Every finding on record at Valley View Haven, Inc

Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to thoroughly assess the use of bed system assistive devices for one of five residents reviewed for accident hazards (Resident 102).Findings include: The facility policy entitled, Proper Use of Mobility Enabler Device(s), last reviewed without changes on February 6, 2026, revealed that it is the facility policy to utilize a person-centered approach when determining the use of mobility enabler device(s). The resident assessment must assess the resident's risk from using bed mobility devices. Examples of the potential risks with the use of bed mobility devices include accident hazards (e.g., falls, entrapment, and other injuries sustained from attempts to climb over, around, between, or through the rails, or over the footboard), barriers to residents from safely getting out of bed, physical restraint, skin integrity issues, etc. The medical record should include evidence of an assessment of the resident, the bed, the mattress, and rail for entrapment risk. The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become trapped. FDA is recommending 60 mm (two and three-eighths inches) as an appropriate dimension for neck diameter. The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA concurs with the dimension of 318 mm (12.5 inches) to represent chest depth for the population vulnerable to entrapment and has used this dimension as the basis for its recommended dimensional limits. This guidance describes seven zones in the hospital bed system where there is potential for patient entrapment. Zone six is the space between the end of the rail and the side edge of the headboard or footboard. This space may present a risk of either neck entrapment or chest entrapment. Clinical record review for Resident 102 revealed that the facility admitted her on February 26, 2026. An active physician order dated February 27, 2026, implemented the use of a right HALO bar (The Halo Safety Ring is an adjustable bed mobility device, specifically designed to assist individuals with limited mobility, helping them regain independence in daily activities.) to promote independence with bed mobility. A physical therapy assessment dated [DATE], included Resident 102's use of a HALO device on the right side of her bed. Observation of Resident 102's room on March 18, 2026, at 11:22 AM revealed that her bed was equipped with a right-sided circular assistive device (HALO), a headboard, and a footboard. Review of a Test Results Worksheet dated February 27, 2026, revealed that staff failed to assess a potential entrapment risk for zone six. The assessment also errantly noted an assessment of an assistive device on the left side of Resident 102's bed when she did not have an assistive device on that side. Interview with Resident 102 on March 19, 2026, at 2:45 PM confirmed that since her admission, she had an assistive device mounted only on the right side of her bed and she never had an assistive device on the left side of her bed. Interview with the Nursing Home Administrator on March 19, 2026, at 11:43 AM reviewed the above findings regarding Resident 102's assistive device assessment. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access for one of 23 residents reviewed (Resident 102) and physician ordered devices for one of 23 residents reviewed (Resident 40).Findings include: The facility policy entitled, Intravenous Therapy, last reviewed without changes on February 3, 2026, revealed that the facility will adhere to accepted standards of practice regarding infusion practices. An emergency kit will be in place at the bedside. Clinical record review for Resident 102 revealed active physician orders dated February 26, 2026, for staff to: Administer Ceftriaxone Sodium (used to treat a wide range of bacterial infections and to prevent infections in certain surgical procedures) intravenous solution, two grams, every 24 hours until April 1, 2026 Monitor right upper extremity PICC line (A PICC line is a long, thin tube inserted into a vein in the arm that reaches the large central veins near the heart, used for long-term delivery of medications, nutrition, or blood draws.) insertion site for increased erythema (redness), edema (swelling), or drainage every shift Observation of Resident 102 on March 18, 2026, at 11:21 AM revealed a sign above her chair that instructed staff to not use her right arm (e.g., for blood pressure assessments). There was no emergency kit visible in Resident 102's living area. Interview with Resident 102 on the date and time of the above observation revealed that staff were to avoid using her right arm because she had a PICC line in that arm. Resident 102 stated that she did not believe there were any dressings or equipment left in her room for her PICC line care. Resident 102 stated that staff bring dressings with them when they are going to change the dressing to the site. Review of the plan of care developed by the facility to address Resident 102's intravenous antibiotics failed to include the intervention of an emergency kit at her bedside or that she had a right arm limb restriction. Observation of Resident 102's room with Employee 1 (licensed practical nurse) on March 19, 2026, at 2:48 PM confirmed that there was no emergency kit in Resident 102's living area. The surveyor reviewed the above concerns regarding Resident 102's PICC line care during an interview with the Nursing Home Administrator and Employee 2 (registered nurse/assistant director of nursing) on March 19, 2026, at 2:00 PM. Clinical record review for Resident 40 revealed an active physician order dated March 3, 2026, for the implementation of thigh-high TED hose (TED hose are stockings that help prevent blood clots and swelling in your legs by applying graduated compression to the legs, which promotes blood flow and reduces the risk of venous pooling and clot formation), ensure applied in the morning, and removed at hour of sleep, every morning and at bedtime. Resident 40's active physician orders instructed staff to administer Eliquis (an anticoagulant that works to prevent blood clotting) 2.5 milligrams two times a day for DVT (deep vein thrombosis, a blood clot in the deep veins of the leg) prophylaxis (prevention) until April 3, 2026. Plans of care developed by the facility to address Resident 40's care needs included that she had self-care performance deficits completing activities of daily living related to a right knee replacement and was at risk for bleeding related to Eliquis use. The plans of care did not address the use of TED hose to prevent the development of DVT. Interview with Resident 40 on March 18, 2026, at 11:41 AM revealed that she was not wearing her thigh-high compression stockings. Resident 40 stated that, .they told (her) that (she) did not need to wear them once (she) was up and around. Observation of Resident 40 on the date and time of the observation revealed that she did not have thigh-high compression stockings on. Resident 40 revealed her left knee incision to the surveyor and she was wearing socks and sneakers. Resident 40's left ankle and lower leg were slightly larger when compared to her right ankle and lower leg. Review of Resident 40's treatment administration record (TAR, electronic documentation completed by licensed staff for the completion of treatments) dated March 2026 revealed that staff initialed the implementation of the thigh-high TED hose (ensure applied in AM and removed at HS) every morning and at bedtime for March 18 and 19, 2026. Interview with Resident 40 on March 19, 2026, at 2:47 PM confirmed that she was not wearing thigh-high compression stockings. Resident 40 reiterated that she believed that she did not need to wear them once she was, up and around. Interview with Employee 1 (licensed practical nurse) on March 19, 2026, at 2:48 PM indicated that she believed Resident 40 had her compression stockings on, and initialed for the implementation of them on this date. She did not apply the stockings or interview Resident 40 if she had the stockings on. The surveyor reviewed the above concerns regarding Resident 40's compression stockings during an interview with the Nursing Home Administrator and Employee 2 on March 19, 2026, at 2:00 PM. 483.25 Quality of carePreviously cited deficiency 04/14/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 18).Findings include: Clinical record review for Resident 18 revealed the facility admitted her on October 25, 2025, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 18's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 25, 2025, indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. Nursing documentation dated February 4, 2026, at 5:44 PM revealed Resident 18 was bothering other residents, getting very close, and telling them they need to move to other locations. Nursing documentation dated February 10, 2026, at 10:10 AM revealed Resident 18 made an accusation toward a staff member because Resident 18 was upset that she could not enter her room since her heater was being repaired. Documentation revealed Resident 18 has a history of accusing family and other residents of abuse. The facility implemented two staff for all Resident 18's care. Nursing documentation dated February 11, 2026, at 8:58 PM revealed Resident 18 stopped the laundry aide in the hallway, nursing staff intervened. Nursing documentation dated February 28, 2026, at 1:00 PM revealed activities staff placed a resident in a chair and when her husband tried sitting in the seat beside his wife, Resident 18 demanded to sit in that chair. Documentation revealed Resident 18 became agitated, began pacing, and nursing staff had to intervene. Nursing documentation dated March 6, 2026, at 5:37 PM, revealed Resident 18 refused her shower, stating that she is a registered nurse and knows when to clean herself. A review of Resident 18's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings for Resident 18 were reviewed with the Nursing Home Administrator during a meeting on March 20, 2026, at 10:49 AM. 483.40(b)(3) Dementia Treatment and ServicesPreviously cited 4/14/2528 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of five nursing units (200 and 300). Findings include: An observation in the facility's main kitchen and the downstairs pantry and cold storage areas on April 8, 2025, at 10:09 AM with Employee 3, Assistant Director of Nutritional Services, revealed the following: The fryer had a moderate amount of black grease build up in the grease trap. Clean pans were stored on top of the oven where there was a considerable amount of dust buildup. The food warmer was observed with dried brown spills/splatters on the interior base of the warmer and on three sheet trays that were holding pans of food inside the warmer. A windowsill in the dishwashing area was caked with white debris. The entire window was coated in a white substance. A box of hamburger patties was observed on a shelf in the walk-in freezer. The box was open, and a bag of hamburger patties was open to air inside the box. A box of chicken breasts was also observed open beside the box of hamburger patties, with a wide open bag of chicken sitting in the box exposed to air. Food debris was observed under the shelving units in the walk-in freezer. A piece of the metal wall covering on the interior back corner of the walk-in cooler was hanging off the wall. A stack of clean dish washing racks was observed next to a shelving unit holding clean dishware. The racks contained pieces of dried food/debris built up in corners/indentations of the racks in several spots. An ice scoop was observed sitting directly on top of the ice machine uncovered. The flooring under the ice machine contained dust and debris. The downstairs dry storage was observed to have several brown stained ceiling tiles and dried liquid inside a ceiling light cover. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on April 10, 2025, at 2:25 PM. An observation of the 200-unit nourishment room refrigerator on April 9, 2025, at 10:05 AM revealed a shelf full of individual containers of juices in a variety of flavors such as apple, grape, and cranberry stored in the refrigerator. There was no evidence to indicate when the juices were placed there, when they needed to be used by, or a manufacturer's expiration date on the containers. A concurrent observation of the 300-unit nourishment area refrigerator also revealed a shelf full of the same kind of juices stocked in the refrigerator. An interview with Employee 3 on April 9, 2025, at 10:05 AM revealed the juices are delivered to the facility frozen, and dietary staff pull the boxes from the freezer to thaw. Employee 3 indicated the staff date the box of juice when they pull it from the freezer, but once the containers are taken out of the box, such as for storing in the refrigerators on the nursing units, they would not be dated. Observation of a case/box of the individual juices with Employee 3 on April 9, 2025, at 12:05 PM revealed manufacturer instructions on the box indicating the product was to be used within 14 days once thawed. There was no evidence to indicate when the juices stored on the nursing units referenced above were pulled from the freezer, thawed, or when the 14-day expiration would occur. The above information regarding the juices was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on April 11, 2025, at 2:35 PM. 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 5/31/24 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for one of 22 residents reviewed (Resident 101), implement appropriate transmission based precautions (TBP) for one of one resident reviewed on TBP (Resident 96), and ensure an environment free from the potential spread of infection with the storage of resident supplies on one of five nursing units (200; Residents 62 and 77). Findings include: The facility policy entitled Isolation, Transmission Based Precautions, last reviewed without changes on May 22, 2024, revealed standard precautions will be used when caring for residents. Transmission based precautions will be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. If a resident is suspected of, or identified as having a communicable infectious disease, the registered nurse supervisor will notify the infection control designee and the resident's physician for appropriate transmission-based precautions. Transmission based precautions will remain in effect until the physician or infection control designee discontinues them. Contact precautions will be used in addition to Standard Precautions for residents with specific infections that can be transmitted by direct and indirect contact. Clinical record review for Resident 96 revealed the facility admitted him on October 21, 2024. Review of Resident 96's physician orders revealed an order dated April 7, 2025, for contact isolation due to a shingles rash on his face and neck. Nursing documentation dated April 8, 2025, at 5:15 AM revealed Resident 96 began on the medication Valtrex (an antiviral medication) related to his diagnosis of shingles. Documentation revealed a pustule rash continues on Resident 96's face, and down the right side of his neck with pustules remaining intact. Contact precautions remain in place. When the rash is still blistered and contains fluid in the blisters, the person is considered contagious if the rash comes in close contact to someone else, so it is best to keep the rash covered. Observation of Resident 96 on April 8, 2025, at 10:12 AM revealed he was in the dining/activity room seated at a table with 11 other residents making Easter eggs. The shingles rash was observed on his face and neck. The shingles rash on Resident 96's neck was exposed with pustules. Resident 96's rash was not covered. Observation of Resident 96 on April 9, 2025, at 10:25 AM revealed he was walking on the unit holding hands with another resident (Resident 96's wife). The shingles rash on Resident 96's neck was again exposed with pustules. Resident 96's rash was not covered. Observation of Resident 96 on April 9, 2025, at 12:29 PM he was in the dining room eating lunch, with two other residents seated at his table. Resident 96 was unable to be interviewed regarding any education he received regarding his rash and contact precautions due to his current cognitive status. Interview with Employee 1, infection control nurse, on April 10, 2025, at 2 PM confirmed these findings. She stated that staff should have covered Resident 96's rash on his neck with the exposed pustules. An observation of Resident 62's bathroom on April 8, 2025, revealed a bag of bladder pads stored directly on the floor beside the toilet. An observation of Resident 77's bathroom on April 8, 2025, revealed a plastic bag of maxi pads stored directly on the floor beside the resident's toilet. The above information regarding Residents 62 and 77 was reviewed with the Nursing Home Administrator and Director of Nursing on April 10. 2025, at 2:30 PM. Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that CMS was issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. In 2019, CDC (Centers for Disease Control) introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP). In July 2022, the CDC released updated EBP recommendations for Implementation of PPE Use in nursing homes to prevent spread of MDROs. The CDC's, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), stipulated that, When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revealed that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. CDC has created examples of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions. Facilities can use these signs or modify them to create signs that work for their facility. Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/media/pdfs/Observations-Tool-for-Enhanced-Barrier-Precautions-Implementation-508.pdf, Enhanced Barrier Precautions (EBP) Implementation-Observations Tool (For use in Skilled Nursing Facilities/Nursing Homes only) reiterated that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. The EBP sign should also include a list of the high-contact resident care activities for which PPE (gown and gloves) should be worn. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure EBP are followed. Signs should not include information about a resident's diagnosis or the reason for the use of EBP (e.g., presence of a resistant germ, wound). A review of the CDC sign for EBP revealed that the first directive is that everyone must clean their hands, including before entering and when leaving the room. Review of the facility's policy entitled, Enhanced Barrier Precautions, last reviewed without changes May 22, 2024, revealed that the compliance guidelines included that the facility would have the discretion on how to communicate to staff which residents require the use of EBP. The implementation of EBP included to make gowns and gloves available near or outside the resident's room, ensure alcohol-based hand rub is in every resident room, position a trash can and linen cart inside the resident room near the exit, the infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education, and provide education to residents and visitors. The facility policy did not include the implementation of the placement of signage visible to individuals entering the room to signal the specific actions they should take to protect themselves and the resident. Clinical record review for Resident 101 revealed a physician's order dated March 28, 2025, for staff to implement enhanced barrier precautions related to an indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine). Observation of Resident 101's room on April 9, 2025, at 10:18 AM revealed that her door was partially shut. There was no signage or indication before entering her room of the implementation of enhanced barrier precautions. Interview with Employee 2 (registered nurse) on April 9, 2025, at 10:33 AM revealed that the sign that indicated Resident 101 required EBP was positioned on the inside of Resident 101's door and was not visible to any person before entering her room. The interview confirmed that the sign positioned on the inside of Resident 101's door was the CDC Enhanced Barrier Precautions sign that included the directive that, Everyone must clean their hands, including before entering and when leaving the room. Interview with the Nursing Home Administrator on April 10, 2025, at 10:00 AM confirmed that the facility's EBP policy did not include the necessity of signage to notify staff and/or visitors that EBP were necessary. Interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2025, at 10:35 AM confirmed that the facility policy did not include an expectation that staff would post a sign visible to individuals entering the room to signal the specific EBP actions they should take to protect themselves and the resident. The interview also confirmed that the facility policy did not include how the facility would provide education to residents and visitors regarding EBP requirements. The interview indicated that generally Employee 1 (assistant director of nursing/infection preventionist) ensures that a sign is posted. The Director of Nursing stated that she believed that current nationally accepted standard guidance regarding EBP did not require the use of a sign. The surveyor referred the Director of Nursing and the Nursing Home Administrator to the CDC and CMS guidance noted above. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding a resident assessment for pressure ulcer concerns for one of 23 residents reviewed (Resident 150). Findings include: Clinical record review for Resident 150 revealed that they were admitted to the facility on [DATE], with a sacral (triangular area at the bottom of the spine) ulcer. Facility staff completed an initial assessment of Resident 150's sacral ulcer with measurements noted as 10 cm (centimeters) long by 8 cm wide by no depth, with red, watery drainage. Staff ordered appropriate treatment. On April 6, 2025, at 3:55 PM staff documented that at 9:30 AM they went to change Resident 150's sacral dressing, however, there was no dressing on the wound. Staff cleansed and applied a new dressing, noting that they observed yellow slough (dead skin) on the wound bed (base of wound) with a slight odor. On April 6, 2025, at 5:40 PM staff documented that they changed Resident 150's sacral dressing at 3:40 PM and noted a change/concern in the wound drainage (now with a tan/gray drainage) and an increase in depth near the top of the wound. Staff measured Resident 150's wound as 7.2 cm (centimeters) long by 5 cm wide by 1.5 cm deep in the center of the wound. At the top of the wound, staff measured a depth of 2.2 cm. Staff notified Employee 1, registered nurse, assistant director of nursing/infection preventionist, of the concern. On April 10, 2025, at 10:33 AM and 10:43 AM (3.75 days later) Employee 1 documented that they assessed Resident 150's sacral ulcer and observed the above noted slough. The slough was able to be moved with bone now visualized at the base of the wound. Employee 1 measured the wound as 7.2 cm long by 5 cm wide and 2.5 cm deep with no undermining or tunneling (wound channeling under tissue) with a mixture of purulent (pus like) and serous (clear) drainage. Employee 1 determined the need to change/update the resident's sacral ulcer dressing order based on their assessment. Employee 1 did not assess Resident 150's sacral wound timely to identify potential wound and dressing changes. The above information was reviewed during an interview on April 15, 2025, at 10:40 AM with the Nursing Home Administrator. 483.25 Quality of Care Previously cited 5/31/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 28). Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 28 revealed the following current physician orders: Oxygen at 2 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose) to keep SpO2 (oxygen saturations) greater than 91 percent as needed Further clinical review for Resident 28 revealed that they last utilized oxygen on March 28, 2025, at 6:02 AM. Observation of Resident 28's room on April 8, 2025, at 11:03 AM, and April 9, 2025, at 10:27 AM revealed that there was an oxygen concentrator beside his bed. Attached to the concentrator there was an undated humidification cannister that had an unbagged, undated nasal cannula tubing attached. The tubing was draped over the concentrator and onto the floor. Concurrent interview with Resident 28 on April 8, 2025, at 11:03 AM revealed that he had not utilized oxygen recently. The above information was reviewed with the Nursing Home Administrator during an interview on April 10, 2025, at 2:10 PM. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility documentation, clinical record review, employee personnel record information, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration, the care and assessment of residents with indwelling urinary catheters, and gastrostomy tubes for one of five employees reviewed for competencies (Employee 2; Residents 101 and 57). Findings include: The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. The facility assessment reviewed during the onsite survey last updated March 31, 2025, revealed that RN (registered nurse) competency and training would include catheter insertion and flushing (Foley, indwelling urinary catheters, flexible tubing inserted into the bladder to drain urine) and medication administration. The assessment stipulated that the lists were not all inclusive. Although the list of competencies and trainings did not refer to RN care and services for artificial feeding systems, the LPN (licensed practical nurse) competency and training list included enteral feeding (PEG, a flexible tube inserted through the abdominal wall and into the stomach for the purpose of administering nutrition, fluids, and medications) and use of pumps or feeding by gravity. A review of the facility Resident Matrix (CMS-802, form used to identify pertinent care categories for residents who reside in the facility) documentation revealed that the facility had a total of nine residents with indwelling urinary catheters within the 107 resident facility census (8.4 percent). Clinical record review for Resident 101 revealed active physician orders for staff to irrigate a urinary catheter every eight hours as needed for blockages and to change a 16 French (The French scale, also known as the French gauge, is a widely used measurement system for the size of catheters) urinary catheter every 28 days and as needed for occlusion or leakage as needed. Clinical record review for Resident 57 revealed active physician orders to change an indwelling urinary catheter, size 16 or 18 French coude (A coude catheter is a type of urinary catheter that features a curved tip, designed to navigate around obstacles in the urethra, such as an enlarged prostate or strictures), monthly and as needed for occlusion or leakage, and to irrigate the foley catheter with 60 milliliters (ml) of normal saline daily and as needed. Resident 57's active physician orders also instructed staff to flush his PEG tube two times a day with 240 ml of water and to assess his feeding tube placement every shift and with every use. Staff were also to flush the PEG tube as needed with 30 ml of water before and after medication administration with 10 ml between each medication as needed if Resident 57 was unable to take his meds orally. Review of Employee 2's (registered nurse) personnel records revealed that the facility completed new hire orientation training on September 17, 2024. The orientation training list provided did not include evidence of any competencies completed related to indwelling urinary catheters, PEG tubes, or medication administration. Email communication from the Nursing Home Administrator dated April 11, 2025, at 10:35 AM confirmed that the facility had no evidence of Employee 2's competencies. The facility could only provide the RN orientation checklist that did not include the verification of competencies in medication administration, indwelling catheter care, or PEG tube care. 28 Pa Code 201.20(a) Staff development

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 27). Findings include: Clinical record review for Resident 27 revealed the facility admitted her on January 8, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 27's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 9, 2024, indicated that the facility assessed Resident 91 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 27's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on April 10, 2025, at 2:00 PM. On April 11, 2025, at 10:23 AM the Nursing Home Administrator confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 27's dementia prior to surveyor's questioning. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents reviewed for medication regime concerns (Resident 101). Findings include: Clinical record review for Resident 101 revealed that the facility admitted her on March 14, 2025. An active physician order dated March 14, 2025, instructed staff to administer Lunesta (Eszopiclone, a sedative hypnotic medication used to induce and maintain sleep) 2 mg (milligram) by mouth at bedtime. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 19, 2025, identified that staff administered a hypnotic medication to Resident 101, and the facility would proceed to a care plan for the psychotropic medication use. Review of care plans developed for Resident 101 did not include the use of a sedative hypnotic for sleep, did not include non-pharmacological interventions used, and did not identify target behaviors that the facility would monitor to support the rationale for the continued use of the medication. Interviews with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing/infection preventionist) on April 10, 2025, at 2:00 PM and with the Director of Nursing on April 11, 2025, at 9:30 AM confirmed that there was no plan of care or target behaviors identified or monitored for Resident 101's use of the sedative hypnotic. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations (Resident 4). Findings include: The policy entitled Pneumococcal Vaccination of Residents, last reviewed without changes May 22, 2024, revealed all residents of the facility and/or admissions to the facility will be offered the pneumococcal immunization. The resident and/or representative will receive information regarding the types of vaccinations available, and the benefits and potential side effects of the vaccine. Each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated or if they have already been immunized. Each resident's pneumococcal immunization status will be determined upon admission, or soon afterwards, and will be documented on the pneumococcal consent form and in the resident's medical record. The immunization/vaccine will be administered according to the standing physician order as per CDC (Centers for Disease Control) recommendations. Clinical record review revealed the facility admitted Resident 4 on February 1, 2022. Documentation in Resident 4's clinical record revealed she received two pneumococcal vaccines (Pneumovax 23 and Prevnar 13) prior to her admission in 2022. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 4's pneumococcal vaccinations would not be completed until she received a Prevnar 20 or Prevnar 21 at least five years after the last pneumococcal vaccine dose. There was no documented evidence to indicate that the facility offered Resident 4 an updated pneumococcal vaccination. Interview with Employee 1, infection control preventionist, on April 11, 2025, at 10:05 AM confirmed the above findings for Resident 4. Employee 1 stated at the time of sending Prevnar 20 consents (January 2024) Resident 4 was not yet eligible. Employee 1 indicated when Resident 4 became eligible the facility missed obtaining a consent and offering her the updated pneumococcal vaccination. Employee 1 contacted Resident 4's family and they indicated that they would like her to receive the vaccination. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's discharge status for one of three residents reviewed (Resident 105). Findings include: Clinical record review for Resident 105 revealed a discharge MDS (minimum data set, an assessment completed at periodic intervals of time to assess resident care needs) dated February 3, 2025, where facility staff assessed the resident's discharge status as being discharged to a hospital on that date. Further record review for Resident 105 revealed a discharge summary dated February 3, 3025, at 12:07 PM, and that the resident was discharged to home, not a hospital. The above information regarding Resident 105 was reviewed with the Nursing Home Administrator and Director of Nursing on April 10, 2025, at 2:30 PM. On April 11, 2025, at 11:58 AM facility staff provided evidence of a corrected MDS for Resident 105, indicating the residents discharge status was to reflect the resident was discharged to home and the prior MDS indicating the resident discharged to the hospital was coded in error. 28 Pa. Code 211.5(f)(iv)(xi) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and five of five open nursing units (unit 200, 400, 500, 600, 700). Findings include: An observation in the facility's main kitchen on [DATE], at 10:00 AM with Employee 2, assistant director of nutrition services, revealed the following: The wall area to the right of the dish machine contained significant dried food splatter from ceiling to floor, which extended to a door in the area and the wall past the door towards the kitchen preparation area. The exterior of a large garbage can by the pot washing sink was covered with dried liquid spills and food. Vents along the front of the hood unit above the cooking area were covered in dust. A [NAME] by the food serving line stacked with racks of bowls and cups had a buildup of crumbs, dried food, and debris. An observation of the nourishment area on the 400 unit on [DATE], at 11:12 AM revealed a large brown water stain in the interior of the cabinet under the pipes of the sink, dried brown water stains were also present along a plastic tube extending across the interior of the cabinet. The interior of a drawer located beside the refrigerator with beverage mugs and thickening packets was significantly worn with the wipeable finish removed throughout most of the drawer exposing a paperboard surface with the potential to absorb liquid/contaminants. Another cabinet drawer located in the nourishment area contained several individual packs of peanut butter, two bags of ketchup packs, a bag of tartar sauce packets, and a bag of saltine cracker packets. There was no evidence of a date the packets were placed in the area or when they expired. An observation of the 500-unit nourishment area on [DATE], at 11:23 AM revealed a refrigerator/freezer in the nourishment room. The freezer had multiple ice cream cups in it also contained a folded towel on the lower shelf as several therapeutic ice packs. The bottom storage bins of the refrigerator contained dust, debris, and a dried brown substance covering the interior of one of the drawers. The wall beside and behind the trash receptacle located in the room contained dried liquid splatter, and large gauged areas of the drywall. An observation of the 200-unit nourishment area on [DATE], at 11:33 AM revealed a refrigerator/freezer unit in the room. Ice cream cups and bowls of ice cream were observed in the freezer. Multiple therapeutic ice packs were stored in the freezer with the ice cream. An observation of the 600-unit kitchen area on [DATE], at 11:39 AM revealed a small upright freezer unit in which multiple packs of meat were stored including a bag of beef patties and a pan of fish. A box of ice cream sandwiches was stored touching the bags of frozen meat products on the same shelf. An observation of the 700-unit kitchen area at 11:46 AM on [DATE], revealed a small upright freezer with multiple packs of frozen meat products, and a plastic bag with packs of ice cream bars was stored on the same shelf and packed in with the frozen meat products. The above information was reviewed with the Director of Nursing on [DATE], at 1:30 PM and [DATE], at 12:00 PM. 483.60 (i)(2) Food storage safe and sanitary Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for two of four residents reviewed for accident hazards (Residents 97 and 106). Findings include: A Test Results Worksheet (form the facility used to document the assessment of entrapment risk zones) revealed that the facility only assessed zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), and three (between the edge of the mattress and inside of the rail). The assessment did not capture zone four (between the top of the compressed mattress and the bottom of the rail at the end of the rail, zone five (between the split [head and foot] bed rails), zone six (between the end of the rail and the side edge of the head or foot board), or zone seven (between head or foot board and end of mattress). Observation of Resident 97's room on May 28, 2024, at 12:23 PM, and May 29, 2024, at 9:26 AM revealed that there were bilateral halo (circular) enabler bars observed on the bed. Clinical record review for Resident 97 revealed a Test Results Worksheet dated April 30, 2024, that revealed the facility measured, assessed, and passed the halo enabler bars for zones one, two, and three. Staff who completed the form indicated N/A (not applicable) for zones four, six, and seven. Zone five will not apply to this resident as they did not have head and foot split bed rails. Observation of Resident 106 on May 28, 2024, at 11:52 AM revealed that there was a halo enabler bar on the door side of the bed. There was no documentation that indicated the facility assessed Resident 106's halo enabler bar for entrapment zones six or seven. Zone five will not apply to this resident as they did not have head and foot split bed rails. The surveyor reviewed the above information during an interview with the Director of Nursing on May 30, 2024, at 2:25 PM. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to respect a resident's privacy for one of 25 residents reviewed (Resident 11). Findings include: The policy entitled Sound Monitoring, last reviewed without changes on May 22, 2024, revealed the facility may utilize a sound monitoring system in a resident's room to alert staff when a resident is attempting to rise without assistance. The sound monitoring system will only be used when other interventions have proven to be ineffective to prevent falls or injury. Permission for sound monitoring will be received from the resident or resident representative before sound monitoring is initiated. The consent will be documented in the resident's electronic medical record. Observation of the 700-nursing unit on May 28, 2024, at 11:42 AM revealed there was an audio monitor in the nurses' station. Resident 61 was in her wheelchair in the nurses' station at this time. There was a male and female voice coming from the audio monitor. The female voice was discussing toileting needs with Resident 11. Observation of the 700-nursing unit on May 29, 2024, at 9:12 and 11:07 AM revealed there were again voices on the audio monitor. Clinical record review for Resident 11 revealed the facility admitted Resident 11 on August 11, 2022. Further review of Resident 11's clinical record revealed no consent for Resident 11's audio monitor. A review of Resident 11's plan of care revealed the facility added a sound detection monitor to be utilized during sleeping hours to help alert the team when Resident 11 is rising on October 4, 2023. Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2024, at 2:04 PM revealed the facility utilizes audio monitors in resident rooms and confirmed there was no evidence in Resident 11's clinical record that the facility obtained permission for the audio monitor. The Director of Nursing confirmed Resident 11's audio monitor was only to be used during sleeping hours. The facility failed to protect Resident 11's right to privacy. 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of a thorough investigation of missing medications for one of three residents reviewed (Resident 21). Findings include: The policy entitled Abuse Prevention Program reviewed on May 24, 2024, indicates that the facility will develop investigation protocols for misappropriation of property. This surveyor attempted multiple times to obtain further facility policies and/or procedures regarding the investigation protocols for misappropriate of medications without success. The policy entitled Medication Error Guidelines reviewed on May 24, 2024, indicates that the facility will do a search for a missing medication. If the medication cannot be found, the responsible staff member may have to be suspended pending outcome of an investigation conducted by facility administration. Review of Resident 21's clinical record revealed nursing documentation dated April 27, 2024, at 4:56 AM that Resident 21's narcotic count was off. Resident 21's medication card was checked, and it was determined that one of her Phenobarbital (a medication used to treat seizures that has the potential for diversion due to its sedative and hypnotic properties) pills were missing and not signed out by the medication nurse. The documentation indicated that Employee 1, licensed practical nurse, did not know what happened to the pill and that it was unknown if she gave it to Resident 21 as an extra dose. Review of the facility's investigation into Resident 21's missing Phenobarbital revealed that the facility only determined that Employee 1 must have given Resident 21 an extra dose (possibly) and did not investigate the missing medication thoroughly to determine if misappropriation took place. The facility was not able to provide documented evidence that an investigation was initiated regarding Resident 21's missing phenobarbital, and its possible misappropriation. There were no witness statements from Employee 1, previous shift medication nurse, or the registered nurse supervisor on duty at the time of the findings. Interview with the Director of Nursing on May 30, 2024, at 2:30 PM confirmed the above findings for Resident 21. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three of five residents reviewed for hospitalization s (Residents 56, 97, and 105). Findings include: Clinical record review revealed that Resident 97 was transferred to the hospital on April 26, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 105 was transferred to the hospital on April 2, 2024, and April 27, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident's responsible party upon transfer out to the hospital. The surveyor reviewed the above information for Residents 97 and 105 during an interview with the Director of Nursing on May 30, 2024, at 2:15 PM. Clinical record review revealed that Resident 56 was transferred to the hospital on April 9, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The Nursing Home Administrator and Director of Nursing confirmed these findings for Resident 56 on May 30, 2024, at 11:17 AM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 21, 2024, and May 14, 2024, that indicated the facility assessed him an having an active pneumonia infection and a sepsis (a life-threatening condition when the body responds to an infection) diagnosis. Resident 37 had not had an active pneumonia infection and/or sepsis since December 16, 2023. Interview with the Administrator on May 30, 2024, at 12:03 PM confirmed the above findings for Resident 37. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions and treatments for one of 25 residents (Resident 105). Findings include: Clinical record review for Resident 105 revealed a current physician order for staff to place a bilateral halo (circular) enabler bar on her bed. Observation of Resident 105's bed on May 28, 2024, at 12:01 PM revealed that the bed did not have bilateral halo bars on it. Clinical record review for Resident 105 revealed that she attended a podiatry appointment on April 24, 2024, for a right ankle fracture. Resident 105 was ordered a boot to the RLE (right lower extremity) as a result of the fracture. The podiatrist indicated to take the RLE boot off daily and wash the leg. When staff reapplied the RLE boot, they were to ensure that Resident 105 was wearing a sock, that the foot was flat in the boot, and the heel was in the back of the boot. Facility staff acknowledged the podiatrist's orders on April 24, 2024. Review of Resident 105's physician orders and treatment and task documentation revealed no indication that staff were removing, washing, ensuring proper placement of the RLE boot, and reapplying daily after April 24, 2024, until identified by the surveyor. The surveyor reviewed the above information during an interview on May 30, 2024, 1:02 PM with the Director of Nursing. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for three of five residents reviewed (Residents 56, 97, and 105). Findings include: Clinical record review for Resident 97 revealed that they were transferred to the hospital on April 26, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address (mailing and email) information for the Office of the State Long-Term Care Ombudsman, and information (mailing and email address and telephone number) for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and a statement of resident's appeal rights, including name, address (mailing and email) and telephone number of entity which receives requests. Clinical record review for Resident 105 revealed that they were transferred to the hospital on April 2, 2024, and April 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident, or their responsible party as required regarding the transfer that included the required contents listed above. The surveyor reviewed the above information during an interview with the Director of Nursing on May 30, 2024, at 2:15 PM. Clinical record review 56 revealed that they transferred him to the hospital from April 9 to 11, 2024, after a change in his condition. There was no evidence to indicate that Resident 56's responsible party was provided written notification that included the above required contents. The Nursing Home Administrator and Director of Nursing confirmed these findings for Resident 56 regarding transfer notices on May 30, 2024, at 11:17 AM. 483.15(c)(3)-(6)(8) Notice Requirements Before Transfer/discharge Previously cited 6/9/23. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to prevent a resident accident that resulted in serious injury for one of 24 residents reviewed, who sustained a fractured right femur (Resident 3). Findings include: The facility policy entitled, Fall Risk Assessment and Reduction, last reviewed on September 11, 2017, indicated a Licensed Practical Nurse or Registered Nurse would complete a post fall assessment to include a referral to the Rehabilitation department for a screen (physical and/or occupational therapy). Clinical record review for Resident 3 revealed a nursing progress note dated July 10, 2017, at 4:52 PM indicating that Resident 3 fell in the bathroom and complained of pain in her right hand and left leg. The facility transferred Resident 3 to the emergency room . Resident 3 returned with a [DIAGNOSES REDACTED]. Resident 3 was independent with ambulation and transfers at the time of the fall. Therapy completed a screen on July 11, 2017, and requested that Resident 3 utilize a mechanical lift for all transfers. The physician agreed and Resident 3's transfer status was updated on her nurse aide treatment Kardex. Clinical record review revealed that on July 13, 2017, therapy recommended that Resident 3's transfer and ambulation status be changed to extensive assist of two with a platform walker and a boot to the left lower extremity when in her room. The nurse aide Kardex indicated that mechanical lift transfers were discontinued on July 13, 2017, but failed to indicate the new transfer and ambulation status recommended by therapy (two assist with a platform walker and a boot to the left lower extremity). Clinical record review revealed a nursing progress note dated July 27, 2017, at 5:15 PM indicating that Resident 3's knees gave out while being transferred by two nurse aides and she was lowered to the floor. Review of the facility investigation into Resident 3's fall dated July 27, 2017, revealed that Employee 2, Nurse Aide, transferred Resident 3 by herself and Resident 3 fell to the floor. The facility transferred Resident 3 to the emergency room where she was diagnosed with [REDACTED]. Interview with Resident 3 on October 18, 2017, at 1:00 PM revealed that Employee 2 transferred her by herself. Resident 3 stated that she tried to tell Employee 2 that she required two staff to transfer her and she would not listen. A statement from Employee 2 dated July 29, 2017, revealed that she tried to transfer Resident 3 by herself. During the transfer, Resident 3 stated to Employee 2 that her knees were giving out and she fell to the floor. Interview with the Director of Nursing and the Nursing Home Administrator on October 19, 2017, at 2:30 PM confirmed that the facility failed to implement therapy recommendations for ambulation and transfer status resulting in Resident 3 sustaining a fall with actual harm. 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices Previously cited 11/1/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/18/16, 11/1/6, 3/24/16, 10/23/15

Based on clinical record review, observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess, monitor, and implement interventions to prevent skin breakdown for three of 24 sampled residents (Residents 64, 83, and 95). Findings include: The policy entitled "Pressure Ulcer Risk Assessment," last reviewed August 24, 2011, revealed that the facility needs to identify residents at risk and implement interventions promptly to attempt to prevent pressure ulcers. Clinical record review for Resident 95 revealed nursing documentation dated February 27, 2011, indicating that a nurse aide removed Resident 95's Geri sleeve (skin protective device), and noted a "sore" between his right thumb and index finger. Nursing documentation dated February 28, 2011, revealed that Resident 95's Geri sleeve was over his thumb causing pressure to the web of skin between his right thumb and index finger. Nursing documentation identified the area as a Stage III pressure area (full tissue loss) measuring 0.5 cm by 1.5 cm. Review of the facility investigation into Resident 95's pressure area revealed that the pressure ulcer was a result of the Geri sleeve causing pressure. Review of the physician's orders [REDACTED]. Interview with the Director of Nursing and the Administrator on October 20, 2011, at 2:15 PM confirmed that the pressure ulcer was caused from the Geri sleeve. The facility failed to follow physician orders [REDACTED]. A Braden scale assessment indicates that anything greater than a 10 places the resident at high risk for developing pressure ulcers. Clinical record review for Resident 83 revealed Braden scale assessments (skin assessment that determines pressure ulcer risk) with the following results: November 18, 2010, 11 February 16, 2011, 14 May 5, 2011, 13 August 8, 2011, 12 September 14, 2011, 11 Clinical record review for Resident 83 revealed displaced [MEDICAL CONDITION] femur on August 11, 2011. The physician wrote an order dated August 13, 2011, for a right leg splint and ace wrap from Resident 83's toes to thigh. Nursing documentation dated August 22, 2011, at 5:50 PM revealed that staff placed an immobilizer on Resident 83's right leg, from thigh to and including her right foot. A physician order [REDACTED]. Resident 83's treatment records revealed that the facility signed for completion of this task once from August 23- 25, 2011. Clinical record review revealed that on August 25, 2011, Resident 83 developed a red area on her right heel measuring 6.9 cm (centimeters) by 5.8 cm, with a drained purple blister measuring 1.8 cm by 1 cm. Review of facility investigation into Resident 83's pressure area revealed that the pressure ulcer was a result of the immobilizer being too large and sliding on Resident 83's leg. The facility notified Resident 83's physician on August 25, 2011. The physician notification/order request form dated August 25, 2011, revealed that the facility placed a "heelzup" (pressure relieve device) on the bed and a pillow under her thigh to keep her leg in proper alignment per therapy recommendations. A physician order [REDACTED]. The LPN was also to assess the immobilizer placement every four hours. Interview with the Administrator on October 20, 2011, at 2:00 PM confirmed that the immobilizer caused the pressure ulcer. The facility failed to adequately assess, plan, and implement measures in a timely manner to prevent a pressure area to Resident 83's right heel. Clinical record review for Resident 64 revealed nursing documentation dated September 20, 2011, indicating that a nurse aide removed Resident 64's sock and noted a 2 cm by 1 cm, dark purple pressure sore on his right heel. Review of the facility investigation into Resident 64's pressure area, dated September 21, 2011, revealed that Resident 64 was propelling himself in his easy chair using his feet and he did not have a shoe on his right foot. The facility investigation indicated that therapy supplied Resident 64 a L'Nard splint (a protective device) that he was to wear in bed, or his easy chair. Review of the physical therapy note dated September 21, 2011, revealed that nursing staff reported that Resident 64 had a pressure area on his heel, and requested a boot for his bed. The nurse aide documentation dated September 2011, revealed that Resident 64 was only wearing the L'Nard splint when he was in bed. Nursing documentation dated September 29, 2011, revealed that nursing identified a new blister to Resident 64's right heel, next to the previously affected area. The blister measured 2 cm by 1.5 cm. Review of the facility investigation into Resident 64's second pressure area dated September 29, 2011, indicated that Resident 64 was only wearing the splint when in bed. The physical therapist stated that the L'Nard splint "must be on at all times, except with ambulation." Interview with the Director of Nursing on September 21, 2011, at 11:15 AM, confirmed that the facility identified that Resident 64 developed the pressure sore on his heel on September 20, 2011, from self propelling in his easy chair; however, the facility only implemented the L'Nard splint when he was in bed. The Director of Nursing confirmed that Resident 64 developed a second pressure area on his heel from continuing to propel himself in his easy chair with no shoe. The facility failed to adequately assess and implement measures timely to prevent a reoccurring pressure area to Resident 64's heel. 483.25(c) Treatment/services to Prevent/heal Pressure Sores. Previously cited 9/23/10 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/23/10 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/23/10