of the medication for the PRN use of Zolpidem. Review of Resident R87's physician's orders instructed to give one tablet of Zolpidem Tartrate 10 mg, every 24 hours as need for sleep related insomnia, dated November 1, 2023. Review of Resident 87's clinical record revealed on November 2, 2023 the consulting pharmacist recommended to the physcian evaluate the use of prn Zolpidem. The note indicated that per CMS regulation effective 11-28-2017 all PRN psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior. The same note indicated that in order to extend the PRN order past the 14 days, the prescriber must document the rationale in the medical record and indicate the duration of the PRN order. Further review of the same note, the physician response (not dated) disagree and insomnia chronic but failed to provide the duration of the medication. Interview with Director of Nursing on November 16, 2023, at 2:15 p.m. confirmed that the physician failed to provide to included the duration or end date of the medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast in three of three nursing units. (A, B, and C nursing units). Findings include: A review of facility policy titled Nutritional Services last revised March 2023 revealed The facility is committed to meeting the nutritional needs of and creating a memorable dining experience for its residents by providing a choice of snacks at bedtime (HS). A review of the established meal schedule for the residents revealed that the dinner meal was scheduled for 5 p.m., and that the breakfast meal the following morning was offered at 8:00 a.m. This was a 15-hour meal span of time until breakfast the following day. An interview was held on November 14, 2023, at 10:28 a.m. with Resident R27 who reported that he/she eats dinner at 5:00 PM and breakfast is being served at 8:30 AM and no one offers snacks. Resident R27 does go hungry and one time he requested night snack and was staff told kitchen closed. During the Resident Council meeting on November 15, 2023, at 1:15 p.m. Residents (R201, R197, R2, R23, R4), who were alert and oriented reported that they do not received night snack. An interview with Dietician, Employee E5 held on November 15, 2023, at 2:47 p.m. revealed that snacks are not being labeled for diabetic, variety stacks are stored in the refrigerator in the sunshine room for evening staff to offer it to resident. A observation of diabetic snacks such as salami, egg salad sandwiches, yogurt with low sugar, have been observed in the sunshine room refrigerator. On November 16, 2023, at 9:16 a.m. with a license nurse unit manager, Employee E3 a walk thru the B and C unit was conducted and diabetic Residents R1, R4, R20, R27, R29, R89 were interviewed in their room who reported that they did not receive a night snack during last night November 15, 2023. 28 Pa. Code: 201.14(a) Responsibility of license

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the physician notes were was accessible in one of 14 resident clinical records reviewed (Resident R14). Findings include: Review of Resident R14's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of sepsis (acute infection) ischemic cardiomyopathy (the hearts decreased ability to pump blood), leading to heart failure (fluid builds in lungs causing excess fluid in the body and weight gain). The resident was documented with a weight of admission of 214.5 pounds and was ordered medications to rid the body of excess fluid. On November 15, 2023 the resident weighed 151.4 pounds a loss of 63.1 pounds in 41 days. Review of Resident R14's clinical records since admission revealed no documented evidence of physician notes recorded in the electronic clinical record and/or paper record for review. Interview with the Director of Nursing on November 16, 2023 at 2:30 p.m. stated the physician did not use the computer but the progress notes were handwritten. It wasn't until the surveyor requested these documents that the physician emailed the notes to the surveyor. 28 Pa Code 211.5(f)(ii) Medical records

Based on clinical record review, facility policies and procedures, facility documentation and staff interviews, it was determined that the facility failed to ensure that residents were free of significant medication errors related to the administration of anticoagulant medication for three of four residents ordered anticoagulation therapy (Resident R2, R3 and Resident R11). This failure placed Resident R3 in an Immediate Jeopardy situation, with the continued administration of an anticoagulant medication. Subsequently Resident R3 developed critical PT/INR levels, requiring emergent transfer to the hospital, [DIAGNOSES REDACTED]. Finding include: A review of Davis's Drug Guide for Nurse's, Twelfth Edition, dated 2011, revealed that some medications, such as anticoagulants ([MEDICATION NAME]& [MEDICATION NAME]) have a greater potential for harm than others. These medications have been identified by the Institute for Safe Medication Practices as high alert drug's. Davis's Drug Guide for Nurses additionally stated that residents over [AGE] years old . exhibit greater than expected PT/INR response (PT-[MEDICATION NAME] time is a blood test that measures how long it takes the blood to clot. Normal range is 11 seconds 13.5 seconds) and INR (international normalized ratio- a system established by the world health organization and the international [MEDICAL CONDITION] and hemostasis committee for reporting the results of blood coagulation (clotting) test. All results are standardized, normal range is 0.8 to 1.1). Monitor for side effects at lower therapeutic ranges and taking [MEDICATION NAME]/[MEDICATION NAME] along with Aspirin (over the counter blood thinning medication) may increase the response to [MEDICATION NAME]/[MEDICATION NAME] and increase the risk of bleeding. Further review of Davis's Drug guide for Nurses revealed that Medication errors involving anticoagulants have resulted in serious harm or death from internal or intracranial (within the skull) bleeding. A review of the facility policy title, Anticoagulation Therapy- Medication Administration Record (MAR) dated February 26, 2015, revealed that the purpose of the policy is to insure safe and effective anticoagulation therapy. All residents receiving anticoagulation therapy will have a physician's order stating parameters designating the targeted therapeutic level of anticoagulation in the form of [MEDICATION NAME] time, International Normalization Ratio (INR) or Partial [MEDICATION NAME] Time, as well as orders for ongoing laboratory monitoring of anticoagulation. Physicians choosing not to set parameters are to be called after each PT/INR result is obtained before giving 5:00 p.m. dose. Any time a dosage is changed the old order will be discontinued and a new order written with specific instructions. The physician will be notified immediately if laboratory values are outside the set parameters, or if any bleeding /bruising occurs. The [MEDICATION NAME] flow sheet is also documented to assure a definitive review and tracking of a therapy documentation. A review of the facility policy titled [MEDICATION NAME] protocol dated March 15, 2012, revealed that the purpose to the policy is to ensure the recommended usage as per the manufacturer are being followed and continue therapy contains documentation necessity. A review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the resident's five -day Minimum Data Set (MDS -a periodic review of the resident's needs) dated February 27, 2020, revealed that the resident was independent in decision making skills. The MDS further identified the resident received 7 days of an anticoagulant medication. A review of Resident R3's care plan titled The resident is on anticoagulant therapy dated February 28, 2020, revealed the following interventions: administer anticoagulant as the physician ordered, monitor for side effects and effectiveness every shift, daily skin inspection, give medication the same time every day, labs as ordered, report abnormal labs to physician, monitor for signs and symptoms of bleeding and intervene accordingly. Review of admission physician's orders dated February 21, 2020, revealed an order for [REDACTED]. An additional order obtained on February 21, 2020 for [MEDICATION NAME] 5 milligrams, one time only, by mouth. Further review of the physician's admission order included [MEDICATION NAME] (an anticoagulant medication) 100 milligrams/milliliters, inject one vial subcutaneously (medication injected into the skin) two times a day for [MEDICAL CONDITION], at 9:00 a.m. and 5:00 p.m. and Aspirin 81 milligrams, give one tablet, by mouth one time a day for [MEDICATION NAME] (preventative). Further review of February 2020, physician's orders revealed an order obtained on February 25, 2020, for [MEDICATION NAME] 2 milligrams by mouth one pill at bedtime. Review of the February 2020, Medication Administration Record revealed that on February 21, 22, 23, 24, 25, 26, 27, 2020, Resident R3 was administered [MEDICATION NAME] 5 milligrams one tablet, by mouth at bedtime at 9:00 p.m. Review of a nurse's note dated February 25, 2020, revealed that the physician was notified that the resident's INR was 3.1 (normal range 0.8-1.1). A new physician's order was obtained to start [MEDICATION NAME] 2 milligram, to recheck INR on February 28, 2020, and to discontinue [MEDICATION NAME] 100 milligrams. Review of February 2020, Medication Administration Record revealed that on February 25, 26, and 27, 2020, the resident was administered [MEDICATION NAME] 2 milligrams one tablet, by mouth at 9:00 p.m. in addition to the 5 milligrams of [MEDICATION NAME] for a total of 7 milligrams of the anticoagulant medication [MEDICATION NAME]. Further review of the Medication Administration Record for February 2020, revealed that on February 21, 2020, a second order for [MEDICATION NAME] 5 milligrams, one tablet by mouth, one time only, was administered to the resident at 2:43 a.m. for a total of 10 milligrams administered on February 21, 2020. Review of Resident R3 February 2020, nursing notes revealed no documented evidence as to the reason for an administration of [MEDICATION NAME] 5 milligrams at 2:43 a.m. and at 9:00 p.m. on February 21, 2020. Review of a nurse' note dated February 28, 2020, at 11:20 a.m. revealed that licensed nursing staff, Employee E13, received a call from the laboratory of the local hospital regarding Resident R3's with a critical PT/INR level. The resident PT was 61.7 seconds (normal range 11 seconds to 13.5 seconds) and INR is 7.1 (normal range is 0.8 to 1.1). The physician was notified and ordered to repeat PT and INR and if results still high to administer Vitamin K 5 milligrams by mouth one time. PT and INR stat (Immediate) noted and ordered. Review of physician's note dated February 28, 2020, at 3:49 p.m. revealed will recheck stat INR, will give Vit K po (by moth) once results available. Review of nurse's note dated February 28, 2020, at 3:52 p.m., revealed that the resident was noted with bright red blood during a bowel movement. This nurse call the physician and ordered that the resident be sent to the emergency room . The resident responsible party was with the resident. Report given to the emergency room nurse. A review of a nurse's note dated February 28, 2020, at 8:51 p.m. revealed that the hospital called and stated that the resident was admitted with a [DIAGNOSES REDACTED]. A review of Resident R3's hospital History and Physical dated February 28, 2020, revealed that the resident was admitted to the intensive care unit due to the resident's clinical condition. Further review of the hospital records revealed that this is a [AGE] year old female with recurrent lower extremities [MEDICAL CONDITION] admitted with a [MEDICAL CONDITION] (bleeding in the intestinal tract) and [MEDICAL CONDITION]. The problem/assessment plan stated: problem #1-had recent abdominal surgical history, hemoglobin (the red blood cells that carry oxygen through the body), was 4.7 ( normal range 12.0 to 16.0) on admission, status [REDACTED]. The patient had an episode of bloody stool overnight and hemoglobin at that time was 8.3, stable. The resident is tolerating a full liquid diet, will advance as tolerated. A fourth unit of blood was given. During a phone interview with the resident's physician on October 19, 2020, at 2:00 p.m. revealed that when the physician was asked by the surveyor if a [MEDICATION NAME] order was to be discontinued once a new [MEDICATION NAME] order was given. The physician stated, I need to look at the patient's medical record before I can comment. During an interview with the Assistant Director of Nursing on October 19, 2020, at 11:00 a.m. it was confirmed that the resident received 7 milligrams of [MEDICATION NAME] on February 25, 26 and 27, 2020. Instead of the 2 milligrams the physician ordered. Further it was also confirmed that on February 21, 2020, the resident was administered 10 milligrams of [MEDICATION NAME] instead of the 5 milligrams as ordered by the physician. The Assistant Director of Nursing indicated that there were no facility staff currently employed who would have completed an investigation related to Resident R3 receiving the incorrect dosage of an anticoagulant medication. The Assistant Director of Nursing was unable to provide evidence that facility staff was educated on significant medication errors related to anticoagulation therapy. A review of Resident R11's closed clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of December 2019, physician's orders revealed that an order was obtained on December 28, 2019 for [MEDICATION NAME] 6 milligrams one tablet by mouth at bedtime (9:00 p.m.) and [MEDICATION NAME] 0.5 milligrams by mouth at bedtime (9:00 p.m.) to be given with 6 milligrams to equal 7.5 milligrams with a discontinued date January 21, 2020. Review of the Medication Administration Records revealed that the physician's order for [MEDICATION NAME] 0.5 milligrams by mouth at bedtime (9:00 p.m.) to be given with 6 milligrams to equal 7.5 milligrams was recorded twice on the MAR and on December 31, 2019, the resident was administered 8 milligrams of [MEDICATION NAME] and not 7.5 milligrams as ordered by the physician. Further review of December 2019, physician's orders revealed that an order was obtained on December 28, 2019 for [MEDICATION NAME] 0.5 milligrams by mouth at bedtime. A review of the resident's December 2019 Medication Administration Record revealed two orders for [MEDICATION NAME] 0.5 milligrams by mouth at bedtime. The resident was administered a total of 10 milligrams of [MEDICATION NAME] on December 28, 29, 30, 2020 and not 5 milligrams of [MEDICATION NAME] as ordered by the physician. An interview with licensed nursing staff, Employee E11, on October 20, 2020, at 11:00 a.m. confirmed that it could not be determined how much [MEDICATION NAME] the resident received and that the dosage of [MEDICATION NAME] 0.5 milligrams and [MEDICATION NAME] 6 milligrams does not equal 7.5 milligrams and it was incorrect. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. A review of the resident's five day Minimum Data Set (periodic review of the resident's needs), dated February 25, 2020, revealed that the resident was independent in decision making skills. Review of physician's orders dated February 13, 2020, revealed an order for [REDACTED]. A review of Resident R2's February 2020, Medication Administration Record, revealed that on February 17, 2020, [MEDICATION NAME] 40 milligrams was administered to the resident at 9:00 a.m. and at 9:19 p.m. which indicated that the resident received the medication twice in one day and not one time a day as it was ordered by the physician. An interview with licensed nurse, Employee E11, on October 20, 2020, at 11:00 a.m. confirmed that the resident received the [MEDICATION NAME] twice on February 17, 2020. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Assistant Director of Nursing on October 20, 2020, at 3:20 p.m. The Nursing Home Administrator and Director of Nursing failed to ensure residents were free of significant medication errors related to the administration of anticoagulant medications. The corrective action plan included the following interventions: -An audit was conducted of a total of six patients receiving anticoagulation therapy. The physician's orders were compared to the dosages received and all dosages of anticoagulant therapy medications were administered to the patients as prescribed at their correct does. -the Medical Director reviewed the current [MEDICATION NAME] ([MEDICATION NAME]) protocol in place and has discontinued this current protocol -A new policy will be implemented October 20, 2020, stating that all patients receiving [MEDICATION NAME] will have the results called to the attending physician for further medical management. -The facility 24 hour chart check policy was reviewed and all orders will be checked every night to ensure that medication are transcribed correctly. -All 11-7 a.m. licensed nurses on tonight's schedule, will be re-educated on the 24 hour chart check policy and process. Ongoing re-education to capture all other 11-7 a.m. nurses. The facility administration will ensure that all licensed nurses on all shifts will be inserviced prior to the start of their shift. Receiving & Discontinuing [MEDICATION NAME] ([MEDICATION NAME]) orders: -When receiving a new order for [MEDICATION NAME] ([MEDICATION NAME]) therapy, the nurse will enter this order into the electronic medical record, print it out and place into patient's paper medical chart. -The nurse will next discontinue the previous [MEDICATION NAME] therapy order within the electronic charting system and additionally, discontinue this same order within the paper chart by write 'DC across the page where the do order was listed, the date it should be discontinued, the nurse's initial with signature and the signature of a cosigner, a nursing supervisor only. -When INR lab result is ready to be reviewed, the nurse will the physician. Receiving & Discontinuing other anticoagulation therapy orders: -When receiving a new order for an alternate anticoagulation therapy, the nurse will enter this order into the electronic medical record, print it out and place into patient's paper medical chart. -The nurse will next discontinue the previous alternate anticoagulation therapy order within the electronic charting system and additionally, discontinue this previous order within the paper chart by writing 'DC' across the page where the old order is listed, by recording the date it should be discontinued, and lastly, by documenting the nurse's initials with signature and the signature of a cosigner, a nursing supervisor only. -The nurse will additionally ensure that he patient receiving any kind of anticoagulation therapy is to have bleeding precautions instituted, assessing for evidence of bleeding, bruising, petechiae (round brown-purple spots due to bleeding), and the promptly alerting the physician if exhibiting such. -Administration will do daily audits times 4 weeks of all patients receiving [MEDICATION NAME] to sure the ordered labs were obtained, results were received, and the result were reviewed with the Attending physician for appropriate medical management. -After the 4 week audit and competency is established, the facility will continue auditing the [MEDICATION NAME] and the 24 hour chart check monthly thereafter. -The results of all audits will be presented and reviewed at the quarterly Quality Assessment and Performance Improvement program. Monitoring visit was conducted on October 21, 2020, to verify the implementation of the immediate action plan and to review staff re-education documentation. All staff in the building at the time of the visit on October 21, 2020 had been in-serviced on 24 hour chart check and in receiving and discontinuing [MEDICATION NAME] and other anticoagulation therapy orders. Interviews conducted with staff during the monitoring visit on the date stated above reported and verified that they had been in-serviced on the facility new [MEDICATION NAME] and other anticoagulation policy. The Immediate Jeopardy was lifted on October 21, 2020, at 7:10 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code:201.18(e)(1) Management 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.10(d)Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, facility policies and procedures, facility documentation and staff interviews, it was determined that the facility failed to ensure that the physician's orders were followed related to the administration of anticoagulant medication for three of 13 residents reviewed (Resident R2, Resident R3 and Resident R12), which resulted in actual harm to Resident R3 receiving the incorrect dosage of an anticoagulant medication, developing critical PT/INR levels, requiring emergent transfer to the hospital, [DIAGNOSES REDACTED]. Additionally, the facility failed to ensure that residents were appropriately assessed and monitor for signs and symptoms of Covid-19 for one of six closed clinical records reviewed.(Resident CL1) Finding include: A review of Davis's Drug Guide for Nurse's, Twelfth Edition, dated 2011, revealed that some medications, such as anticoagulants ([MEDICATION NAME]& [MEDICATION NAME]) have a greater potential for harm than others. These medications have been identified by the Institute for Safe Medication Practices as high alert drug 's. Davis's Drug Guide for Nurses additionally stated that residents over [AGE] years old . exhibit greater than expected PT/INR response (PT-[MEDICATION NAME] time is a blood test that measures how long it takes the blood to clot. Normal range is 11 seconds 13.5 seconds) and INR (international normalized ratio- a system established by the world health organization and the international [MEDICAL CONDITION] and hemostasis committee for reporting the results of blood coagulation (clotting) test. All results are standardized, normal range is 0.8 to 1.1.) Monitor for side effects at lower therapeutic ranges and taking [MEDICATION NAME]/[MEDICATION NAME] along with Aspirin (over the counter blood thinning medication) may increase the response to [MEDICATION NAME]/[MEDICATION NAME] and increase the risk of bleeding. Further review of Davis's Drug guide for Nurses revealed that Medication errors involving anticoagulants have resulted in serious harm or death from internal or intracranial (within the skull) bleeding. A review of the facility policy titled, Anticoagulation Therapy- Medication Administration Record [REDACTED]. All residents receiving anticoagulation therapy will have a physician's order stating parameters designating the targeted therapeutic level of anticoagulation in the form of [MEDICATION NAME] time, International Normalization Ratio (INR) or Partial [MEDICATION NAME] Time, as well as orders for ongoing laboratory monitoring of anticoagulation. Physicians choosing not to set parameters are to be called after each PT/INR result is obtained before giving 5:00 p.m. dose. Any time a dosage is changed the old order will be discontinued and a new order written with specific instructions. The physician will be notified immediately if laboratory values are outside the set parameters, or if any bleeding /bruising occurs. The [MEDICATION NAME] flow sheet is also documented to assure a definitive review and tracking of a therapy documentation. A review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the resident's five -day Minimum Data Set (MDS -a periodic review of the resident's needs) dated February 27, 2020, revealed that the resident was independent in decision making skills. The MDS further identified the resident received 7 days of an anticoagulant medication. A review of Resident R3's care plan titled, The resident is on anticoagulant therapy, dated February 28, 2020, revealed the following interventions: administer anticoagulant as the physician ordered, monitor for side effects and effectiveness every shift, daily skin inspection, give medication the same time every day, labs as ordered, report abnormal labs to physician, monitor for signs and symptoms of bleeding and intervene accordingly. Review of admission physician's orders dated February 21, 2020, revealed an order for [REDACTED]. Further review of February 2020, physician's orders revealed an order obtained on February 25, 2020, for [MEDICATION NAME] 2 milligrams by mouth one pill at bedtime. Review of the February 2020, Medication Administration Record [REDACTED] Review of a nurse's note dated February 25, 2020, revealed that the physician was notified of the resident INR was 3.1 (normal range 0.8-1.1). A new physician's order was obtained to start [MEDICATION NAME] 2 milligram, to recheck INR on February 28, 2020, and to discontinue [MEDICATION NAME] 100 milligrams. There was no evidence in the resident's clinical record that the previous order for [MEDICATION NAME] 5 milligrams was discontinued upon receiving the new order of [MEDICATION NAME] 2 milligrams as stated in the facility's policy. Review of February 2020, Medication Administration Record [REDACTED]. Review of a nurse' note dated February 28, 2020, at 11:20 a.m. revealed that licensed nursing staff, Employee E13, received a call from the laboratory of the local hospital regarding Resident R3's with a critical PT/INR levels. The resident PT was 61.7 seconds (normal range 11 seconds to 13.5 seconds) and INR is 7.1 (normal range is 0.8 to 1.1). The physician was notified and ordered to repeat PT and INR and if results still high to administer Vitamin K 5 milligrams by mouth one time. Pt and INR stat (Immediate) noted and ordered. Review of nurse's note dated February 28, 2020 at 3:52 p.m. revealed that the resident was noted with bright red blood during a bowel movement. Licensed nurse, Employee 36 contacted the resident's physician and an order was obtained to the send the resident to the emergency room . A review of Resident R3's hospital History and Physical dated February 28, 2020, revealed that the resident was admitted to the intensive care unit due to the resident's clinical condition. Further review of the hospital records revealed that the resident was admitted with a [DIAGNOSES REDACTED]. The resident hemoglobin (the red blood cells that carry oxygen through the body), was 4.7 (normal range 12.0 to 16.0) and requiring blood transfusion of four units of packed red blood cells. During an interview with the Assistant Director of Nursing on October 19, 2020, at 11:00 a.m. it was confirmed that the resident received 7 milligrams of [MEDICATION NAME] on February 25, 26 and 27, 2020. Instead of the 2 milligrams the physician ordered. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. A review of the resident's five day Minimum Data Set (periodic review of the resident's needs), dated February 25, 2020, revealed that the resident was independent in decision making skills. Review of physician's orders dated February 13, 2020, revealed an order for [REDACTED]. A review of Resident R2's February 2020, Medication Administration Record, [REDACTED]. An interview with licensed nurse, Employee E11, on October 20, 2020, at 11:00 a.m. confirmed that the resident received the [MEDICATION NAME] twice on February 17, 2020. Review of Resident R12's closed clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of physician's orders dated November 19, 2019, revealed an order for [REDACTED].>Review of Resident R12's November 2019, Medication Administration Record [REDACTED]. A review of nurse' notes dated November 19, 2019, revealed no evidence as to the reason the anticoagulant medication was not administered to the resident. Interview with licensed nursing staff, Employee E11, on October 20, 2020, at 12:00 p.m. confirmed that the medication [MEDICATION NAME] was not signed out as administered to the resident. Employee E11 indicated that licensed nursing staff have access to [MEDICATION NAME] in the facility. That it is available in the Pyxis system (a locked medication storage system that the pharmacy sets up in a facility to have extra medication on hand.) and could have been retrieved from the Pyxis. Review of facility policy and procedure titled, COVID -19, dated July 14, 2020, indicated For new patients, Admitting nurse will complete a Coronavirus Identification Assessment and identify if patient exhibits fever and acute respiratory illness. and . All patients will be screened for signs and symptoms of COVID-19. Vital signs will be monitored every shift including oxygen saturation. Reviewof the clinical record for Resident CL1 revealed a physician's order dated April 21, 2020, which indicated the following Diagnoses: [REDACTED]. Review of Resident CL1's May 1, 2020 physician order's revealed that the resident had a [DIAGNOSES REDACTED]. Review of nursing notes from the time of admission until May 1, 2020, indicated that Resident CL1 was in isolation (resided in a private room) and was on contact precautions (isolation technique designed to minimize the transmission of infectious organisms by direct or indirect contact with an infected patient or his environment). Further review of Resident CL1's progress notes revealed that on May 7, 2020, Resident CL1 was transferred to the hospital for evaluation and treatment of [REDACTED]. Additonal review of Resident CL1's clinical record revealed that from the time Resident CL1's admission into the facility on [DATE], until the time of the COVID-19 [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing on October 16, 2020, at 1:15 p.m. indicated that Resident CL1 was placed on isolation and contact precautions due to being admitted from the hospital and related to COVID-19. The ADON further indicated that these measures would be in place for a period of 14 days. Further interview with the Assistant Director of Nursing on October 16, 2020, at 1:15 p.m., indicated that every resident who was admitted from a hospital and was placed on isolation/droplet precautions, was to have a COVID-19 assessment completed every shift, documenting vital signs and other related information on symptoms. During the interview, the Assistant Director of Nursing further confirmed that there were no COVID-19, assessments completed every shift for Resident CL1, from the time of admission until the resident's discharge from the facility. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code:201.18(e)(1) Management 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, medication error reports, select incident and accident reports and staff interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 18 residents reviewed (Resident R92). Findings include: Review of Resident R92's clinical record revealed that the resident was admitted to the facility on (MONTH) 25, 2019, with [DIAGNOSES REDACTED]. Continued review of the clinical record revealed a physician's orders [REDACTED]. The average normal range of INR for a person taking certain blood thinning medications is 2.00-3.00) was less than 2.0. Review of laboratory results for Resident R92 revealed on (MONTH) 13, 2019, an INR level of 2.5; (MONTH) 14, 2019, an INR level of 3.0; (MONTH) 15, 2019, an INR level of 2.3 and on (MONTH) 16, 2019, and an INR level of 2.2. Review of the Medication Administration Record [REDACTED] Review of the facility Incident/Accident Report dated (MONTH) 16, 2019, at 5:30 p.m. revealed that Hematuria (blood in the urine) was observed in the Foley drainage bag. On investigation, Pt. received 4 doses of Eliquis with INR > (greater than) 2.0. Eliquis, 5 milligrams, was to be given twice a day when the INR < (less than) 2.0 and that Eliquis was administered 2/14, 2/15, 2/16 when INR > 2.0. Review of the Medication Error Report dated (MONTH) 16, 2019, at 5:30 p.m. revealed an Administrative Error (Any error as it relates to how the medication was incorrectly given or not given by the nurse). The medication as it was intended to be or should have been administered as described above. The immediate action was to address and or correct this error was Eliquis discontinued. MD notified and pt sent to ER for evaluation of hematuria. Additional information on the Medication Error Report revealed Gross hematuria observed in pts Foley bag. Checked MAR for anticoagulants ordered. Noted order for Eliquis and administration instructions. PT/INR drawn today. INR=2.2. Further review on the Medication Error Report revealed that the error was not self-reported and that the resident received too many doses, specifically four doses. Documentation for Education: Individual Clinical Referral Form, dated (MONTH) 27, 2019, revealed that Employee E13, Licensed Practical Nurse (LPN) was educated for a Medication Error: Documentation of Critical Medication (Eliquis) given while parameters are to be held if patient INR is greater than 2.0. Medication given 2/15/19 @ 5 p.m. Further review of education also revealed Review 5 rights of Medication Safety - Patient, Drug, Dose, Route, and Time. Also review any specific parameters in medication orders, i.e. lab results, BP parameters. Additional Documentation for Education: Individual Clinical Referral Form, dated (MONTH) 28, 2019, revealed that Employee E18, LPN, was educated for a Medication Error: Documentation of Critical Medication (Eliquis) given while parameters are to hold if patient INR is greater than 2.0. Medication given at 9:00 a.m. on 2/14 and 2/16 by nurse (INR 2.2 on 2/16/19. Further review of education also revealed Review 5 rights of Medication Safety- Patient Drug, Dose, Route, and Time. Also review any specific parameters in medication orders, i.e. lab results, BP parameters, insulin coverage. Review of Hospital records dated (MONTH) 16, 2019, revealed that the Resident R92 was admitted for a primary [DIAGNOSES REDACTED]. Further review of hospital records on (MONTH) 16, 2019, also revealed that upon admission into the emergency room the resident's INR level was elevated at 3.4 at 19:06 (7:09 p.m.), contributing to the resident's hematuria. Interview with Employee E1, Nursing Home Administrator and Employee E2, the Director of Nursing, on (MONTH) 7, 2019, at approximately 2:30 p.m. confirmed that the Licensed Practical Nurses, Employee E13 and Employee E18, violated the rights of medication administration when taking care of Resident R92 on (MONTH) 2, (YEAR). The facility failed to ensure that one resident was protected from a serious medication error resulting in harm to the resident and requiring transport to the hospital for an emergent evaluation and treatment following a medication error. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/25/18, 02/01/17 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 01/04/18, 02/01/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/01/17