Every finding on record at Third Avenue Health & Rehab Center

Based on observations, clinical record review, select facility policy review, and staff and family interviews, it was determined that the facility failed to provide and ensure implementation of specialized rehabilitative services in accordance with professional standards of practice for positioning assessment, intervention, care planning, and staff training for 1 of 17 residents reviewed (Resident 12).Findings include: Review of the facility policy titled Seating and Positioning Program last reviewed by the facility on February 24, 2026, indicated that positioning is a cooperative effort between nursing and therapy services. Evaluation of the resident with recommendations for positioning is the responsibility of the Occupational and/or Physical Therapy Department under a physician's order. Development of the positioning program and provision of positioning aids is the responsibility of the Physical (PT) and Occupational Therapy (OT) Departments. Upon completion of the positioning program and provision of the positioning aids, nursing carries out the positioning program. In-services for specific positioning techniques, use of positioning aide, and positioning schedule will be provided by therapies in cooperation with nursing. Upon completion of the in-services, the program will become the responsibility of nursing. The Therapy Department will also provide instructions in positioning to nursing assistants, nursing staff and other caregivers within the facility. The policy indicated that it is the primary responsibility of the OT or PT with input from the interdisciplinary care team as needed, to determine the need for positioning interventions. It is the responsibility of OT/PT department to order resident positioning aids and to add the appropriate documentation to the resident's care plan throughout their intervention. Prior to nursing providing positioning, unit staff and/or restorative staff will be in-serviced on the positioning program/device and schedule. Therapy will train these staff members to adequately conduct return demonstrations. During an initial facility tour of the facility on March 24, 2026, at 11:55 AM, Resident 12 was observed seated in a Broda chair (a specialized wheelchair with a flexible frame that allows reclining and tilting for positioning and comfort) in the activity room with the chair reclined. The resident exhibited significant left lateral flexion of the neck and trunk (abnormal bending of the head and body toward one side), with the left ear strongly tilted toward the left shoulder. No cervical positioning device (equipment used to support proper head and neck alignment) or visible trunk support was in place. At 12:20 PM on the same day, Resident 12 was observed being fed by his sister, who had applied a neck pillow (a U-shaped cushion designed to support the head and neck). Interview with the resident's sister revealed she independently provided the neck pillow due to concerns related to worsening head positioning and its impact on swallowing. The resident's sister indicated the facility had not provided appropriate cervical support and reported positioning devices were often not in place during visits. Clinical record review revealed Resident 12 was admitted [DATE], with diagnoses including Parkinson's disease (a disorder of the nervous system that affects movement, commonly causing tremors, stiffness, and slowed movement) and neurocognitive disorder with Lewy bodies (a progressive type of dementia characterized by cognitive decline, changes in alertness, visual hallucinations, and movement problems similar to Parkinson's disease). Review of the quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 19, 2026, indicated Resident 12's BIMS interview (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) was not completed, which indicated that the resident was unable to provide or did not provide answers to complete this section. The MDS indicated that the resident was dependent on staff for all activities of daily living (routine daily care tasks such as transferring, repositioning, and mobility), including positioning. Review of physician orders revealed no orders for positioning devices to address cervical alignment needs. Review of Resident 12's comprehensive care plan dated February 25, 2026, identified impaired positioning and included interventions related to armrest cushions and invert bilateral upper wing support (placing cushions upside down on the upper side supports of the Broda chair). The care plan lacked clear, measurable, and individualized instructions and did not address the resident's cervical contracture (permanent tightening of muscles resulting in abnormal positioning) or include specific interventions to maintain proper head and neck alignment. Review of the Occupational Therapy Evaluation dated February 24, 2026, indicated the reason for referral was poor positioning in the Broda chair. The evaluation indicated that the resident exhibited a left lateral neck contracture (no measurements documented), that the contracture affected his functional skills, and that skilled therapy was needed to address this impairment. Clinical impressions from the evaluation indicated the resident displayed a left lateral neck contracture as well as curvature resulting in the right side of his torso pressing against the side of the Broda chair with his left upper extremity hanging over the left side of the chair. OT was recommended to reduce the risk for development of wounds. Goals included the use of adaptive equipment/devices to achieve midline position while sitting in the wheelchair. Review of the Occupational Therapy Discharge summary dated [DATE], indicated the resident achieved the short-term goal of maintaining midline positioning while seated using adaptive equipment for greater than eight hours. Interventions included trial of alternative wheelchair cushions and supports and training of staff and caregivers in positioning techniques. The discharge summary failed to identify the specific positioning devices or modifications required for continued implementation of the positioning program. Review of therapy documentation revealed no evidence staff received training regarding positioning techniques, devices, or schedules as required by facility policy. Observation on March 25, 2026, at 8:25 AM and again at 8:40 AM revealed Resident 12 seated in common areas with unsupported left lateral trunk and cervical positioning. The Broda chair lateral supports were not positioned as identified in the care plan. Interviews with multiple staff, including the Nursing Home Administrator and Physical Therapist, revealed staff were unable to explain or demonstrate the care plan intervention described as invert bilateral upper wing support. During an interview on March 25, 2026, at 2:40 PM, the Director of Rehabilitation confirmed cervical positioning devices were not identified in the discharge summary and confirmed staff training regarding positioning interventions and devices had not been documented. The Director of Rehabilitation further confirmed the resident's family provided the neck pillow. The facility failed to ensure therapy-identified positioning needs were translated into clearly defined and individualized care plan interventions, failed to ensure specialized rehabilitative services recommendations were implemented following therapy discharge, and failed to ensure staff were trained and competent to carry out the positioning program as evidenced by observations of the resident without appropriate support to maintain functional body alignment necessary to support safe swallowing, comfort, and prevention of complications associated with abnormal positioning. 28 Pa. Code 211.12 (d)(5) Nursing services.28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure licensed nurses accurately administered prescribed medication consistent with professional standards of practice for one of five residents sampled for unnecessary medications (Resident 1).Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled General Dose Preparation and Medication Administration last reviewed by the facility on February 24, 2026, revealed that prior to administration of medication facility staff should take all measures required by facility policy and applicable law, including verify each time a medication is administered that it is at the correct dose (amount of medication given), correct route (how the medication enters the body, such as by mouth), correct rate (how fast the medication is given, when applicable), correct time, and for the correct resident. The policy indicated staff should obtain vital signs (measurements of basic body functions such as blood pressure, pulse, breathing rate, and temperature) when required by the medication order. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and chronic combined systolic (phase when the heart squeezes) and diastolic (phase when the heart relaxes) congestive heart failure (heart muscle is both too weak to pump effectively and fill properly leading to inability to meet the body's oxygen needs, causing fluid congestion in the lungs and body). Review of a physician's order dated February 7, 2026, revealed an order for Midodrine (medication used to treat low blood pressure) 5 mg one tablet by mouth for systolic blood pressure (top number in a blood pressure reading) less than 100 mm/Hg (milliliters of mercury) three times per day as needed. Review of the Medication Administration Record (MAR) for February 2, 2026, through February 28, 2026, and March 1, 2026, through March 25, 2026, revealed Midodrine was not administered on four occasions when the resident's systolic blood pressure was below 100 mm/Hg, as evidenced by the following documented blood pressure readings: February 10, 2026, 1:35 PM BP 98/60 mm/Hg February 28, 2026, 4:48 PM BP 99/71 mm/Hg March 1, 2026, 11:49 AM BP 97/65 mm/Hg March 2, 2026, 10:50 AM BP 98/66 mm/Hg These medication omissions occurred despite the physician's explicit parameters to administer the medication for a systolic reading of less than 100 mm/Hg. During an interview on March 26, 2026, at 11:00 AM, the assistant director of nursing (ADON) acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. The ADON confirmed medications are to be administered as prescribed, in a safe and timely manner, and in accordance with physician orders. 28 Pa. Code 211.5(f)(ii)(ix) Medical records. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, select policy review, and staff and resident interview, it was determined the facility failed to ensure the timely acquisition and availability of prescribed medications for one of 20 residents reviewed (Resident 7).Findings include:Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnosis to include (a chronic medical condition in which the body cannot properly regulate blood sugar levels) and required injectable medication to maintain acceptable blood glucose levels. A review of Resident 7's quarterly Minimum Data Set assessment, (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 2, 2026, revealed that Resident 7 was cognitively intact with a BIMS score of 14, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates the resident is cognitively intact).Review of physician orders for March 2026 revealed Resident 7 was prescribed degludec (a long-acting insulin used to control blood sugar levels) to be administered nightly at 9:00 PM. Review of the facility policy titled Emergency Deliveries, dated February 24, 2026, revealed the facility is to immediately notify the pharmacy when a physician order requires emergency medication delivery to ensure medications are available for administration as prescribed. Review of the Medication Administration Record (MAR) dated March 17, 2026, at 9:00 PM and a nurse's note dated March 18, 2026, at 3:07 AM revealed the ordered degludec insulin was not available for administration at the scheduled time of 9:00 PM on March 17, 2026. Documentation indicated the medication was not administered until 3:00 AM on March 18, 2026. At that time, Resident 7's blood glucose level measured 346 mg/dL (milligrams per deciliter, a unit used to measure the amount of sugar in the blood; normal fasting levels are generally 70-120 mg/dL), indicating significantly elevated blood sugar levels. During an interview on March 26, 2026, at 9:30 AM, Resident 7 confirmed the ordered insulin was not available at the scheduled time and reported staff awakened him during the early morning hours (in the middle of the night) to administer the injection. During an interview on March 27, 2026, at 9:30 AM, the Director of Nursing (DON) confirmed the facility had sent notifications to the pharmacy requesting the prescribed degludec insulin on March 16, 2026, at 10:27 PM and March 17, 2026, at 6:25 PM prior to depletion of the medication supply for Resident 7. There was no documented evidence the facility ensured the medication was obtained and available for administration as ordered. 28 PA. Code 211.10 (c)(d) Resident care policies. 28 PA. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation, resident interview, staff interview, and review of facility practices, it was determined the facility failed to ensure effective management and execution of the duties and responsibilities of the food and nutrition services department to provide timely meal service for three of 17 residents reviewed (Residents 66, 23, and 8).Findings include: Observation during the breakfast meal on March 25, 2026, at 8:05 AM revealed Resident 66's roommate was eating breakfast in their semi-private room (a room shared by two residents). Interview with Resident 66, who was alert and oriented (able to understand and respond appropriately), at that time revealed she had not received her breakfast meal tray despite her roommate receiving a tray. Resident 66 confirmed she prefers to eat meals in her room and does not attend the dining room. Observation of the food cart located in the hallway outside Resident 66's room revealed the resident's breakfast tray was not present on the cart. Interview with Employee 3 NA (nurse aide) on March 25, 2026, at 8:10 AM confirmed she delivered a breakfast tray to Resident 66's roommate but did not see a tray for Resident 66. Employee 3 NA indicated that meal trays are not always placed on the cart in room number order. The Food Service Director (FSD) arrived at the nursing unit at that time and confirmed Resident 66's meal tray should have been present on the food delivery cart designated for the resident's room number. The FSD returned to the food and nutrition services department to have a breakfast meal prepared and delivered to Resident 66. Resident 66 received her breakfast tray at 8:15 AM. During a resident group interview conducted on March 25, 2026, at 10:00 AM, Residents 23 and Resident 8 reported they have experienced missed meal trays. Resident 23 stated the missed tray happened just last week, and Resident 8 stated missed trays occur once in a while. Both residents reported that when they notify nursing staff, the food and nutrition services department sends a tray. Interview with the FSD on March 26, 2026, at 8:15 AM confirmed that a meal ticket (printed document generated from the computerized meal tray program identifying each resident's ordered diet and meal) is printed for each resident for every meal to ensure each resident receives the correct diet as ordered. The FSD confirmed meal tickets are counted prior to meal service to ensure a ticket is present for each resident. The FSD confirmed Resident 66's breakfast tray was delayed on March 25, 2026, due to a missing meal ticket. The FSD indicated that when staff notify the food and nutrition services department that a resident did not receive a tray, a meal is prepared according to the ordered diet and delivered to the nursing unit. Interview with the Nursing Home Administrator on March 26, 2026, at 10:00 AM confirmed meal trays are expected to be delivered in a timely manner, and a meal ticket is to be printed for each resident at each meal to ensure meal service accuracy and timeliness. The facility failed to effectively manage the food and nutrition services department to ensure a meal ticket was generated for Resident 66, resulting in delayed delivery of the resident's breakfast meal on March 25, 2026. The facility also failed to ensure consistent systems were in place to prevent missed meal trays as reported by Residents 23 and 8. 28 Pa. Code 201.18 (b)(3)(e)(3)(6) Management.

Based on review of clinical records, facility policy, admission documentation, and staff interview, it was determined the facility failed to provide and maintain required written admission information and documentation for one of 17 residents reviewed (Resident 63).Findings include: Review of the facility policy titled Admissions Policy, last reviewed February 24, 2026, indicated the facility will admit only those individuals whose clinical (medical), physical (body function and mobility), psychosocial (mental health and social well-being), and emotional needs can be met by the facility. Review of the facility admission Agreement revealed the agreement included services, charges and fees, termination of the agreement, and miscellaneous areas to be reviewed with each newly admitted resident and/or resident representative. The admission Agreement included an admission Agreement signature page. Clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that included cervical myelopathy (compression of the spinal cord in the neck which may cause pain, weakness, or difficulty with movement) and generalized muscle weakness (reduced muscle strength). Resident 63 was discharged from the facility on February 21, 2026. Review of Resident 63's admission Minimum Data Set assessment (MDS, a federally required standardized assessment used to evaluate resident needs and develop a plan of care) dated January 5, 2026, revealed Resident 63 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a structured cognitive screening tool used to assess memory and orientation; a score of 13-15 indicates intact cognition). Documentation indicated that the resident and resident representative participated in the assessment process. Review of Resident 63's clinical record, including social service documentation and communication with the resident's family, failed to include documented evidence that required admission information was provided and acknowledged at the time of admission. Documentation did not include evidence the resident and/or resident representative received written information regarding patient portion liability (the amount the resident is responsible to pay), daily rate cost structure, resident rights, appeal rights (the right to formally dispute decisions regarding care or services), consent to treatment (permission allowing the facility to provide care), the right to choose ancillary services (services such as therapy providers or pharmacy), bed hold policy (a policy describing whether the facility will hold a resident's bed during hospitalization and any associated cost), or consequences for failure to pay. During an interview on March 27, 2026, at 9:30 AM the Nursing Home Administrator (NHA) confirmed that admission paperwork is to be reviewed with each resident and/or resident representative upon admission to the facility. The NHA failed to provide documented evidence that admission paperwork was completed as required for Resident 63. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.5 (f)(i)(xi) Medical records. 28 Pa. Code 211.10 (c)(d) Resident care policies

Based on clinical record review, observation, and resident and staff interviews, it was determined the facility failed to ensure one of 17 residents reviewed (Resident 8) was fully informed of, and participated in decision-making regarding, a restriction preventing the resident from using the bathroom connected to the bedroom.Findings include: Clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic condition affecting the body's ability to regulate blood sugar) and above-the-knee amputation of the left leg (surgical removal of the leg above the knee joint).A review of Resident 8's admission Minimum Data Set (MDS, a federally required standardized assessment used to evaluate a resident's functional and cognitive status and assist with care planning) dated December 16, 2025, revealed Resident 8 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a structured assessment of memory and orientation; scores of 13-15 indicate intact cognition).During an interview on March 25, 2026, at 11:00 AM, Resident 8 stated they were unaware why they were unable to use the bathroom connected to their bedroom to void (urinate). Resident 8 stated they would feel more comfortable using the bathroom in their room rather than being transferred to a commode (portable toilet) located in the shower room down the hall. Resident 8 indicated the only explanation provided was that the wheelchair would not fit through the bathroom doorway. An interview with Resident 8 on March 25, 2026, at 11:00 AM, revealed that Resident 8 was unaware of why they were unable to use the bathroom connected to their bedroom to void (urinate). Resident 8 stated they would feel more comfortable using the bathroom in their room rather than being transferred to a commode (portable toilet) located in the shower room down the hall. Resident 8 indicated the only explanation provided was that the wheelchair would not fit through the bathroom doorway.Observation on March 25, 2026, at 11:00 AM revealed Resident 8's wheelchair was able to fit through the doorway connecting the bedroom to the bathroom and was not inhibiting them from entering the bathroom.Review of Resident 8's clinical record and most recent care plan dated December 16, 2025, failed to include documentation that the resident was informed of the reason for the restriction, the risks or safety concerns associated with bathroom use, alternative options considered, expected duration of the intervention, or plans for reassessment of the resident's ability to use the bathroom in their room. Documentation also failed to reflect the resident's understanding of the restriction or the resident's preferences regarding this intervention.During an interview on March 26, 2026, at 10:30 AM, Employee 1, an occupational therapist (OT) stated the resident's bathroom did not allow adequate space for certain transfer equipment (devices used to assist a person in safely moving from one surface to another). Employee 1 OT stated the shower room provided additional space to assist the resident on and off the commode. During an interview on March 26, 2026, at 11:00 AM, Employee 1 OT and the Director of Nursing (DON) were unable to provide documentation that Resident 8 was fully informed of the reason for the restriction, the anticipated duration of the intervention, potential alternatives, or any plan to reassess the resident's ability to safely use the bathroom connected to their bedroom. Documentation also failed to demonstrate the resident's participation in the decision-making process or confirmation of resident understanding. 28 Pa. Code 201.29(4) Resident rights. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services.

Based on observations, review of clinical records, select facility policy review, and staff interview it was determined the facility failed to consistently ensure the provision of respiratory care and supplemental oxygen in accordance with physician orders and facility policy for one resident out of 17 residents reviewed. (Resident 65) Findings included: A review of the facility policy titled Oxygen Administration (all routes) last reviewed by the facility on February 24, 2026, indicated that licensed clinicians with demonstrated competence are responsible for administering oxygen via the ordered route. The policy further requires staff to monitor oxygen delivery systems, including checking oxygen cylinder (oxygen tanks which contain oxygen under pressure) gauges to ensure an adequate oxygen supply is available to meet the residents' needs. During an initial facility tour of the facility on March 24, 2026, at 12:12 PM, Resident 65 was observed seated in a wheelchair in the main dining room with an oxygen tank attached to the back of the wheelchair. The oxygen tank gauge indicated the tank was empty. This observation was confirmed by the Director of Nursing (DON). Review of the clinical record revealed Resident 65 was admitted to the facility on [DATE], with diagnoses including respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath), centrilobular emphysema (type of chronic obstructive pulmonary disease characterized by the destruction of air sacs in the center of the lung nodule, causing shortness of breath, coughing, and reduced oxygen exchange), and pneumothorax (collapsed lung). A physician's order dated March 19, 2026, specified oxygen at 3 liters/minute via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen), to be administered continuously. Review of the admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 24, 2026, indicated the resident was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 represents severe cognitive impairment) and required extensive assistance from staff for activities of daily living, bed mobility, and transfers, indicating reliance on staff to ensure ordered treatments were implemented. An observation conducted on March 25, 2026, at 9:45 AM, revealed Resident 65 lying in bed on the left side, asleep, without oxygen in use. The oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) and nasal cannula were observed 3.5 feet away from the resident, with the oxygen tubing and nasal canula lying directly on the floor and not in use. This observation was confirmed by Employee 2 Licensed Practical Nurse (LPN). The facility failed to ensure consistent delivery and monitoring of physician ordered oxygen therapy, failed to maintain oxygen equipment in a ready-to-use state, and failed to follow facility policy for oxygen administration. During an interview on March 26, 2026, at 10:45 AM, the DON revealed the facility was unable to provide documentation identifying the frequency of monitoring oxygen tanks. The DON acknowledged that the facility failed to ensure oxygen therapy was administered as ordered for Resident 65. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident Policies.

Based on a review of select facility policy, facility investigative reports, clinical records, and staff interviews, it was determined the facility failed to ensure a complete and accurate investigation was conducted into an allegation of misappropriation of medication for one of ten sampled residents (Resident 1).Findings included: A review of a facility policy entitled Pennsylvania Resident Abuse revealed it is the policy of the facility to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. The policy further defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Further review of the policy revealed the person investigating an incident is to interview the residents, the accused, and all witnesses. The policy stated that witnesses generally include anyone who witnessed or heard about the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. The facility would obtain written statements from the residents, if possible, the accused, and each witness. A review of Resident 1's clinical record revealed admission on [DATE], with diagnoses including ambulatory dysfunction secondary to prosthetic joint infection of the left hip (difficulty walking due to complications of hip surgery). The admission Minimum Data Set (MDS-a federally mandated standardized assessment used to plan resident care) dated July 30, 2025, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status-a tool assessing attention, orientation, and recall) score of 15, a score of 13-15 equates to being cognitively intact. A review of the resident's physician orders initially dated July 27, 2025, indicated the resident was to receive Oxycodone (a narcotic pain medication) 5 milligrams(mg) every 4 hours as needed for pain. A review of a grievance filed by Resident 1 dated July 30, 2025, revealed the resident reported that at 11:00 PM, he requested his PRN pain medication from a female nurse but never received it. The grievance further documented the resident again told a female aide at approximately 2:00 AM that he wanted his pain medication, but his request again went unanswered. The grievance also noted conflicting information when Resident 1 later reported he had asked a male nurse for his medication. The facility did not identify these individuals, document efforts to determine their identities, or reconcile these inconsistencies.A typed, undated note attached to the grievance, authored by the Director of Nursing (DON), concluded that the allegation was unsubstantiated and stated the resident had been sleeping between 2:15 AM and 6:00 AM, with the next medication request occurring at 11:00 AM on July 31, 2025. The note further stated that to prevent future occurrence, two employees will be assigned to administer the resident's medications.A review of Resident 1's July 2025 Medication Administration Record (MAR) revealed documentation that the PRN Oxycodone was administered on July 30, 2025, at 9:59 PM by Employee 1 (LPN) and again on July 31, 2025, at 2:20 AM by Employee 2 (RN), despite Resident 1's consistent report that he had not received the medication that evening. A review of a facility investigative documentation contained a single witness statement from Employee 3 (LPN), who indicated she had not been informed that Resident 1 requested medication throughout the night shift and stated that Resident 1 told her he had asked a male nurse for his pain medication. There was no documented evidence that either Employee 1 or Employee 2, both of whom recorded medication administration were interviewed or asked to provide written statements. The facility failed to conduct a complete and accurate investigation by not identifying the staff members referenced by the resident as male or female, not obtaining written statements from all potentially involved staff, and not reconciling conflicting reports about the administration of the medication. This failure resulted in an incomplete investigation that did not substantiate or disprove the allegation in accordance with facility policy. An interview with the Nursing Home Administrator and Director of Nursing on October 7, 2025, at approximately 11:00 AM confirmed the facility was unable to provide any additional witness statements from staff who documented the administration of the medication despite the resident's claim he did not receive any medication and acknowledged that the investigation contained no evidence identifying the male or female individuals referenced by the resident. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on review of clinical records, facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to consistently provide adequate supervision and implement appropriate, individualized fall prevention interventions based on assessed needs to ensure the safety of one of 18 sampled residents (Resident 50), resulting in multiple unwitnessed falls and significant injury, including a traumatic subdural hemorrhage and multiple fractures of the arm. Findings include: A review of the facility policy titled Fall Prevention and Management Policy, last reviewed by the facility February 13, 2025, revealed it is the policy of the facility to assist in fall management and prevention. The policy indicated an individualized, person-centered nursing care plan will be initiated and/or updated by the interdisciplinary team upon readmission to the facility. A clinical record review revealed Resident 50 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (gradual loss of kidney function), and history of recurrent falls. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2024, revealed that Resident 50 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A review of a Fall Risk assessment dated [DATE], revealed the resident lacks understanding of her physical and cognitive limitations and was assessed as being at high risk for falls. A review of the resident's plan of care initially dated October 30, 2024, revealed the resident had a series of falls and was at risk for injury Interventions included: use of a brightly colored call bell reminder sign, anti-rollback devices on the wheelchair, pre-bedtime toileting, rest period after dinner, therapy referrals, and application of Dycem (a thin, non-slip material) to the wheelchair. The care plan did not include documented interventions specifically addressing the resident's poor safety awareness, severe cognitive impairment, or repeated attempts to self-transfer. Progress notes revealed a repeated pattern of Resident 50 attempting to rise or transfer without staff assistance, despite her severely impaired cognition and known fall risk status. A review of a progress note dated November 14, 2024, at 6:30 PM revealed the resident was sitting near the entrance of the TV area. Staff heard someone say, she's on the floor. Staff found the resident on the floor in front of her wheelchair with her back against the wall. The resident asked to go to bed. No injury was noted at that time. A progress note dated November 15, 2024, at 6:31 AM documented the resident attempted to rise without assistance. The note further described her gait as unsteady with one-person assistance during transfers. On November 16, 2024, at 7:05 PM, another progress note indicated the resident continued to attempt rising without assistance at times. A review of a progress note dated November 30, 2024, at 11:03 AM indicated the resident was observed in the process of self-transferring between bed and wheelchair. Staff noted that redirection efforts were ineffective due to her cognitive status. A review of a progress note dated December 7, 2024, at 3:11 AM revealed the resident was found sitting on the floor against the wall in her room. She had sustained skin tears to the left elbow, left upper arm, and left ring finger. A review of a progress note dated December 18, 2024, at 10:22 PM, revealed the resident was using the phone in her room. When she stood up to hang up the phone and then attempted to sit back down, she missed the chair and landed on her buttocks. Staff documentation indicated that the resident was re-educated on waiting for assistance, despite her severe cognitive impairment, which made such education ineffective as an intervention. On December 21, 2024, at 6:05 PM, staff were called to the resident's room and found her sitting on the floor with her wheelchair behind her and the bathroom door closed. Her roommate reported the resident had attempted to stand up and slid to the floor. The wheelchair brakes were not fully engaged at the time of the incident. Despite the repeated self-transfer attempts, the only new intervention added was the application of Dycem to the wheelchair. Between November 14 and December 25, 2024, multiple progress notes documented Resident 50 attempting to rise without assistance and engaging in unsafe self-transfer behaviors. Staff repeatedly documented the resident required redirection, which was often ineffective due to her cognitive status. Despite this pattern, the facility did not revise the plan of care to include additional supervision or more targeted interventions to prevent further falls. A review of a progress note dated December 25, 2024, at 7:38 AM, revealed at 6:50AM the resident was found lying on the floor at the head of the bed. She sustained two additional skin tears, which were treated with saline, Xeroform gauze (wound dressing), and a dry sterile dressing. Once again, staff documented the resident was educated on the use of her call bell, even though prior documentation repeatedly identified her as severely cognitively impaired and resistant to redirection. According to the investigative documentation provided by the facility the cause of this fall was due to the resident's self-transfer attempts. A Progress note on December 25, 2024, indicated later that same day, at 6:57 PM, staff were alerted by another resident and found Resident 50 lying face down on the floor, with blood above her right eyebrow and complaints of pain in the left shoulder and arm. She had been lying on her broken eyeglasses. The resident's roommate reported she had walked into the room and fell . The physician was notified, and new orders were obtained for stat (immediate) X-rays. A review of the facility provided investigative documentation identified the root cause as another unassisted attempt to ambulate and noncompliance with transfer assistance. A review of a progress note dated December 26, 2024, at 3:25 AM revealed the resident was medicated for complaints of pain to her left upper extremity. An X-ray performed the following morning, December 26, 2024, at 11:00 AM revealed that Resident 50 sustained a closed fracture of the left shoulder and wrist. She was transferred to the emergency department for further evaluation. Hospital records documented a traumatic subdural hemorrhage (a life-threatening collection of blood between the brain and its outer covering), a closed fracture of the distal end of left ulna (a break in the lower end of the ulna bone), a closed fracture of the left proximal humerus (a break in the upper arm bone), and lacerations of multiple sites (a wound caused by a tear or cut in the skin caused by trauma). The facility failed to implement enhanced interventions in response to the resident's ongoing fall attempts and did not reassess or revise the care plan to provide more frequent supervision, scheduled checks, or appropriate use of assistive technology such as bed or chair alarms. Furthermore, repeated re-education efforts were inappropriate for a resident with a severe cognitive deficit. An interview conducted with the Director of Nursing (DON) on May 29, 2025, at approximately 1:00 PM confirmed the facility failed to provide adequate supervision and implement appropriate fall prevention interventions based on the resident's assessed needs to prevent falls with injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observations, a review of facility-provided documents, and resident and employee interviews, it was determined the facility failed to maintain an effective pest control program, including observations made on one of the three nursing units (Grey Unit- bedrooms of Residents 4, 23, and 39), experiences reported by one resident out of 18 sampled (Resident 23), and experiences reported by two residents during a group interview (Residents 27 and 28). Findings include: According to the Centers for Disease Control (CDC), Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. During an interview on May 28, 2025, the Director of Maintenance indicated the facility has an external pest management company that provides services to the building about once a month. The Director of Maintenance explained the pest management company has not reported any identification of rodent activity. The Director of Maintenance provided invoices for services rendered by the pest management company; however, a review of the invoices from December 2024 through May 2025 revealed the external company failed to identify any rodent activity. A review of facility-provided pest control invoices from December 2024 through May 2025 revealed no documented evidence of rodent or other pest activity. A facility tour and observations on May 28, 2025, revealed evidence of rodent activity in multiple resident rooms and common areas: An observation at 9:40 AM of Resident 39's bedroom revealed several mouse-like droppings (small, long, black pellets that were tapered at the ends- resembling a black grain of rice) on the floor in the window-side corner of the room. An observation at 12:38 PM of Resident 4's bedroom revealed over 20 mouse-like droppings in the window-side corner of the room. At the time of the observation, the Assistant Director of Nursing (ADON) confirmed the observation of the mouse-like droppings. An observation at 12:48 PM of Resident 23's bedroom revealed several mouse-like droppings on the floor, against the wall, and behind the window-side bed. An interview with Resident 23 at the same time as the observation revealed that he has seen mice a few times over the past few months running across the floor in his room. An observation on May 28, 2025, at 1:15 PM, revealed evidence of mouse activity in the facility's main dining room. Over 50 mouse-like droppings were seen on the floor in the resident main dining room underneath a cabinet running along the kitchen-side wall. During an observation on May 28, 2025, at 1:20 PM, active signs of mouse activity were noted in two areas of the kitchen. The dry storage area contained mouse droppings on the floor under metal storage racks. In the corner of the kitchen, additional mouse-like droppings were identified scattered amongst silicone caulking pieces found near a crevice in the wall, suggesting a potential entry point or an attempt by the mice to access the wall void. During a resident group interview, two out of eight residents interviewed (Residents 27 and 28) indicated they observed rodents at the facility. Resident 27 recalled seeing a mouse last week in her bedroom. She explained she has been seeing the rodents for a few months and has reported it to staff. Resident 28 indicated that she saw mice a few months ago at the facility but has not had any recent experiences. During an interview on May 30, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed the facility had no documented evidence of an effective pest management program, including identification of mouse activity, specifically, mouse-like droppings in the facility kitchen, dining room, and multiple resident rooms. The NHA confirmed it is the facility's responsibility to maintain an effective pest control program to ensure the facility is free of rodents. Refer F812 28 Pa. Code 201.18 (e)(2.1) Management.

Based on observation, a review of facility-provided documents, and employee interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination, including rodent activity, which increased the risk of food-borne illness in multiple areas of the kitchen. Findings include: According to the Centers for Disease Control (CDC), Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. During an interview on May 28, 2025, the Director of Maintenance indicated the facility has an external pest management company that provides services to the building about once a month. The Director of Maintenance explained the pest management company has not reported any identification of rodent activity. The Director of Maintenance provided invoices for services rendered by the pest management company; however, a review of the invoices from December 2024 through May 2025 revealed the external company failed to identify any rodent activity. An observation on May 28, 2025, at 1:15 PM, revealed evidence of mouse activity in the facility's main dining room. Over 50 mouse-like droppings were seen on the floor in the resident main dining room underneath a cabinet running along the kitchen-side wall. During an observation on May 28, 2025, at 1:20 PM, active signs of mouse activity were noted in two areas of the kitchen. The dry storage area contained mouse-like droppings on the floor under metal storage racks. Also, in the corner of the meal preparation area of the kitchen, additional mouse-like droppings were identified scattered amongst silicone caulking pieces. The mouse-like droppings were found near a crevice in the wall, suggesting a potential entry point or an attempt by the mice to access the wall void. During an interview on May 30, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed the presence of mouse-like droppings in the facility's kitchen. The NHA confirmed it is the facility's responsibility to maintain acceptable practices for the storage and service of food to prevent the potential for contamination, including rodent activity, which increases the risk of food-borne illness. Refer F925 28 Pa. Code 201.18 (e)(2.1) Management.

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure that one resident out of 18 sampled (Resident 26) was afforded the right to participate in care and treatment decisions, to be fully informed of treatment, and to make choices about preferred treatment options. The findings include: Review of the clinical record revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses to include osteoarthritis (a joint disease characterized by the breakdown of cartilage causing pain and stiffness), and chronic pain. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2025, revealed that Resident 26 was severely cognitively impaired with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information (a score of 13-15 indicates a resident is cognitively intact). A review of Resident 26's clinical record revealed an order for Torsemide 20mg (diuretic medication used to help the body eliminate excess salt and water) to be administered as two tablets by mouth once daily as needed. On May 27, 2025, at approximately 8:45 a.m., during observation of the morning medication pass, Employee 4 (Licensed Practical Nurse) was observed placing multiple medications, including Torsemide, into a medication cup and offering them to Resident 26. During this interaction, Resident 26 expressed concern and stated he did not want to take his water pill because it would cause him to urinate excessively throughout the day. In response, Employee 4 stated, There is no water pill in here, please take your medications, and proceeded to administer the medications, including the Torsemide, despite the resident's verbal refusal. An interview conducted with Employee 4 following the observation confirmed that she administered the Torsemide to Resident 26. She further stated that she was unaware Torsemide was a diuretic, commonly referred to by residents as a water pill. During an interview on May 27, 2025, at approximately 12:00 p.m., the Nursing Home Administrator (NHA) confirmed the nurse failed to provide Resident 26 with the opportunity to refuse the medication and acknowledged the resident's right to participate in treatment decisions was not upheld. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 53) out of 13 residents sampled. Findings include: Review of the facility Restorative Nursing Services Policy last reviewed February 13, 2025, indicated residents who could benefit from the nursing restorative programs can be identified at the following times: on admission, when other assessment are required such as a Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care), from the 24-hour report and the change of shift report, at morning standup meeting, at care planning, and other resident-focused meetings, at risk management meetings such as behavior management, nutrition at risk, and during weekly restorative weekly reviews. If appropriate the resident will begin the restorative program. Care plan will be developed. Orders are not needed for resident to participate in restorative programming. Review of the clinical record revealed that Resident 53 was initially admitted to the facility on [DATE], transferred to the hospital on March 23, 2025, and readmitted to the facility on [DATE], with diagnoses which include obstructive hydrocephalus (a condition where the normal flow of cerebrospinal fluid is blocked within the brain's ventricles or the pathways connecting them leading to a buildup of fluid and increased pressure within the brain) with placement of a ventricular intracranial communicating shunt (device used to treat hydrocephalus), anxiety, and depression. Review of an admission MDS dated [DATE], indicated the resident was severely cognitively impaired and was non-ambulatory. Further review of the clinical record revealed that Physical Therapy was provided to the resident from April 16, 2025, until May 15, 2025. Review of the resident's Physical Therapy Discharge Summary dated May 15, 2025, indicated at the time of discharge the resident could ambulate 25 feet with contact guard assistance (a hand or two is placed on the resident's body to help with balance). Prognosis to maintain current level of functioning was described as good with consistent staff follow-through. Discharge recommendations included gait (ambulation) with rolling walker (walker with wheels) to bathroom or short distances. Review of a care plan initially dated May 19, 2025, revealed the resident required training and skill practice in walking with a goal to walk in room with the assistance of one staff with a rolling walker for 10 feet. Review of Resident 53's Point of Care Restorative Nursing Report for Walking dated May 19, 2025, through May 29, 2025, indicated that staff were to document the distance and number of minutes the resident walked on the first and second shift. The report indicated the resident ambulated on only four of 11 days. Reasons for not being ambulated included refusal, deferred due to condition, and unavailable. Further review of the clinical record revealed no documented evidence that licensed staff were aware that the resident's newly implemented ambulation program was not being implemented as planned to ensure the resident's ambulation goal was met to the extent possible. Interview with the Assistant Director of Nursing (ADON) on May 30, 2025, at approximately 1:30 PM failed to provide documented evidence that Resident 53's restorative ambulation program was implemented as planned. The ADON failed to provide documented evidence that Resident 53's reasons for refusal to ambulate or episodes of staff not providing ambulation assistance to the resident as planned were evaluated at the time of occurrence by licensed staff to ensure the resident's goals for ambulation are met to the extent possible. 28 Pa. Code: 211.5(f)(viii) Medical records 28 Pa Code 211.12(c)(d)(5) Nursing services

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Teal Hall). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility February 13,2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the medication cart located on Teal Hall unit on May 29, 2025, at 8:24 AM, in the presence of Employee 2 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed two (2) multi-dose insulin pens of Insulin Lispro ( a fast acting insulin medication used to lower blood sugar ) and Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened. An interview with Employee 2 (LPN) on May 29,2025, at 8:24 AM, confirmed both multi dose insulin pens: Insulin Lispro and Insulin Glargine were opened, and available for use, and not dated when initially opened. Interview with the Nursing Home Administrator (NHA) on May 29,2025, at approximately 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practice for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of facility investigative documentation, clinical records, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses promptly assessed and evaluated a resident after a significant medication error occurred to assure the resident received necessary care and services timely for one resident (Resident 1) and failed to implement physician's orders for wound treatments for two residents (Resident 3 and 4) out of 12 sampled. Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 1's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024 revealed a BIMS score of 3 (BIMS- brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00- 07 equates to severe cognitive impairment). A review of a facility investigation documentation dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a medication not prescribed to her. It was indicated Resident 1 was given short acting insulin (a regular or short-acting insulin injection treats diabetes. It uses human-made insulin to lower the blood sugar. Regular insulin is most effective between two and three hours after injection. It reduces the blood sugar for three to six hours after it starts working) prior to lunch in error on Sunday September 15, 2024. Further it was indicated that nursing was made aware on September 18, 2024. The report failed to identify the name of the insulin, the amount administered, and which resident's insulin was given to Resident 1. A review of a witness statement from Employee 1 LPN (licensed practical nurse) dated September 18, 2024, revealed on Sunday, September 15, 2024 Employee 2 LPN was on orientation and preparing Resident 2's insulin and medications. Employee 1, LPN stated Employee 2, LPN asked where Resident 1 was located and Employee 1, LPN stated the resident was in the dining room doing activities. Employee 1, LPN stated she told Employee 2, LPN the resident would answer to her name if she asked and she assumed Employee 2, LPN would ask other staff member to identify Resident 2. Employee 1, LPN revealed Employee 2, LPN came back to her and stated she gave the wrong resident the insulin. Employee 2, LPN stated to Employee 1, LPN that Employee 3. a nurse aide had witnessed her give Resident 1, Resident 2's insulin. At that time, Employee 1, LPN then reported the medication error to Employee 4, RN (registered nurse). Employee 1, LPN stated that Employee 4, LPN told her she spoke with the Director of Nursing (DON), and she was aware of the medication error. A review of a witness statement from Employee 2, LPN, on orientation at the time, dated September 18, 2024, revealed the employee was being trained in the area identified as the gray hall. The employee stated she was preparing medication for Resident 2 and asked Employee 1, LPN who the resident was. Employee 2, LPN indicated that Employee 1, LPN told her that Resident 2 responds to her name. The employee stated she went down to the activities room and called out Resident 2's name three times. The employee indicated that Resident 1 answered to the name, and she administered 12 units of insulin to Resident 1. (Resident 1 was identified with severe cognitive impairment and was just responding to a name being called). At that time Employee 3, nurse aide, asked her if she knew who that resident was. The employee stated yes. Employee 3, nurse aide stated to her, I didn't know you were helping on both halls. Residents from all areas of the facility were located in the dining room. Employee 3 nurse aide realized at that time Employee 2, nurse aide gave the wrong resident the insulin. The employee indicated she told Employee 1, LPN what had happened, and they both told Employee 4, RN that Resident 1 received Resident 2's insulin. A review of a witness statement from Employee 3, nurse aide (statement not dated) indicated on September 15, 2024, the employee entered the dining room. The employee stated she observed Employee 2, LPN give Resident 1 an injection (insulin) in her right upper arm. The employee stated she asked Employee 2, LPN if she was helping the nurses on both medication carts because Resident 1 did not reside in the gray hall where Employee 2, LPN was on orientation. Employee 2, LPN walked swiftly away without a response. Employee 3, nurse aide stated she went to Employee 5, LPN at that time to tell her what she witnessed. A review of a witness statement from Employee 5, LPN dated September 18, 2024, revealed on September 15, 2024, during the morning medication pass Employee 3, Nurse Aide pulled this employee into the clean utility closet to speak in privacy. Employee 5, LPN stated Employee 3, nurse aide told her that Employee 2, LPN gave insulin to the wrong resident. Employee 5, LPN stated she asked Employee 2. LPN if she gave Resident 1 Resident 2's insulin. Employee 2, LPN stated that she did give Resident 1, 12 units of insulin. Employee 5, LPN stated that Employee 1, LPN told Employee 4, RN about the medication error. Employee 4, RN stated to Employee 5, LPN she reached out to the DON. Employee 5 stated a couple hours passed and they were still waiting for the DON to return their call. Employee 5, LPN stated the DON finally called the facility back and told Employee 4, RN to tell Employee 5, LPN to give Resident 1 glucagon (a medication that stimulates the liver to release stored sugar into the blood, which raises blood sugar levels) mixed in with Boost high calorie supplement. The employee indicated she administered the glucagon and high calorie supplement. The resident drank 100 percent of the supplement. Further, Employee 5, LPN indicated the DON advised them not to document the medication error due to the Department of Health revisit approaching. A review of a witness statement from Employee 4, RN, dated September 19, 2024, revealed she was made aware by Employee 1 LPN, that Employee 2, LPN, gave insulin to Resident 1. The Employee stated she asked Employee 2, LPN if this error was true and she would not admit to it. Employee 4 RN, asked Employee 5, LPN to check Resident 1's blood sugar (no documented result noted in clinical record) and monitor the resident. Employee 4, RN stated she reached out to the DON and told her what had happened. The employee stated the DON told her education would be completed and she would follow up the next day. Employee E4 stated she gave the resident one teaspoon of glucose (sugar supplement) in boost and had the resident drink it. A review of the Resident 2's clinical record revealed a physician's order for Lispro insulin (a fast-acting, human-made insulin that helps regulate blood sugar levels in people with diabetes) 100 units/ml (milliliter) inject 12 units subcutaneously (under the skin) at 8:00 AM, 12:00 PM, and 5:00 PM. A review of Resident 1's clinical record revealed the licensed staff failed to assess Resident 1 after the resident received 12 units of insulin in error. There was no documented evidence the resident's blood sugar was monitored to ensure the resident did not have side effects from receiving Resident 2's insulin such as low blood sugar resulting in but not limited to, shakiness, sweating, and dizziness The facility staff failed to call the physician after the medication error had occurred. The staff provided treatment of glucagon and Boost supplement without a physician's order. An interview with the Director of Nursing on September 20, 2024, at approximately 12:00 PM confirmed the facility staff failed to provide a timely assessment to Resident 1 after the resident was administered Resident 2's insulin. The Director of Nursing confirmed facility staff provided medication and a supplement to Resident 1 without a physician order. A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (condition in which narrowed blood vessels reduce blood flow to the limbs) and type 2 diabetes (high blood sugar). A review of a skin and wound note dated September 16, 2024, at 12:29 PM revealed the resident was being seen for left lower leg wounds. The resident was noted to have a venous wound (a wound on the leg or ankle caused by abnormal or damaged veins) to the left calf measuring 5.7 cm (centimeters) x 6.3 cm x 0.3 cm. The wound consultant indicated the resident is to receive the following treatment: cleanse the wound with Hibiclens (antiseptic skin cleanser), apply Vitamin A&D ointment (ointment that provides a protective barrier) to intact skin on the left lower leg before the application of zinc paste wrap (bandage soaked in zinc oxide which provide soothing and cooling properties to relieve itching and soreness) to the base of the wound, secure the zinc paste wrap with an ace bandage, and change the dressing every other day. A review of the resident's Medication and Treatment Administration Record for September 2024 revealed the facility staff failed to implement the resident's treatment as indicated by the wound consultant. The resident had gone four days without the recommended treatment. A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the vulva (cancer of the female genitals). A review of a skin and wound note dated September 16, 2024, at 1:03 PM revealed moisture associated skin damage (MASD inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus, or saliva). The resident was noted to have a MASD to the sacrum (area at the base of the spine) measuring 5cm x 7. 5cm x 0. 1cm. The wound consultant indicated the resident is to receive the following treatment: cleanse the wound with soap and water, pat dry, apply zinc based barrier cream to the base of the wound, secure with and ABD (gauze pads are used to absorb discharge), and change the dressing daily and as needed. A review of the resident's Medication and Treatment Administration Record for September 2024 revealed the facility staff failed to implement the resident's treatment as indicated by the wound consultant. The resident had gone four days without the recommended treatment. An interview with the Director of Nursing on September 20, 2024, at approximately 2:15 PM confirmed the facility staff failed to implement physician's orders for wound treatments. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records

Based on review of resident clinical records, select facility policy, facility investigative reports, and staff interview it was revealed the facility failed to assure that one of 12 residents reviewed were free of significant medication errors (Resident 1). Findings include: A review of a facility pharmacy policy, entitled General Dose Preparation and Medication Administration last reviewed April 30, 2024 revealed prior to the administration of medication facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, and the correct route, at the correct rate, at the correct time, for the correct resident. Further it is indicated the facility staff should verify the resident's identification (e.g. picture, armband, name). A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 1's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024 revealed a BIMS score of 3 (BIMS- brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00- 07 equates to severe cognitive impairment). A review of a facility investigative report dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a medication not prescribed to her. It was indicated Resident 1 was given short acting insulin (a regular or short-acting insulin injection treats diabetes. It uses human-made insulin to lower the blood sugar. Regular insulin is most effective between two and three hours after injection. It reduces the blood sugar for three to six hours after it starts working) prior to lunch in error on Sunday September 15, 2024. Further it was indicated that nursing was made aware on September 18, 2024. The report failed to identify the name of the insulin, the amount administered, and which resident's insulin was given to Resident 1. A review of a witness statement from Employee 1, LPN (licensed practical nurse) dated September 18, 2024, revealed on Sunday September 15, 2024 Employee 2, LPN was on orientation and preparing Resident 2's insulin and medications. Employee 1, LPN stated Employee 2, LPN asked where the resident was and Employee 1, LPN stated the resident was in the dining room where they do activities. Employee 1, LPN stated she told Employee 2, LPN the resident would answer to her name if she asked and that she assumed Employee 2, LPN would ask other staff who the resident was. Employee 1, LPN revealed Employee 2, LPN came back to her and stated she gave the wrong resident the insulin. Employee 2, LPN stated to Employee 1, LPN that Employee 3, nurse aide had witnessed her give Resident 1 the wrong medication. At that time, Employee 1, LPN then reported the medication error to Employee 4 RN (registered nurse). Employee 1, LPN stated that Employee 4, RN told her she spoke with the Director of Nursing (DON), and she was aware of the medication error. A review of a witness statement from Employee 2, LPN dated September 18, 2024, revealed the employee was on orientation under the supervision of and LPN located in the grey hall. The employee stated she was preparing medication for Resident 2 and asked Employee 1, LPN who the resident was. Employee 2, LPN indicated that Employee 1, LPN told her that Resident 2 responds to her name. The employee stated she went down to the activities room and called out Resident 2's name three times. The employee indicated that Resident 1 answered to the name, and she administered 12 units of insulin to Resident 1. At that time Employee 3, nurse aide asked her if she knew who that resident was. The employee stated yes. Employee 3, nurse aide realized at that time she gave the wrong resident the insulin. The employee indicated she told Employee 1, LPN what had happened, and they both told Employee 4, RN that Resident 1 received Resident 2's insulin. A review of a witness statement from Employee 3, nurse aide (statement not dated) indicated on September 15, 2024, the employee entered the activity dining room. The employee stated she noticed Employee 2 by Resident 1 and, observed her give the resident an injection in her right upper arm. The employee stated she asked Employee 2, LPN if she was helping both nurses, not just the nurse on the gray hall. Employee 2, LPN walked swiftly away. Employee 3, nurse aide stated she went to Employee 5, LPN at that time to tell her what she witnessed. A review of a witness statement from Employee 5, LPN dated September 18, 2024, revealed on September 15, 2024, during the morning medication pass Employee 3, nurse aide pulled this employee into the clean utility closet. Employee 5, LPN stated that Employee 3, nurse aide told her that Employee 2, LPN gave the wrong resident insulin. Employee 5, LPN stated she asked Employee 2, LPN if she gave Resident 1 Resident 2's insulin. Employee 2, LPN stated that she did give Resident 1, 12 units of insulin. Employee 5, LPN stated that Employee 1, LPN told Employee 4, RN about the medication error. Employee 4, RN stated to Employee 5, LPN that she reached out to the DON. Employee 5, LPN stated a couple hours passed and they were still waiting for the DON to call the facility back. Employee 5, LPN stated the DON finally called the facility back and told Employee 4, RN to tell Employee 5, LPN to give Resident 1 glucagon ( a medication that stimulates the liver to release stored sugar into the blood, which raises blood sugar levels) mixed in with Boost high calorie supplement. The employee indicated she administered the medication and supplement, and the resident drank 100 percent. Employee 5, LPN indicated the DON advised not to document on the medication error due to the Department of Health revisit approaching. A review of a witness statement from Employee 4, RN dated September 19, 2024, revealed she was made aware by Employee 1, LPN that Employee 2, LPN gave insulin to Resident 1. The Employee stated she asked Employee 2, LPN if she gave the wrong resident insulin, and she would not admit to it. Employee 4, RN asked Employee 5, RN to check Resident 1's blood sugar and monitor the resident. Employee 4, RN stated she reached out to the DON and told her what had happened. The employee stated the DON told her education would be completed and she would follow up the next day. Employee 4, RN stated she gave the resident one teaspoon of glucose (sugar supplement) in boost and had the resident drink it. A review of the Resident 2's clinical record revealed a physician's order for Lispro insulin (a fast-acting, human-made insulin that helps regulate blood sugar levels in people with diabetes) 100 units/ml (milliliter) inject 12 units subcutaneously (under the skin) at 8:00 AM, 12:00 PM, and 5:00 PM. A review of Resident 1's clinical record revealed no documentation on September 15, 2024, that the resident was administered Resident 2's insulin. Further there was no documentation the physician was made aware of the medication error or orders obtained to obtain the resident's blood sugar, administer medications, or supplements. An interview with Employee 2, LPN on September 20, 2024, at 10:18 AM revealed she had just started employment at the facility on September 12, 2024. The employee stated she was by herself on the medication cart on September 15, 2024. The employee stated she prepared 12 units of Resident 2's insulin and went to the dining room, where the resident was located, to administer it. The employee stated she called out Resident 2's name three times and Resident 1 answered. Employee 2, LPN stated she gave the insulin to the resident who had answered to the name. The employee stated she did not look at the photo because they don't always look like the resident, and she did not ask any staff to help identify the resident. The employee stated Employee 3, nurse aide asked her if she knows who she just gave insulin to. The employee stated she said yes Resident 2, and that is when Employee 3 told the employee that she was not Resident 2 but Resident 1. The employee stated she went and told Employee 1, LPN who in return told Employee 4, RN that a medication error had occurred. The employee stated that she did not have competencies completed to ensure she was competent in medication pass prior to administering medications without supervision. She stated she had only been working at the facility a couple of days. An interview with Employee 4, RN on September 20, 2024, at 10:30 AM revealed on September 15, 2024, Employee 1, LPN had told her that Employee 2, LPN had administered Resident 2's insulin to Resident 1. The employee stated that she called the DON and told her that Resident 1 received the wrong medication. The employee stated the DON informed her education would be provided. The employee stated she was not told to call the doctor, so she did not make him aware of the medication error. The Employee stated she had Employee 5, LPN check the resident's blood sugar and give her glucagon in Boost supplement. When asked if she received an order to obtain the resident's blood sugar and provide treatment, this employee stated no. An interview with Employee 5, LPN on September 20, 2024, at 10:40 AM revealed the employee stated that she was pulled aside by Employee 3, Nurse Aide and was informed that Employee 2, LPN had given Resident 1, Resident 2's insulin. The employee stated she then asked Employee 2, LPN if she had administered 12 units of insulin to the wrong resident and she confirmed she did administer the insulin to the wrong resident. She stated she was then informed by Employee 4, RN to check the resident's blood sugar and give her glucagon in a Boost supplement. The employee stated she provided that treatment however there was no documentation of the resident;s blood sugar results. A telephone interview was conducted with Employee 1, LPN on September 20, 2024, at 12:53 PM. revealed she was instructed by Employee 4, RN to let Employee 2, LPN administer medications on September 15, 2024. Employee 1, LPN stated Employee 4, RN told her Employee 2, LPN, who was on orientation, she needed to learn. The employee stated Employee 2, LPN asked where Resident 2 was, and she stated she told Employee 2, LPN she was in the activities room. The employee stated the next thing she knew Employee 2, LPN came up to her and stated I just gave the wrong resident the insulin. The employee stated at that time she reported to Employee 4, RN that Resident 1 had received Resident 2's insulin. The employee indicated Employee 4, RN told her the DON was aware and she would make the regional nurse aware. Resident 1 received 12 units of insulin which was not prescribed to her. The resident did not have a diagnosis to require insulin. An interview with the Nursing Home Administrator and Director of Nursing on September 20, 2024 at approximately 2:15 PM confirmed that Employee 2, LPN who at the time was on orientation, administered the incorrect medication to Resident 1, failing to ensure the resident was free from significant medication errors. Cross Refer F684, F726, F580 28 Pa. Code 211.12 (d)(5) Nursing Services. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy Services.

Based on review of clinical records, and staff interview, it was determined that the facility failed to timely notify the physician and the resident's responsible party of medication error for one resident out of 12 sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 1's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024 revealed a BIMS score of 3 (BIMS- brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00- 07 equates to severe cognitive impairment). A review of a facility investigative report dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a medication not prescribed to her. It was indicated Resident 1 was given short acting insulin (a regular or short-acting insulin injection treats diabetes. It uses human-made insulin to lower the blood sugar. Regular insulin is most effective between two and three hours after injection. It reduces the blood sugar for three to six hours after it starts working) prior to lunch in error on Sunday September 15, 2024. Further it was indicated that nursing was made aware on September 18, 2024. The report failed to identify the name of the insulin, the amount administered, and which resident's insulin was given to Resident 1. A review of a witness statement from Employee 1, LPN (licensed practical nurse) dated September 18, 2024, revealed on Sunday September 15, 2024 Employee 2, LPN was on orientation (required supervision by licensed nurse) and preparing Resident 2's insulin and medications. Employee 1, LPN stated Employee 2, LPN asked where the resident was and Employee 1, LPN stated the resident was in the dining room where they do activities. Employee 1 stated she told Employee 2, LPN the resident would answer to her name if she asked and she assumed Employee 2, LPN would ask other staff to confirm the resident's identity. Employee 1, LPN revealed Employee 2, LPN came back to her and stated she gave the wrong resident the insulin. Employee 2, LPN stated to Employee 1, LPN that Employee 3, NA (nurse aide) had witnessed her give Resident 1, Resident 2's insulin. At that time, Employee 1 then reported the medication error to Employee 4, RN (registered nurse). Employee 1 stated that Employee 4, RN told her she spoke with the Director of Nursing (DON), and she was aware of the medication error. Resident 1 did not have a diagnosis of diabetes (is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period) and did not require insulin. A review of a witness statement from Employee 2, LPN dated September 18, 2024, revealed the employee was on orientation in the grey hall. The employee stated she was preparing medication for Resident 2 and asked Employee 1, LPN who the resident was. Employee 2, LPN indicated that Employee 1, LPN told her that Resident 2 responds to her name. The employee stated she went down to the activities room and called out Resident 2's name three times. The employee indicated that Resident 1 answered to the name, and she administered 12 units of insulin to Resident 1. At that time Employee 3, nurse aide asked her if she knew who that resident was. The employee stated yes. Employee 3, nurse aide stated to her, I didn't know you were helping on both halls. Employee 3, nurse aide realized at that time she gave the wrong resident the insulin. The employee indicated she told Employee 1, LPN what had happened, and they both told Employee 4, RN that Resident 1 received Resident 2's insulin. A review of Resident 1's clinical record revealed no documented evidence the facility had contacted the physician on September 15, 2024, to inform the physician Resident 1 received 12 units of insulin in error. Further review revealed the facility failed to notify Resident 1's representative of the medication error. An interview with the Director of Nursing and Nursing Home Administrator on September 20, 2024, at approximately 2:15 PM confirmed the facility failed to notify the resident's responsible party and physician of a significant medication error. 28 Pa Code 211.12 (c)(d)(3)(5)Nursing services.

Based on a review of clinical records, a facility investigative report, nurse competencies and staff interview, it was determined the facility failed to to ensure that licensed nursing staff possessed the skills and competencies necessary to assure administration of medications accurately and safely for one resident out of 12 sampled (Residents 1). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (1) undertake a specific practice only if the licensed practical nurse has the necessary knowledge, preparation, experience, and competency to properly execute the practice. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of Resident 1's quarterly minimum data set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2024 revealed a BIMS score of 3 (BIMS- brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00- 07 equates to severe cognitive impairment). A review of a facility investigative report dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a medication not prescribed to her. It was indicated Resident 1 was given short acting insulin (a regular or short-acting insulin injection treats diabetes. It uses human-made insulin to lower the blood sugar. Regular insulin is most effective between two and three hours after injection. It reduces the blood sugar for three to six hours after it starts working) prior to lunch in error on Sunday September 15, 2024. Further it was indicated that nursing was made aware on September 18, 2024. The report failed to identify the name of the insulin, the amount administered, and which resident's insulin was given to Resident 1. A review of a witness statement from Employee 2, LPN dated September 18, 2024, revealed the employee was training and on orientation in the grey hall. The employee stated she was preparing medication for Resident 2 and asked Employee 1, LPN who the resident was. Employee 2, LPN indicated that Employee 1, LPN told her that Resident 2 responds to her name. The employee stated she went down to the activities room and called out Resident 2's name three times. The employee indicated that Resident 1 answered to the name (not the resident who was prescribed the insulin), and she administered 12 units of insulin to Resident 1. At that time Employee 3, nurse aide asked her if she knew who that resident was. The employee stated yes. Employee 3, nurse aide stated to her, I didn't know you were helping on both halls. Employee 3, nurse aide realized at that time she gave insulin to the wrong resident. The employee indicated she told Employee 1, LPN what happened, and they both told Employee 4 RN, that Resident 1 received Resident 2's insulin. A review of the Resident 2's clinical record revealed a physician's order for Lispro insulin (a fast-acting, human-made insulin that helps regulate blood sugar levels in people with diabetes) 100 units/ml (milliliter) inject 12 units subcutaneously (under the skin) at 8:00 AM, 12:00 PM, and 5:00 PM. An interview with Employee 2 LPN on September 20, 2024, at 10:18 AM revealed she had just started employment at the facility on September 12, 2024. The employee stated she was by herself on the medication cart on September 15, 2024. The employee stated she prepared 12 units of Resident 2's insulin and went down to the activities room to administer it. The employee stated she called out Resident 2's name three times and Resident 1 answered. Employee 2, LPN stated she gave the insulin to the resident who had answered to the name. The employee stated she did not look at the photo because they don't always look like the resident, and she did not ask any staff to help identify the resident. The employee stated Employee 3, nurse aide asked her if she knows who she just gave insulin to. The employee stated she said yes Resident 2 and that is when Employee 3, nurse aide told the employee that she was not Resident 2 but Resident 1. The employee stated she went and told Employee 1, LPN who in return they both told Employee 4, RN that a medication error had occurred. The Employee stated that she did not have competencies completed to ensure she was competent in medication pass prior to administering medications alone. She stated she had only been working at the facility a couple of days. An interview with the Nursing Home Administrator (NHA) on September 20, 2024, at approximately 12:30 PM revealed the facility has an orientation check list for licensed nurses that needs to be completed prior to being assigned their duties. The NHA stated that all licensed staff are to have medication administration competencies completed with the Director of Nursing (DON) prior to administering medications without supervision. A review of Employee 2's, LPN employee file revealed the facility failed to complete the medication administration competencies with Employee 2, LPN prior to allowing her to safely administer medications to residents. Further review of the employee's file revealed no competencies were completed during her orientation prior to the assumption of her assignment. During an interview on September 20, 2024, at approximately 2:15 PM, The Nursing Home Administrator and Director of Nursing confirmed that Employee 2, LPN failed to demonstrate competency on accurately and safely administering medication for Resident 1. The facility failed to ensure that licensed nursing staff possessed the skills and competencies related to medication administration. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.9 (a)(1)(b)(d)(k) Pharmacy services.

Based on a review of pharmacy documentation, clinical records and staff interviews it was determined the facility failed to implement procedures to assure timely acquiring and administration of medications to one of 12 sampled residents (Resident 4). Findings include: A review of Resident 4's clinical record revealed the resident was readmitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the vulva (cancer of the female genitals). A review of physician orders dated September 13, 2024, revealed the following orders: Oxycodone (narcotic pain medication) 5mg (milligrams) every 6 hours as needed for moderate to severe pain. Ativan (anti-anxiety medication) 0.5mg every 12 hours as needed for generalized anxiety disorder. A review of a pharmacy delivery slip dated September 17, 2024, revealed the resident's medications were not delivered to the facility until September 17, 2024, four days after the medication was ordered. The resident did not receive the medications as ordered due to the failure of the timely arrival of the medications by the pharmacy. An interview with the Nursing Home Administrator on September 20, 2024, at 12:15 PM revealed the facility failed to assure timely acquiring and administration of medications to provide medications as ordered to meet the needs of residents. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.9 (a)(1)(d)(k)(l)(1) Pharmacy services.

Based on review of clinical records and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 12 sampled residents (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills). A review of a facility investigative report dated September 18, 2024 at 12:38 PM revealed on September 15, 2024, the resident was given a medication which was not prescribed to her. It was indicated Resident 1 was given short acting insulin prior to lunch in error, on Sunday September 15, 2024. Further it was indicated that nursing was not made aware on September 18, 2024. The report failed to identify the name of the insulin, the amount administered, and which resident's insulin was given to Resident 1. A review of a witness statement from Employee 5, LPN dated September 18, 2024, revealed on September 15, 2024, during the morning medication pass Employee 3, Nurse Aide pulled this employee into the clean utility closet to speak in privacy. Employee 5, LPN stated Employee 3, nurse aide told her that Employee 2, LPN gave insulin to the wrong resident. Employee 5, LPN stated she asked Employee 2. LPN if she gave Resident 1 Resident 2's insulin. Employee 2, LPN stated that she did give Resident 1, 12 units of insulin. Employee 5, LPN stated that Employee 1, LPN told Employee 4, RN about the medication error. Employee 4, RN stated to Employee 5, LPN she reached out to the DON. Employee 5 stated a couple hours passed and they were still waiting for the DON to return their call. Employee 5, LPN stated the DON finally called the facility back and told Employee 4, RN to tell Employee 5, LPN to give Resident 1 glucagon (a medication that stimulates the liver to release stored sugar into the blood, which raises blood sugar levels) mixed in with Boost high calorie supplement. The employee indicated she administered the glucagon and high calorie supplement. The resident drank 100 percent of the supplement. Further, Employee 5, LPN indicated the DON advised them not to document the medication error due to the Department of Health revisit approaching. A review of the resident's clinical record revealed the facility failed to document the medication error on September 15, 2024. The clinical record failed to identify what time the medication error occurred, what medication Resident 1 received in error, or the dosage of medication the resident received. Further there was no documentation that the resident's physician was notified after the resident received the wrong medication. The record also failed to indicate if the resident sustained any side effects from receiving medication that was not prescribed for her. A review of the resident's Medication Administration Record for September 2024, failed to identify the resident received blood glucose monitoring, administration of glucagon gel, or Boost high calorie supplement as indicated by Employee 5,LPN. An interview with the Nursing Home Administrator and Director of Nursing on September 20, 2024, at approximately 2:15 PM confirmed the facility's nursing staff failed to document consistently and accurately in the residents' clinical records. As a result, the residents' clinical records were inaccurate and incomplete. 28 Pa. Code 211.5 (f)(iii) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on resident and staff interviews and a review of clinical records and select incident reports it was determined that the facility failed to consistently provide necessary precautionary measures planned to maintain resident safety and prevent injury during transport resulting in a fractured ankle and pain for one resident out of four sampled (Resident 55). Findings include: A review of the clinical record revealed that Resident 55 was admitted to the facility on [DATE], with diagnoses to include nontraumatic intracerebral hemorrhage (stroke) and muscle weakness. A review of a Quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 10, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status - a tool to assess cognitive function; a score of 15 indicates intact cognition). The resident required extensive staff assistance of one person for transfers, exhibited an impairment on one side of both the upper and lower extremity (arm and leg) and required substantial/maximal assistance to propel a wheelchair. Resident 55 had a physician order, initially dated dated September 28, 2022, and care planned intervention, dated May 15, 2023, for pressure reducing cushion to high back reclining wheelchair with rear anti-tippers (form of wheelchair stabilizer that prevent chair from flipping backwards), left arm bolster and padding to left wheelchair leg rest. A review of a facility incident report dated May 27, 2023, revealed that the occupational therapist was transporting Resident 55 in the wheelchair from therapy back to the resident's room on May 26, 2023. During transport the resident's foot caught on the carpet and bend backwards. Resident 55's description of the event was that my foot got caught on the carpet and bent backwards. Nursing noted that an x-ray was obtained of the resident's left ankle on May 27, 2023, with the conclusion that shows: mild degenerative change with possible avulsion fracture (when a tendon or ligament fractures off a piece of the bone to which it its attached) of the medial malleolus (inner ankle). An orthopedic consult completed on June 2, 2023, revealed that the resident had sustained a closed avulsion fracture of the left medial malleolus of the left tibia (long bone of the lower leg) and closed avulsion fracture of the lateral malleolus left fibula (calf bone, the smaller of the two bones in the lower leg located on the lateral side of the tibia). Interview with Resident 55 on May 30, 2023, at 10:18 AM revealed that on May 26, 2023, after finishing with morning therapy, Employee 1 (Occupational Therapist) was pushing Resident 55's wheelchair down the hallway when her left foot dropped and twisted under the wheelchair. Resident 55 reported that the left leg rest was not on her wheelchair at the time of the incident. Resident 55 stated that since the incident she is now non-weight bearing on her left leg and is unable to transfer into her wheelchair by standing and pivoting. She stated that she now required the use of a mechanical lift (an assistive device that uses electrical/hydraulic power to lift and transfer a person) in order to get out of and into bed so to adhere to her physician orders for non-weight bearing. She expressed frustration with now having to use the mechanical lift and no longer being able to stand and pivot for transfers. The resident also stated that after the incident the pain in her left ankle was 8 out of 10. The resident stated that she asked nursing staff for for pain medication, but was only given Tylenol because they told me they couldn't get anything stronger because it's a holiday weekend. Interview with Employee 1 (Occupational Therapist) on May 31, 2023, at 12:37 PM confirmed Resident 55's left wheelchair leg rest was not on the wheelchair while she was transporting the resident down the hallway at the time of the incident. As a result of the incident during transport on May 26, 2023, Resident 55's care plan for transfer status was revised on May 30, 2023, from requiring transfers with assist of two persons, to the use of a mechanical lift with assist of two persons. Interview with the Director of Nursing (DON) on June 1, 2023, at 9:25 AM confirmed the wheelchair leg rest should be on the resident's wheelchair at all times during transport in the wheelchair. The DON confirmed that during the resident's transport on May 26, 2023, the left wheelchair leg rest was not in place and the resident sustained a fractured ankle. The DON also confirmed that Resident 55's transfer abilities have declined as the result of the injury as the resident was now non-weight bearing on her left leg and required to use the mechanical lift for all transfers. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.11 (d) Resident care plan