Every finding on record at United Zion Retirement Communi

Based on observation, review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to ensure staff monitored temperature of hot liquids to mitigate the risk of injury. This failure resulted in actual harm to one resident (Resident R1), who sustained burn injuries to the chest and upper thigh.Findings include:Findings include:Review of the facility policy titled Safety of Hot Liquids, dated October 2014, revealed facility interventions to prevent burns included maintaining hot liquid serving temperatures at no more than 180 degrees Fahrenheit.Review of a facility procedure, undated and untitled, stated: All liquids heated in the microwave should be heated at 6 ounces per one beverage setting cycle.Review of information dated January 21, 2026, submitted by the facility to the Department of Health, revealed Resident R1 sustained first- and second-degree burns to the right chest and lateral right thigh from hot tea. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure (heart's inability to pump sufficient amount of blood throughout the body) and muscle wasting and Atrophy (thinning of the muscle mass). Further review of the clinical record revealed Resident R1 was discharged home on January 22, 2026.Review of Resident R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident R1 had a BIMS score of 15, indicating intact cognitive function. The MDS further indicated Resident was independent with eating.Review of Resident R1's clinical record revealed an Occupational Therapy treatment note dated October 2025 which indicated Resident R1 required set-up and clean-up assistance for meals.Review of Resident R1's clinical record including nursing progress note dated January 15, 2026, at 9:50 p.m., revealed Resident R1 spilled hot tea on (his/her) right chest and right hip. Skin slightly red and thin layer of skin peeling off. Resident was reclining the recliner chair, and caught the bottom of the bedside table, tilting the table and spilling the hot tea onto resident.Review of Resident R1's skin evaluation completed by a Wound Specialist on January 20, 2026, identified two burn wounds:Right posterior thigh: full-thickness wound measuring 13.7 cm x 5 cm, depth unmeasurable due to tissue overgrowthRight chest: wound measuring 4 cm x 5.6 cm, depth unmeasurable due to tissue overgrowthWound treatment orders for the right posterior thigh included:Xeroform (non-adhesive) gauze applied three times per week and as needed for 30 daysSterile gauze sponge applied three times per week and as needed for 30 daysRetention tape applied three times per week and as needed for 30 daysWound treatment orders for the right chest included:Xeroform (non-adhesive) gauze applied three times per week and as needed for 30 daysSterile gauze sponge applied three times per week and as needed for 30 daysRetention tape applied three times per week and as needed for 30 daysReview of the facility's investigative report completed by the Director of Nursing (DON) on January 16, 2026, at 9:16 a.m., indicated Resident R1 was provided hot tea of an unknown temperature.Review of facility investigation documents revealed a written statement by Certified Nursing Assistant (CNA) Employee E3 dated January 15, 2026; At change of shift while giving report, approximately 2145 hrs. (9:45 p.m.) Resident R1 requested pretzels, hot tea, and 4 packets of honey. I prepared a ceramic mug of water in the microwave for two minutes with water from the ice and water machine. There was 8-10 oz of water in the mug. I added 4 packets of honey and an [NAME] gray tea bag. I stirred it with a plastic spoon. This process took approximately 3-5 minutes. I placed the mug, saucer, and pretzels in front of (him/her) on the table. The resident took (his/her) recliner remote and began to raise the chair to move (himself/herself) closer to the table. The table upended and the hot tea spilled onto (resident). Gown removed. Nurse alerted. Cold water and cool compress immediately applied.During an interview conducted with the DON on February 4, 2026, at approximately 9:45 a.m., the DON reported the incident occurred after kitchen hours when no dietary staff were present. The DON further revealed that food and beverages prepared by non-dietary staff after hours are not tempted.Observations conducted in the first-floor kitchenette at approximately 11:35 a.m. revealed ceramic mugs with a maximum capacity of 8 fluid ounces.Additional observations of the microwave revealed signage stating: Nursing after hours heating liquids: 6 oz for one beverage cycle only.During an interview conducted with Dietary Aide Employee E4 at approximately 11:45 a.m., Employee E4 reported the microwave signage was placed after Resident R1 sustained multiple burn injuries.Reenactment exercise was conducted on February 4, 2026, at approximately 11:55 a.m. with Dietary Aide Employee E4. One ceramic mug was filled with approximately 8 ounces of cold water (which left no room for honey or tea bags) and heated in the microwave for two minutes. Immediately following the heating cycle, the water temperature measured 187.6 degrees Fahrenheit. During interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) at approximately 1:35 p.m., both confirmed Resident R1 received a hot beverage of unknown temperature, resulting in multiple burn injuries.The facility failed to ensure staff monitored and controlled the temperature of hot liquids provided to residents, resulting in actual harm to Resident R1.28 Pa Code 201.18(b)(1) Management.28 Pa Code 211.10 (d) Resident care policies.28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 57). Findings include: Review of Resident 57's clinical record revealed that the resident was discharged from the facility on May 6, 2024. Further review of Resident 57's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 18, 2024 at 11:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record

Based on clinical records review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indication was provided before administering as-needed anti-anxiety medication for one of 5 residents reviewed (Resident 14). Findings include: Review of Resident 14's physician's order dated June 14, 2024, revealed an order for Lorazepam (anti-anxiety medication) 0.5 mg (milligram) one tablet twice daily as needed for anxiety. Review of Resident 14's June 2024, Medication Administration Records (MAR) from June 15, 2024, until June 26, 2024, Resident 14 was administered as-needed Lorazepam seven times without appropriate indication for use and was administered ten times without attempts to provide a non-pharmacological intervention before administering the medication. Interview conducted with the Nursing Home Administrator on July 18, 2024, at 11:00 a.m., confirmed the facility failed to document evidence of non-pharmacological interventions provided before administering the medication and no appropriate indication for the drug. The facility failed to ensure non-pharmacological interventions were attempted, and appropriate indications were present before administering Resident 14 with as-needed anti-anxiety medication. 28 Pa. Code: 211.12(d)(5) Nursing Services 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services

Based on clinical record and facility documentation review, and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the humerus (long bone of the upper arm). Findings include: Review of Resident 9's clinical record included diagnoses of, but not limited to, Cerebrovascular accident (stroke) with left side hemiparesis (weakness or paralysis on one side of the body), Dementia (decline in cognitive abilities that affects the brain's ability to think, remember, and function normally), and Ambulatory Dysfunction (abnormal gait that makes it difficult or impossible to walk). Review of Resident 9's fall risk assessment dated [DATE], revealed a score of 18. The assessment indicated that if the score is 10 or greater, the resident should be considered high risk for potential falls. Review of Resident 9's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) completed May 19, 2023, revealed resident had a BIMS (brief interview for mental status - structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 4, indicating severe cognitive impairment. The MDS assessment revealed that the resident required extensive assistance of two persons for transfers and toileting. Review of Resident 9's care plan identified, the resident at moderate risk for falls related to impaired mobility, osteoporosis, unsteady balance, and hemiplegia. The care plan included an intervention initiated April 1, 2017, with a revision date of February 22, 2021, to anticipate and meet the resident's needs. Assist with toileting and do not leave in bathroom unattended. Review of interdisciplinary note dated May 21, 2023, at 2:18 p.m. revealed resident found on bathroom floor laying on left side, head against wall where night light is, hoyer lift used to lift off floor into bed, resident has left shoulder pain and left hip pain. Further review of interdisciplinary note dated May 21, 2023, at 2:30 p.m. revealed fall noted, stat xray shoulder 2 views and stat xray left hip 2 views. Review of interdisciplinary note dated May 21, 2023, at 4:29 p.m. revealed resident's results from x-ray showed the hip was intact but the left shoulder was broken. The humerous (sic) was broken at neck at shoulder joint. Doctor decided to send out due to pain and mobility issues. Resident left at 4:40 p.m. via ambulance. Review of Employee E4's statement obtained on May 21, 2023, revealed resident must have tried to transfer herself. She was on pot with bell, trying to have BM (bowel movement). We heard her yell for help, but she already fell till we ran in there. Review of facility documentation revealed a follow up interview conducted by the Director of Nursing with Employee E4 on May 22, 2023, indicated resident was toileted at 12:40 p.m. and checked approximately one minute before the fall. Resident indicated he/she wanted to stay on the toilet to have a BM. Fall occurred at 12:45 p.m. Interview with Employee E3 on September 29, 2023, at 11:37 a.m. revealed that Resident 9 was not assigned to Employee E3 on the day of the fall. Employee E3 indicated Employee E3 was sitting at the care base with Employee E4 when they heard the resident fall. Interview with the Director of Nursing on September 28 , 2023, at 1:50 p.m. indicated that the resident's care plan was not followed and that staff were in the vicinity at the time of the fall. The facility failed to ensure Resident 9 was provided with supervision during toileting which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the left humerus. 28 Pa. Code: 211.5(f) Clinical records Previously cited 10/18/21 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services

Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to document and follow wound care protocol as ordered after the development of a pressure ulcer for one of 3 residents reviewed. (Resident 51) Findings Include: Review of facility policy and procedure titled Wound Care Guidelines, undated, revealed a wound care protocol for a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) to have hydrogel (gel applied to wounds to moisten wound and promote healing) and a border gauze (bandage surround by adhesive layer for attachment to healthy skin) placed to the wound every three days or as needed. Review of Resident 51's Weekly Wound Assessment revealed resident 51 was observed with a stage 2 pressure ulcer measuring 3 centimeters (cm) long and 0.8 cm wide with no depth, a scant (small) amount of serous (thin watery consistency) drainage to the sacrum (lower back just above buttocks). The treatment placed was a border gauze. Review of Resident 51's skin observation tool, dated October 1, 2021, revealed no documentation of the wound. A note stated Resident gets a bed bath. What I found was that her buttocks was open and I applied a foam dressing to it for pressure relief. Review of Resident 51's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's Treatment Administration Record for September 2021 and October 2021 revealed there was no documented administration of a treatment to Resident 51's sacrum until October 6, 2021. Interview with the Nursing Home Adminsitrator and the Director of Nursing on October 18, 2021 at 10:15 a.m. confirmed the wound care protocol was not followed as ordered and the facility failed to document the administration of treatments to Resident 51. The facility identified a stage II pressure ulcer on September 29, 2021 and did not follow the wound care protocol as ordered and failed to document treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 8 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on a review of employee personnel records and staff interview, it was determined that the facility failed to complete performance reviews for five of five nurse aides reviewed (Employee E7, E8, E9, E10, E11). Findings include: A review of facility documents, employee personnel records, revealed no documented evidence that an annual performance evaluation was completed for Employee #E7, E8, E9, E10, and E11. An interview with the Nursing Home Administrator (NHA) on (MONTH) 8, 2020, at approximately 11:15 a.m., confirmed that the annual performance evaluations for Employee #E7, E8, E9, E10, and E11 were not completed. 28 Pa Code 201.19 Personnel policies and procedures

Based on a review of the facility's policies, clinical records review, staff, and resident interview, it was determined that the facility failed to thoroughly and timely investigate an injury of unknown origin for two out of 13 Residents reviewed (Resident #8, Resident #21). Finding include: A review of the facility nursing policy manual titled Investigation of Injuries of Unknown Origin, undated, revealed the following: 1. All staff shall be responsible for promptly identifying and reporting all injuries to the nurse on duty. 2. Upon the receipt of the report, the nurse shall immediately evaluate the resident. 3. The bruise/skin tear will be reported through the electronic process which is automatically forwarded to the Director of Nursing (DON), if the injury cause is not immediately known, the nurse shall initiate and complete the first section of the Investigation of Unknown Origin Form. 4. The DON or designee will interview the charge nurses and assigned caregivers of the current and preceding three shifts. The interview should include observations and or resident activities that were witnessed by the staff and that may be related to the cause of injury. 5. All allegation/suspicion of abuse shall be immediately reported to the DON, Nursing Home Administrator (NHA), an abuse investigation will be initiated. 6. If further investigation revealed potential abuse/neglect, the DON will report to the NHA and all authorities as required by the Abuse Prevention policy. Review of Resident #8's [DIAGNOSES REDACTED]. A review of Resident #8's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated (MONTH) 31, 2019, revealed that Resident #8 had a moderate cognitive impairment. Review of the same MDS revealed that Resident #8 required extensive with two-person assistance with transferring, bed mobility, toileting, and extensive with one-person assistance with personal hygiene and grooming. Review of the facility progress note dated (MONTH) 20, 2019, revealed that Resident #8 had behaviors of crying, yelling out, and abusive behaviors. Review of the facility progress note dated (MONTH) 26, 2019, at 9:23 p.m., revealed: Purple bruise under left elbow reported by CNA (nursing assistant), after discussion another CNA reported that she had reported this bruise to the nurse on (name of the unit) last evening. A review of the same progress note revealed that the bruise was four by four centimeters. Review of the facility documentation, incident report dated (MONTH) 26, 2019, revealed that on (MONTH) 26, 2019, at 7:30 p.m., CNA reported a purple bruise under the left elbow after providing care. The bruise had a measurement of four by four centimeters. The incident report further revealed that the Resident was confused. Additional review of the facility documents, Employee E6 statement, dated (MONTH) 25, 2019, revealed that while using stand aid (a mechanical lift used for transferring residents) on resident, a bruise approximately three by three on inside elbow, dark purple in color was seen, reported to (name of the nurse). Review of the facility documentation revealed no documented evidence that Resident #8's bruise of unknown origin identified on (MONTH) 25, 2019, was investigated, assessed and reported to the DON and NH[NAME] Further review of the facility documentation revealed statements completed by the two-nursing assistant on (MONTH) 26, 2019, when the bruise on Resident #8 ' s under elbow was observed again during evening care. Both statements do not have any information that can lead to the possible cause of the unknown bruise on resident #8 ' s elbow. The facility failed to provide statements from the caregivers from the preceding shifts. An interview with the DON on (MONTH) 9, 2020, at approximately 11:00 a.m., confirmed that no additional statements were completed to determine the cause of Resident #8's bruise on the elbow. Review of Resident #21's admission MDS assessment dated (MONTH) 12, 2019, revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. Review of Resident #21's incident note of (MONTH) 18, 2019, revealed this nurse was doing residents AM care this morning, when this nurse was washing residents lower back this nurse observed bruising to lower back and sacrum area. bruises appear purple in color. lower back bruise measures 5.9x5.3cm and sacrum area bruise measures 5.2x5cm. resident did have a fall on 8/10/19 . Review of facility documentation revealed that statements were obtained from the current shift and two of the three preceding shifts. Review of statement obtained from Employee E12 revealed that Employee E12 worked day shift on (MONTH) 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E13 revealed Employee E13 worked second shift on (MONTH) 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E14 revealed that Employee E14 worked second shift on (MONTH) 17, 2019, but did not observe the resident's skin. Intereview with the DON on (MONTH) 9, 2020, at 12:27 p.m. indicated that facility procedure is to obtain statements for 24 hours preceding the identification of the injury. The DONconfirmed that statements were not obtained from all preceding three shifts and from staff who provided direct care to Resident #21. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 1/31/19 28 Pa. Code 201.18(b)(1)(e)(1)Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code: 211.12(d)(1) Nursing service Previously cited 1/31/19

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 13 residents reviewed (Residents #6 and #17). Findings include: Review of Resident #6's significant change MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 22, 2019, Section N0410 - Medications Received, indicated that the resident received an anticoagulant (blood thinning medication), seven times in the past seven days. Review of the clinical record revealed that the resident did not receive an anticoagulant medication during the assessment time frame. Interview with Employee E5, Registered Nurse Assessment Coordinator, on (MONTH) 9, 2020, at 10:00 a.m. confirmed that Resident #6 did not receive an anticoagulant and the assessment did not accurately reflect the resident's status. A review of the clinical records revealed that Resident #17 was admitted on (MONTH) 6, 2019, coming from the facility's Personal Care unit. A review of Resident #17's physician orders [REDACTED]. Review of the facility documentation, Hospice logbook, revealed that Hospice had been providing services to resident #17 since (MONTH) 6, 2019, and prior to that date. An interview with the DON (Director of Nursing) on (MONTH) 8, 2019, at approximately 2:30 p.m., revealed that Resident #17 had been receiving Hospice services prior to transfer to SNF (Skilled Nursing Facility). The Hospice service was continued when Resident #17 was transferred to SNF on (MONTH) 6, 2019. The DON further stated that the Hospice order was missed during admission to SNF. The Hospice order was not written until (MONTH) 17, 2019. A review of Resident #17's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated (MONTH) 13, 2019, under Section O- Special treatment procedure and programs revealed that Resident #17 was not on Hospice care prior and while in the facility. An interview with licensed nurse, Employee E5 on (MONTH) 9, 2020, at approximately 11:00 a.m., revealed that she/he was aware that Resident #17 was on Hospice Care. Employee #5 confirmed that Hospice care for Resident #17 was not accurately documented on Resident's MDS. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, resident and staff interview, it was determined that the facility failed to maintain an environment that was free of accident hazards for one of 13 residents reviewed (Resident #42). Findings include: Observations on (MONTH) 6, 2020, at 5:00 p.m. revealed Resident #42 seated at a table in the dining room. A medication cup containing a white pill was observed on the tray of Resident #42's walker, which was beside the table. At approximately 5:15 p.m., Resident #42 was observed leaving the dining room with the pill still in the medication cup. Observation on (MONTH) 8, 2020, at 11:42 a.m. revealed Resident #42 seated at a table in the dining room. A medication cup containing a bottle of [MEDICATION NAME] eye drops was observed on the tray of Resident #42's walker, which was beside the table. Interview with Resident #42 on (MONTH) 8, 2020, at 11:45 a.m. revealed that the resident was having problems with her vision and the doctor had prescribed the eye drops. Review of Resident #42's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 17, 2019, indicated a BIMS (Brief Interview for Mental Status) score of 13, indicating that the resident was cognitively intact. Further review of the clinical record revealed no order for the [MEDICATION NAME] eye drops. Additionally, there was no order or assessment for self-administration of medications. Interview with the Director of Nursing (DON) on (MONTH) 9, 2020, at 10:56 a.m., confirmed that there were [MEDICATION NAME] eye drops in Resident #42's room and there was no order for the eye drops. The DON also confirmed that the resident did not have an order to self-administer medications, and that the white pill in the medication cup observed on the resident's walker tray in the dining room on (MONTH) 6th should not have been there, and that the pill was not able to be identified. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 1/31/19 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services

Based on observation, review of medication manufacturer guidelines, and staff interview, it was determined that the facility failed to ensure that medications were properly labeled in one of two medication carts (North unit) and one medication room (Main). Finding include: A review of manufactures' storage guidelines for [MEDICATION NAME] Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. Observation of the North Hall medication cart on (MONTH) 7, 2020, at approximately 9:30 a.m., in the presence of Employee E3 revealed one [MEDICATION NAME] Pen opened and undated. An interview with Employee E3 on (MONTH) 7, 2020, at approximately 9:33 a.m., confirmed that the [MEDICATION NAME] pen should have been dated upon opening. Observation of the Main medication room refrigerator on (MONTH) 7, 2020, at approximately 9:50 a.m. in the presence of Employee E4, revealed a bottle of Florajen3 capsules ([MEDICATION NAME] to maintain a healthy digestive tract) containing 5 capsules. The pharmacy label had been peeled off. Interview with Employee E4 on (MONTH) 7, 2020, at approximately 9:55 a.m., confirmed that the Florajen3 pharmacy label should not have been peeled off. Additionally, Employee E4 was unable to determine for whom the medication was prescribed. Further observation of the Main medication room refrigerator on (MONTH) 7, 2020, at approximately 9:50 a.m., revealed two clear small Ziploc (plastic), bags containing [MEDICATION NAME] suppositories (pain reliever and fever reducer). One Ziploc bag contained 6 [MEDICATION NAME] suppositories and one contained 10 [MEDICATION NAME] suppositories, with no pharmacy label indicating medication administration instructions. A small clear Ziploc bag containing seven [MEDICATION NAME] suppositories (stimulant laxative) with no pharmacy label indicating medication administration instructions was also observed. Interview with Employee E4 on (MONTH) 7, 2020, at approximately 9:55 a.m., confirmed that the [MEDICATION NAME] and [MEDICATION NAME] suppositories medication should have been labeled. Employee E4 was unsure to whom the medications belonged. The above findings were discussed with the Director of Nursing on (MONTH) 9, 2020, at approximately 11:00 a.m. The facility failed to ensure that medications on the North medication cart and in the Main medication room were properly labeled. 28 Pa. Code 211.9(g)(h) Pharmacy services 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited on 1/31/2019

Based on observation, review of facility policy, and staff interview it was determined that the facility failed to ensure that food was distributed in accordance with professional standards for two of three dining rooms observed. (Farm House and West Unit country kitchens) Findings include: Review of facility policy titled Handwashing/Hand Hygiene with a revised date of 2003 revealed under Number 1 All personnel shall follow our established handwashing/hand hygiene procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. Review of facility policy titled Good hand hygiene is important review date of 2/19/18 which is directed to dietary staff revealed under section Washing/Sanitizing Hands during Meals subsection bullets of Hands must be washed/sanitized; Between delivering clean plates and removing dirty plates; After touching another person/object; Before putting on gloves (to make ready to eat food). Observation on (MONTH) 28, 2019 at approximately 12:25 p.m. of the Farm House country kitchen revealed non-licensed Employee E3 scratched own pant leg then proceeded to obtain plate and serve dessert to a personal care (PC) resident. Employee E3 proceeded to clear used dishes from the resident of personal care. Employee E3 proceeded to assist resident with rolling walker then retrieved clean coffee cup and placed in front of Resident #9. Continued observation of Farm House country kitchen revealed Employee E3 removing used dishes from tables then proceeding to assist Resident #9 with placing clean utensils before the resident in preparation for resident receiving noon time meal. Employee E3 did not wash hands in between assisting residents and clearing dirty dishes. Observation on (MONTH) 28, 2019 at approximately 4:29 p.m. of West unit country kitchen revealed Employee E4 touched Resident #30's wheelchair handles then proceeded to obtain four glasses and pour drinks for the residents, without washing their hands prior. Continued observation on (MONTH) 28, 2019 revealed Employee E4 gathered and placed Resident #4 utensils in front of the resident, without washing hands after handling medical equipment. Employee E4 was further observed placing disposable gloves on hands then using hands to place bacon on three resident hamburger sandwiches. Employee E4 was observed touching numerous cabinet and drawer handles and then opening the refrigerator. Employee E4 was observed handling hamburger buns, plates, and cups while wearing the same gloves. Employee E4 proceeded to touch a serving cart, multiple cupboard handles, and prior to preparing a room tray without changing gloves or washing hands. Continued observation on (MONTH) 28, 2019 at approximately 4:56 p.m. revealed Employee E4 removed used dishes from tables then proceeded to served desert to the residents without washing hands between handling used dishes and obtaining clean bowls for dessert. Interview on (MONTH) 30, 2019 at approximately 12:52 pm with the Director of Nursing confirmed the observations noted on (MONTH) 28, 2019 of staff not providing food in a sanitary manner. 28 Pa. Code 211.6(d) Dietary services.

Based on clinical record review, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred to acute care facilities for two of 13 residents reviewed (Residents 32 and 41). Findings include: Review of Resident 32's clinical record revealed a nursing progress note dated (MONTH) 9, (YEAR) that indicated that the resident was transferred to the hospital due to increased lethargy, right hand swelling, and abdominal girth (the measurement of the distance around the abdomen). Resident 32 was admitted to the hospital with [REDACTED]. Further review of Resident 32's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 32's transfer from the facility to the hospital. Review of Resident 41's clinical record revealed a nursing progress note dated (MONTH) 3, (YEAR) that indicated that the resident was transferred to the hospital due to poor healing of a blister and missing fingernail of the left pointer finger. Resident 41 was admitted to the hospital with [REDACTED]. Further review of Resident 41's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 41's transfer from the facility to the hospital. Interview with the Director of Nursing on (MONTH) 31, 2019 at 1:15 p.m. confirmed that the facility did not notify the State Ombudsman's office when residents were transferred or discharged . 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 7/16/18 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) ManagementPreviously cited 7/16/18 28 Pa. Code 201.29(a) Resident rights

Based on facility policy and procedure review, staff interview, and clinical record review, it was determined the facility failed to follow physician orders [REDACTED]. (Residents 32 and 47) Findings include: Review of facility policy and procedure Bowel Protocol, effective date (MONTH) 6, (YEAR), revealed that if a resident has not had a bowel movement in two days, they are to be offered prune juice on the evening shift. If the resident has had no bowel movement on the morning of the third day, they are to have four Sennekot (laxative) tablets. If there are no results by the next morning (fourth day), they are to receive a [MEDICATION NAME] suppository. Review of Resident 32's Bowel Elimination record for (MONTH) (YEAR) revealed that the resident did not have a bowel movement from (MONTH) 17, (YEAR) through (MONTH) 21, (YEAR), for a total of four days. Review of Resident 32's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of Resident 32's Bowel Elimination record for (MONTH) (YEAR) revealed that the resident did not have a bowel movement for two days on (MONTH) 26 and 27, (YEAR). Review of Resident 32's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident 32's Bowel Elimination record for (MONTH) (YEAR) revealed that the resident did not have a bowel movement for two days on (MONTH) 27 and 28, (YEAR). Review of Resident 32's (MONTH) (YEAR) MAR indicated [REDACTED]. The facility's failure to follow their bowel protocol for Resident 32 was discussed with the Director of Nursing on (MONTH) 31, 2019 at 1:10 p.m. Review of Resident 47 physician's orders [REDACTED]. Review of Resident 47's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on (MONTH) 31, 2019 at 12:30 p.m. confirmed that the facility failed to follow the physician's orders [REDACTED]. 28 Pa Code 211.12(c)(d)(1)(5) Nursing Services Previously Cited 7/16/18, 11/21/17 28 Pa code 211.10(d) Resident Care Policies Previously Cited 7/16/18, 11/21/17

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of four residents reviewed was free of neglect, which resulted in actual harm to Resident CL1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Findings include: Review of facility policy titled, Care Planning-IDT, revised (MONTH) 5, (YEAR), revealed Nurses and nurse aides are responsible for knowing the needs of residents in their care .checking the Care plan/Kardex (a card that provides instructions on the care for a resident in accordance with the resident's care plan) for any changes in resident status. Review of Resident CL1's [DIAGNOSES REDACTED]. blood); [MEDICAL CONDITION] (reduction in red blood cells); [MEDICAL CONDITION] (low levels of calcium in the body which causes increased thirst and urination). Review of Resident CL1's initial fall evaluation assessment dated (MONTH) 17, (YEAR), indicated that the resident had a history of [REDACTED]. Review of Resident CL1's Admission Minimum Data Set assessment (MDS- periodic assessment of resident needs) dated (MONTH) 24, (YEAR), revealed the resident required supervision with ambulation and toilet use with the assistance of one person. The resident's balance was assessed as not steady but able to stabilize with staff assistance when moving on and off toilet. Review of Resident CL1's care plan initiated (MONTH) 27, (YEAR), identified the resident's deficit with activities of daily living related to muscle weakness. The interventions revealed that the resident required contact guard assistance of one staff with personal hygiene, toilet, and transfer with the use of a rolling walker. Further review of the resident's care plan indicated that the resident had a [DIAGNOSES REDACTED]. The interventions included for the resident to be monitored for signs and symptoms of [MEDICAL CONDITION] which included tiring easily or weakness. Review of Resident CL1's interdisciplinary notes dated (MONTH) 1, (YEAR), at 4:42 a.m. revealed Nursing assistant answered the call bell and assisted him to stand to use the urinal. Nursing aide exited the room and went to the nurse aide charting area and then heard a loud thud a few minutes later. She went to his room, but could not open door and resident could not move himself away from the door, so she called for nurse. Nurse responded at 12:50 a.m. to find resident lying on his back against door and head and neck lying against nightstand with light on. Nurse was able to squeeze through a 4 inch opening of door to get to resident then move resident slightly from the door to allow a second staff member in to assist. Resident had rollator (a wheeled walker with a seat) partially underneath him. Non-skid socks were on. He was incontinent of urine and there was urine in his urinal. Resident alert and oriented and stated I was trying to turn off the light and lost my balance. Initially denied pain of head/neck when first assessed on the floor . Sustained an abrasion 1.4 cm (centimeter) X 2.0 cm below right elbow. Resident without bruising or bleeding at back of head. Stood up with two staff members to folding chair. Able to flex head to chin and rotate head left and right to 45 degrees able to extend neck slightly bur not able to hyperextend without pain. Head and neck kept still and ice pack applied to neck. Physician's answering service called twice without response so 911 (Emergency Medical Services) called for assistance with residents due to complain of neck pain. The ambulance service arrived and the resident was transported to the local hospital at 1:45 a.m. The resident's physician responded at 1:45 a.m. and was made aware of the fall and the resident transfer to the hospital. Further review of the nursing note documented that the nurse aide was instructed to check Kardex transfer status prior to care for resident safety. Review of Resident CL1's interdisciplinary notes dated (MONTH) 1, (YEAR), at 5:17 a.m. revealed that nursing staff called the hospital and it was confirmed that the resident sustained [REDACTED]. Review of X-ray report dated (MONTH) 1, (YEAR), at 3:09 a.m. revealed There is a minimally displaced C2 fracture (broken neck) extending through the base of the odontoid tip (the odontoid is a part of the C2 vertebrae. When the odontoid breaks, the neck can not turn and twist freely). Review of the nurse aide, Employee E4's statement obtained by the facility on (MONTH) 1, (YEAR), at 2:45 p.m. revealed that the nurse aide indicated, I did not look at the Kardex, someone told me resident was independent. Review of the facility's abuse investigation for neglect as a result of Resident's CL1's neck fracture, confirmed that the facility substantiated neglect due to the staff members failure to provide contact assistance to the resident as stated on the resident's care plan. Interview with Nursing Home Administrator and Assistant Director of Nursing on (MONTH) 13, (YEAR), at approximately 3:40 p.m. confirmed that the nurse aide did not follow recommendations by leaving the resident alone during toileting. The facility failed to ensure Resident CL1 was free of neglect which resulted in actual harm to Resident CL1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/28/16 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 10/28/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/21/17, 03/09/17, 10/28/16

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident CL1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Findings include: Review of the facility policy titled, Care Planning-IDT, revised (MONTH) 5, (YEAR), revealed Nurses and nurse aides are responsible for knowing the needs of residents in their care .checking the Care plan/Kardex (a card that provides instructions on the care for a resident in accordance with the resident's care plan) for any changes in resident status. Review of Resident CL1's [DIAGNOSES REDACTED]. blood); [MEDICAL CONDITION] (reduction in red blood cells); [MEDICAL CONDITION] (low levels of calcium in the body which causes increased thirst and urination). Review of Resident CL1's initial fall evaluation assessment dated (MONTH) 17, (YEAR), indicated that the resident had a history of [REDACTED]. Review of Resident CL1's Admission Minimum Data Set assessment (MDS- periodic assessment of resident needs) dated (MONTH) 24, (YEAR), revealed the resident required supervision with ambulation and toilet use with the assistance of one person. The resident balance was assessed as not steady but able to stabilize with staff assistance when moving on and off the toilet. Review of Resident CL1's care plan initiated (MONTH) 27, (YEAR), identified the resident's deficit with activities of daily living related to muscle weakness. The interventions revealed that the resident required contact guard assistance of one staff with personal hygiene, toilet, and transfer with the use of a rolling walker. Further review of the resident's care plan indicated that the resident had a [DIAGNOSES REDACTED]. The interventions included for the resident to be monitored for signs and symptoms of [MEDICAL CONDITION] which inlcuded tiring easily or weakness. Review of Resident CL1's interdisciplinary notes dated (MONTH) 1, (YEAR), at 4:42 a.m. revealed Nursing assistant answered the call bell and assisted him to stand to use the urinal. Nursing aide exited the room and went to the nurse aide charting area and then heard a loud thud a few minutes later. She went to his room but could not open door and resident could not move himself away from the door, so she called for nurse. Nurse responded at 12:50 a.m. to find resident lying on his back against door and head and neck lying against nightstand with light on. Nurse was able to squeeze through a 4 inch opening of door to get to resident then move resident slightly from the door to allow a second staff member in to assist. Resident had rollator partially underneath him. Non-skid socks were on. He was incontinent of urine and there was urine in his urinal. Resident alert and oriented and stated I was trying to turn off the light and lost my balance. Initially denied pain of head/neck when first assessed on the floor . Sustained an abrasion 1.4 cm (centimeter) X 2.0 cm below right elbow. Resident without bruising or bleeding at back of head. Stood up with two staff members to folding chair. Able to flex head to chin and rotate head left and right to 45 degrees able to extend neck neck slightly bur not able to hyperextend without pain. Head and neck kept still and ice pack applied to neck. Physician's answering service called twice without response so 911 (Emergency Medical Services) called for assistance with residents due to complain of neck pain. The ambulance service arrived and the resident was transported to the local hospital at 1:45 a.m. The resident's physician responded at 1:45 a.m. and was made aware of the fall and the resident transfer to the hospital. Futher review of the nursing note documented that the nurse aide was instructed to check Kardex transfer status prior to care for resident safety. Review of Resident CL1's interdisciplinary notes dated (MONTH) 1, (YEAR), at 5:17 a.m. revealed that nursing staff called the hospital and it was confirmed that the resident sustained [REDACTED]. Review of X-ray report dated (MONTH) 1, (YEAR), at 3:09 a.m. revealed There is a minimally displaced C2 fracture (broken neck) extending through the base of the odontoid tip (the odontoid is a part of the C2 vertebrae. When the odontoid breaks, the neck can not be turn and twist freely). Review of the Nursing Aide, Employee E4's statement obtained by the facility on (MONTH) 1, (YEAR), at 2:45 p.m. revealed that the nurse aide indicated I did not look at the Kardex, someone told me resident was independent. Interview with Nursing Home Administrator and Assistant Director of Nursing on (MONTH) 13, (YEAR), at approximately 3:40 p.m. confirmed that the nurse aide did not follow recommendations by leaving resident alone during toileting. The facility failed to ensure Resident CL1 was provided with supervision during toileting which resulted in actual harm to Resident CL1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 11/21/17, 10/28/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/28/16 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 10/28/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 11/21/17, 10/28/16 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 11/21/17, 03/09/17, 10/28/16

Based on review of documentation submitted by the facility, clinical record review and staff interview, it was determined that the facility failed to report an allegation of suspected abuse that resulted in serious physical injury to the Department of Aging for one of four residents reviewed (Resident CL1). Findings include: Review of the Older Adults Protective Services Act (OAPSA), mandates reporting requirements on suspected abuse. Any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local Area Agency on Aging and licensing agencies. If the suspected abuse is sexual abuse, serious physical injury, serious bodily injury, or suspicious death as defined under OAPSA, the law requires additional reporting to the Department of Aging and local law enforcement. Review of documentation submitted by the facility revealed that on (MONTH) 1, (YEAR), Resident CL1 was assisted to stand to use the urinal. The Nurse Aide, Employee E4 exited the resident room and went to the nurse aide charting area and the resident sustained [REDACTED]. Review of Resident CL1's interdisciplinary notes dated (MONTH) 1, (YEAR), at 5:17 a.m. revealed that nursing staff called the hospital and it was confirmed that the resident sustained [REDACTED]. Interview with Nursing Home Administrator and the Assistant Director of Nursing on (MONTH) 13, (YEAR), at approximately 3:40 p.m. confirmed that the Pennsylvania Department of Aging was not notified of Resident CL1 serious bodily injury as required by the Older Adults Protective Services Act. Refer to F600. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/28/16 28 Pa. Code 201.14(c) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 10/28/16 28 Pa. Code 201.18(b)(3)(d) Management 28 Pa. Code 211.12(c)(d)(1)(3) Nursing services Previously cited 11/21/17, 03/09/17, 10/28/16

Based on observations, staff interview and facility documentation, it was determined that the facility failed to maintain the ice storage areas in a clean and sanitary condition for two out of two ice machines. (Main kitchen and scenic dining room ) Findings include: Observation in the main kitchen area on November 17, 2017 at 9:00 a.m. revealed an ice machine. Interview with Dietary Manager, Employee E3 at the time of the observation revealed that Employee E3 was unsure of the last service date but stated she thought that it needed to be cleaned. Surveyor inquired how often the ice machine was clean and Employee E3 stated that she thought it was done quarterly. The facility was not able to could not provide a written policy pertaining to the cleaning of these machines. Review of the work order dated November 17, 2017 revealed that the technician that cleaned the ice machine in the kitchen wrote cleaned ice machine, found very dirty took longer than usual. The work order completed by the technician for the ice machine in the scenic dining room stated cleaned ice machine thoroughly found unit dirty, took longer to clean out. A work order supplied by the facility indicated that the the two ice machines, in the main kitchen and the scenic dining room were cleaned and sanitized on February 6, 2017, 8 1/2 months previously. The nursing home administrator stated on November 29, 2017 at approximately 1:30 p.m. that the maintenance department thought that the ice machines should be cleaned twice a year and confirmed that the cleaning was not completed. F371 483.35(i) Sanitary conditions Previously cited 10/28/2016 28 Pa. Code: 211.6(f) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that care plans were developed and updated to reflect the identified needs of three out of 13 residents reviewed (Resident A4, Resident A7 and Resident E6). Findings include: Review of Resident A4's [DIAGNOSES REDACTED]. Review of Resident A4's Annual Minimum Data Set (MDS - periodic assessment of a resident's needs) dated June 8, 2017 revealed that Resident A4 required the supervision of one staff member while ambulating in resident's room. Review of Resident A4's Quarterly MDS dated [DATE] revealed Resident A4 required the supervision of one staff member while ambulating in resident's room. Review of Resident A4's Fall Risk assessment dated [DATE] revealed a score of 18 which place this resident at high risk for falls. Review of Resident A4's clinical nursing notes and facility documentation revealed that Resident A4 sustained falls in the resident's room on April 14, 2017, June 27, 2017, August 27, 2017, October 7, 2017, October 20, 2017, October 25, 2017, November 12, 2017, November 15, 2017 and November 20, 2017 while unattended by any staff members. Review of Resident A4's active plan of care failed to reveal updated interventions after the above-mentioned falls to prevent further falls. Review of Resident A7's [DIAGNOSES REDACTED]. Review of Resident A7's Quarterly MDS dated [DATE] revealed Resident A7 required the supervision of one staff member while ambulating in resident's room. Review of Resident A7's clinical nursing notes and facility documentation revealed that Resident A7 sustained falls in the resident's room on April 3, 2017, April 14, 2017, April 23, 2017, May 24, 2017, June 9, 2017, June 14, 2017, June 25, 2017, August 12, 2017, August 13, 2017, September 28, 2017, September 30, 2017, October 24, 2017 and November 9, 2017 while unattended by any staff members. Review of Resident A7's active plan of care failed to reveal updated interventions after the above-mentioned falls to prevent further falls. Interview with the Director of Nursing on November 20, 2017 at approximately 1:00 p.m. confirmed that Resident A4's and Resident A7's active plans of care were not updated with new interventions to prevent further falls and potential injury after the above-mentioned falls. Review of Resident E6's clinical record revealed that Resident E6 was admitted into skilled nursing from personal care on September 14, 2017 with [DIAGNOSES REDACTED]. Upon admission, September 14, 2017 Resident E6 had a fall risk assessment (a tool used to identify risk of falling) completed with a score of 7 which place this resident at high risk for falls. Further review of the fall risk assessment revealed that the resident had a history of [REDACTED]. Review of the Resident E6's clincal nursing notes dated September 18, 2017 revealed that the resident fell in the resident ' s bathroom at 3:00 p.m. while self-toileting. Resident was found on floor on his right side and was unable to roll with the right foot turned outward. The resident complained of pain and was transferred to the hospital for evaluation. The resident was admitted to the hospital on September 18, 2017 with right [MEDICAL CONDITION]. A review of the care plan for Resident E6 on admission September 14, 2017 failed to reveal that a care plan and interventions were developed to address the resident fall risk. Interview with the Director of Nursing on November 21, 2017 at 12:15 p.m. revealed that the resident had no care plan in place for falls. 28 Pa. Code: 211.11 (d) Resident care plan Previously cited: 10/28/2016 28 Pa. Code: 211.12 (d) (5) Nursing services Previously cited: 10/28/2016, 3/9/2017

Based on a review of clinical records, facility documentation and facility policy, it was determined that the facility failed to ensure that adequate supervision, monitoring and interventions were provided to prevent falls for two of 13 residents reviewed (Resident A4 and Resident A7). Findings include: Review of facility policy entitled Fall Reduction Policy, revised 2016, revealed It is our policy to identify residents at risk for falls, initiate preventative approaches, provide appropriate strategies and interventions. Each resident to receive adequate supervision and interventions to prevent accidents. Review of Resident A4's [DIAGNOSES REDACTED]. Review of Resident A4's Annual Minimum Data Set (MDS - periodic assessment of a resident ' s needs) dated June 8, 2017 revealed that Resident A4 required the supervision of one staff member while ambulating in resident's room. Review of Resident A4's Quarterly MDS dated [DATE] revealed Resident A4 required the supervision of one staff member while ambulating in resident's room. Review of Resident A4's Fall Risk assessment dated [DATE] revealed a score of 18. which indicated that a resident represents a high risk for falls. Review of Resident A4's clinical nursing notes and facility documentation revealed that Resident A4 sustained falls in the resident's room on April 14, 2017 at 4:30 a.m., June 27, 2017 at 6:30 a.m., August 27, 2017 at 6:50 a.m., October 7, 2017 at 8:00 a.m., October 20, 2017 at 3:15 p.m., October 25, 2017 at 5:55 p.m., November 12, 2017 at 6:30 p.m., November 15, 2017 at 2:35 p.m. and November 20, 2017 3:27 p.m. while unattended by any staff members. Review of Resident A4's clinical record failed to reveal that the facility did not consistently supervised and monitored Resident A4 to ensure the resident's safety and prevent future falls. Review of Resident A7's [DIAGNOSES REDACTED]. Review of Resident A7's Quarterly MDS dated [DATE] revealed Resident A7 required the supervision of one staff member while ambulating in resident's room. Review of Resident A7's clinical nursing notes and facility documentation revealed that Resident A7 sustained falls in the resident's room on April 3, 2017 at 12:00 p.m., April 14, 2017 at 8:30 p.m., April 23, 2017 7:00 p.m., May 24, 2017 at 3:45 p.m., June 9, 2017 at 10:25 a.m., June 14, 2017 at 6:00 p.m., June 25, 2017 at 1:30 p.m., August 12, 2017 at 3:20 p.m., August 13, 2017 5:15 p.m., September 28, 2017 at 10:30 p.m., September 30, 2017 at 2:05. p. m., October 24, 2017 9:50 p.m. and November 9, 2017 7:50 p.m. while unattended by any staff members. Review of Resident A7's clinical record failed to reveal that adequate monitoring and supervision were provided to Resident A7 before, during or after the above-mentioned falls to prevent further falls. 28 Pa. Code 211.10(b) Resident Care Policies 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 10/28/16 28 Pa. Code 211.5(f) Clinical Record 28 Pa. Code 211.11(c)(d) Resident Care Plan Previously cited 10/28/16 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 3/9/17, 10/28/16

Based on clinical record review, staff interview and facility documentation, it was determined that the facility failed to ensure that residents clinical record contained complete documentation for one of 13 resident reviewed. (Resident E7) Findings include: Review of Resident E7's clinical record dated March 28, 2017 at approximately 11:30 a.m. revealed that the resident sustained [REDACTED]. Review of Resident E7 ' s facility fall investigation dated March 28, 2017 confirmed that the resident had a witnessed fall in the activity room (Sunroom) during a podiatry (foot) examination. The Resident E7 wheelchair had tipped backwards during the positioning of her feet for examination sustaining a soft 2 inch by 2 inch hematoma (contained pool of blood outside of a blood vessel) on the back of her head. Review of the entire incident investigation revealed there were no witness statements obtained. Interview with the Director of Nursing on November 20, 2017 at approximately 5:05 p.m. confirmed that no witness statements pertaining to the incident were able to be located. 28 Pa. Code 211.5 (f) Clinical Records Previously cited: 10/28/2016

Based on observations and staff interviews, it was determined that the facility failed to ensure that hot water accessible to the residents was maintained at the safe temperature of 110 degrees Fahrenheit or below, placing the health and safety of the residents in Immediate Jeopardy in the building. Findings include: Observation of the water temperatures on October 26, 2016, from 2:50 p.m. to 3:05 p.m. revealed the following water temperatures at areas that were accessible to the residents: Activity restroom sink = 119.1 degrees Fahrenheit; Resident Room 6 sink = 120 degrees Fahrenheit; Resident Room 8 shower = 115 degrees Fahrenheit; Resident Room 15 shower = 113 degrees Fahrenheit; Resident Room 17 sink = 120.2 degrees Fahrenheit; Resident Room 24 shower = 115.5 degrees Fahrenheit; Resident Room 31 sink = 119 degrees Fahrenheit Review of the facility policy labeled Water Temperature Monitoring undated, revealed that water temperature monitoring was to be checked on a daily basis and was not to exceed 110 degrees Fahrenheit. Temperature readings outside of the target range should be reported immediately to the Maintenance Supervisor or the designated person to be addressed immediately. An interview on October 26, 2016, with the Director of Nursing at approximately 3:25 p.m. revealed that the water temperatures were not to be higher than 110 degrees Fahrenheit in all areas accessible to residents. Observations of the facility water temperatures and the facility mixing valve with the Nursing Home Administrator, the Director of Nursing, and the Director of Environmental Services on October 26, 2016, at approximately 3:30 p.m. revealed the following temperatures at water receptacles that were accessible to residents: Resident Room 6 at the sink = 120 degrees Fahrenheit; Resident Room 17 at the sink = 113 degrees Fahrenheit; At this time, the mixing valve was also noted to be reading 118 degrees Fahrenheit. A further interview conducted with the Director of Nursing and the Director of Environmental Services on October 26, 2016, at approximately 3:45 p.m. revealed that a daily water temperature monitoring sheet was completed from October 1 to October 26, 2016. On the temperature log it stated, if the temperature is greater than 110 degrees, to notify maintenance and do not bathe residents. It was recorded on October 19, 2016, that the water temperature was 112 degrees Fahrenheit in the beauty shop and the water temperature in Resident Room 16 was 112 degrees Fahrenheit. On October 20, 2016, it was recorded that the water temperature was 112 degrees Fahrenheit in the tub room, beauty shop, Resident Room 6, and Resident Room 20. On October 21, 2016, it was recorded that the water temperature was 112 in the tub room, beauty shop, Resident Room 17, and Resident Room 34. On October 25, 2016, it was recorded that the water temperature was 112 degrees Fahrenheit in the tub room, beauty shop, Resident Room 16, and Resident Room 34. On October 26, 2016, it was recorded that the water temperature was 112 degrees Fahrenheit in the tub room and Resident Room 30. Further review of the October 2016 daily water temperature monitoring log revealed no signature of the maintenance staff who recorded the water temperatures or the Maintenance Supervisor who would review the water temperature log to ensure that the water temperatures were below 110 degrees Fahrenheit as stated in the facility's policy. An interview conducted on October 26, 2016, at approximately 3:50 p.m. with the Director of Environmental Services revealed that he was never notified of the water temperatures exceeding 110 degrees Fahrenheit in resident accessible areas for the dates mentioned above (a span of eight days). Observations conducted of the central bathing room on October 26, 2016, at 3:10 p.m. revealed that there was no thermometer observed in the central bathing room accessible to the nursing staff to check/verify the water temperature prior to giving a bath to a resident. Immediate Jeopardy was identified to the Nursing Home Administrator on October 26, 2016, at 5:24 p.m. for failure to maintain water temperatures under 110 degrees Fahrenheit, placing the health and safety of the resident in Immediate Jeopardy. An action plan was requested on October 26, 2016, at 5:24 p.m. to immediately put systems in place to ensure that the hot water temperatures were below 110 degrees Fahrenheit. The facility submitted an acceptable plan of action on October 26, 2016, at 7:09 p.m. which included the following: -the plumber was called and arrived on site at 4:45 p.m. to adjust the return side valve. -the nursing staff were immediately inserviced to take and record temperatures anytime a resident needed a bath, shower or a tub bath. If the water temperature was above 110 degrees Fahrenheit, the nursing staff were to modulate the cold and hot water mixture for the temperature to be under 110 degrees Fahrenheit. -hot water temperatures were monitored every 15 minutes for two hours at the front lobby bathrooms, the boiler room, the tub room and various locations on each hallway until further direction by the State. -the return valve at the boiler was locked in place to prevent accidental adjustment. An interview conducted with the Nursing Staff, Employee E7, on October 27, 2016, at 10:00 a.m. revealed that before the inservice, that was part of the corrective action plan, completed on October 26, 2016, the nursing staff had been directed to feel the water temperature before bathing a resident with their hands to ensure that it was comfortable for the resident. The implementation of the above acceptable plan of action was verified on October 28, 2016, at 9:45 a.m. and the Immediate Jeopardy was removed. The facility failed to ensure that hot water temperatures were maintained below 110 degrees Fahrenheit for the health and safety of the residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 09/08/15 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/08/15 28 Pa. Code 211.12(c)(d)(1) Nursing services Previously cited 09/08/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/16/14, 09/08/15

Based on observation, clinical record review, staff and resident interview, it was determined that the facility failed to timely identify pressure ulcers and provide necessary treatment and services to prevent the development of pressure ulcers for 2 of 15 residents which resulted in harm to Resident E9 (Resident E9 and Resident E17). Findings include: Review of Resident E9 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident E9 ' s nursing admission evaluation revealed that the resident was admitted to the facility with a right buttock Stage II (an ulcer involving loss of the top layers of the skin) pressure ulcer, a right sacral spine wound with a wound vac (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds) , a Stage II pressure ulcer of the left buttock, and a Stage II pressure ulcer on the buttock crease (area between both buttocks). Review of the resident ' s weekly wound assessment forms revealed that an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (tan brown or black) was identified on the resident's coccyx area on August 5, 2015, (20 days after the resident was admitted to the facility) and consisted of 50% eschar (dead tissue that is cast off from the surface of the skin). The form also indicated that there were two black eschar areas in the center of the wound. Interview with Resident E9 on September 8, 2015 at 1:45 p.m. indicated that she was admitted to the facility for the wound on her left buttock and the buttock crease, but confirmed that while at the facility she did acquire another pressure ulcer on her sacral area. Interview with the Director of Nursing on September 8, 2015 at 2:00 p.m. confirmed that the resident developed the unstageable pressure ulcer. The facility failed to timely identify the resident pressure ulcer on the coccyx which resulted in actual harm to the resident with the development of an unstageable pressure ulcer on the coccyx area. Review of Resident E17 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. stroke), diabetes (a disease where an individual ' s sugar levels are not processed effectively in the body causing highs and low of sugar in the blood), [MEDICAL CONDITION] (a mental health disease which can cause not in contact with reality, delusional and paranoid thinking and hallucinations) and depression. Review of Resident E17 ' s nursing progress notes indicated on July 11, 2015 at 2:10 a.m. stated, Left heel red and non-blanchable, no drainage, skin hard to touch. Resident unable to keep boots on. Area cleanse and packed; two pillows placed under feet to keep heels out of pressure. Wound nurse notified. Review of the nursing notes dated July 13, 2015 at 1:15 p.m. completed by the wound nurse stated, wound nurse assessed left heel, unstaged pressure area on left heel, base 100% eschar (scab or slough (dead tissue) over the wound). Recommend skin prep twice a day, continue to float heels and wear heel protectors. This evaluation occurred 36 hours after the non-blanchable area (skin that looses redness with pressure; unblancheable skin does not) was determined on July 11, 2015 at 2:00 a.m. Review of the facility ' s weekly wound assessment form completed by Employee E3 had the first entry date of July 13, 2015 which noted an unstageable pressure ulcer on the left heel measuring 4 x 3.5 centimeters with 100% eschar. The next entry was dated July 30, 2015 (17 days after first entry) stating it was then a Stage I ( redness) wound on the left heel with no exudate (fluid). The next entry was dated August 5, 2015 stating the left heel wound was still a Stage I wound. On August 12, 2015 the weekly wound assessment form noted a the left heel wound as an unstageable wound with 100% eschar again. Further review of weekly skin assessment revealed that seven days later on August 19, 2015 the left heel wound was back again to a Stage I wound. On August 25, 2015 the entry by Employee E3 stated the left heel wound was closed over. Observation of Resident E17 ' s left heel with Employee E4 on September 8, 2015 at 10:30 a.m. revealed that the resident had a round 1.25 by 1.25 centimeter dry, beige, scaly skin area on her left heel with the entire ridge of the circle skin off the surface of her heel with a round 0.5 centimeter center that was dark red in color. When the area was touched by Employee E4 and the unattached area slightly moved by the finger of Employee E4, the resident flinched. The area appeared to be an unstageable pressure ulcer at the center area, not a closed area as documented on the weekly wound assessment form. Interview with Employee E4 on September 8, 2015 at 10:30 a.m. confirmed that there was a small area in the center of the dry scaly skin area on her left heel when observed. The Director of Nursing was informed on September 8, 2015 at 10:50 a.m. of the observation of the Resident E17 ' s left heel. The facility failed to timely identify, monitor and assessed resident left heel pressure ulcer which resulted in actual harm with the development of an unstageable pressure ulcer of the left heel. 28 Pa Code: 201.18(b)(1)(e)(10 Management 28 Pa Code 211.5(f) Clinical Records Previously cited: 10/16/2014 28 Pa code 211.10(a)(c)(d) Resident Care Policies 28 Pa code 211.12(d)(3)(5) Nursing Services Previously cited: 10/16/2015

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to obtain a physician's order for the treatment of [REDACTED]. Findings include: Review of Resident A10's initial assessment of August 12, 2011, included [DIAGNOSES REDACTED]. Physician's orders dated September 14, 2011, included [DIAGNOSES REDACTED]. Review of Resident A10's nursing admission assessment dated [DATE], revealed a 0.5 centimeter (cm) x 1 cm scab on the right second toe, 0.6 cm x 0.4 cm scab on the left great toe, and 0.5 x 0.6 cm scab on the left fifth toe. Review of weekly wound assessment form dated August 15, 2011, revealed an unstageable area on the right second toe measuring 0.5 cm x 1.0 cm with eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges), an unstageable area on the left great toe measuring 0.2 x 0.4 cm with eschar, and a stage I (intact skin with non-blanchable redness of a localized area) of the left fifth toe measuring 0.4 cm x 0.4 cm. Review of nursing note of August 11, 2011, indicated areas assessed as pressure areas from shoes and physician faxed for treatment. Physician order obtained August 11, 2011, for skin prep twice a day (delay of six days). Review of weekly wound assessment form dated September 15, 2011, revealed an unstageable area on the right heel measuring 0.3 x 0.5 cm with 100% yellow slough (tissue that adheres to the wound bed in strings or thick clumps) and unstageable areas on the left heel measuring 1.0 cm x 1.0 cm and 1.0 cm x 1.4 cm with 80% eschar. Physician order obtained September 15, 2011, directed staff to apply santyl (ontiment to promote healing) with dry dressing daily after cleansing with normal saline to right and left heel wounds. Review of treatment record revealed santyl not applied from September 15 - 20, 2011 (6 days). Review of weekly wound assessment form dated September 21, 2011, indicated the right heel was unstageable measuring 0.5 cm x 1.5 cm with scant amount of serosanguinous drainage (consisting of blood and serum) with 90% eschar and the left heel was unstageable measuring 3.0 cm x 2.0 cm with moderate amount of serosanguinous drainage with 90% eschar. Interview with the Director of Nursing on September 23, 2011, at 9:20 a.m. confirmed that there was no treatment applied to the areas on the toes from the time of admission until August 11, 2011. Additionally, the treatment was not applied to the areas on the heels as ordered. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 10/8/10 and 11/22/10