Every finding on record at Valley View Rehab and Nursing Center

Based on a review of select facility policies and procedures, clinical record review, personnel record review, and staff interview, it was determined that the facility failed to protect a resident's right to be free from neglect by staff that resulted in actual harm with a serious injury of a fractured finger for one of six residents reviewed (Resident 1).This deficiency is cited as past noncompliance.Findings include: The current facility policy entitled Abuse Prevention/Elder Justice Act Suspicious Crime Reporting, revealed the facility will protect all residents, resident representatives, visitors, and staff from abuse. The facility will prevent abuse and neglect through screening of potential employees, identifying risk factors through assessment and monitoring of residents with behaviors which lead to abuse, educating employees, residents, and resident representatives, protecting the rights of our residents and staff, prompt reporting and investigation of incidents of alleged resident abuse, and responding to abuse or neglect. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This refers to failure through inattentiveness, carelessness, and omission to provide timely, consistent, safety adequate and appropriate services and treatment. Clinical record review revealed the facility admitted Resident 1 on March 13, 2026. Review of her diagnoses list included the need for assistance with personal care, Alzheimer's disease, and senile dementia (brain disorder that impairs memory, thinking, and the ability to perform everyday activities that contribute to behaviors such as agitation, aggression, delusions, and resistance to care). Review of Resident 1's plan of care (individualized document outlining a resident's medical, functional, and support needs) initiated by the facility on March 13, 2026, to address Resident 1's activities of daily living self-care performance deficit revealed an intervention that included to transfer Resident 1 with a mechanical stand aid lift with the assistance of two staff. A physician's order-initiated May 20, 2026, instructed staff to transfer Resident 1 with a full body mechanical lift with the assistance of two staff. Nursing documentation dated June 2, 2026, at 10:05 AM revealed the licensed practical nurse requested the registered nurse assess Resident 1's left forearm. Resident 1's forearm to her wrist was bruised and there was a hematoma (pooled blood that forms outside of a blood vessel, usually caused by trauma or injury) on her mid forearm that was raised one inch. Review of facility investigation dated June 2, 2026, at 10:05 AM revealed therapy notified nursing of a raised bruise on Resident 1's left forearm, which was painful to touch. A physician's progress note dated June 2, 2026, at 10:08 AM revealed Resident 1 was evaluated due to acute concerns regarding her left arm pain. Nursing staff reported no recent falls or injuries. Resident 1 stated, I don't know what happened. Resident 1 reported pain in her left arm. The physician noted a large hematoma with deformity present, unclear if deformity is from hematoma or underlying musculoskeletal issue. The documentation revealed Resident 1 reported significant discomfort. The physician reported due to acute onset and severity of discomfort, and deformity, will transfer Resident 1 to ER (emergency room) for further evaluation and treatment. Nursing documentation dated June 2, 2026, at 1:49 PM noted Resident 1's daughter called the facility and stated the resident's arm was not broken, but her right pinky finger was found to have a bruise. Resident 1's daughter reported they are going to do a CT scan (a specialized medical imaging test) to make sure there is no active bleeding. Nursing documentation dated June 2, 2026, at 9:07 PM revealed Resident 1 was being admitted to the emergency department for a displaced fracture of her right little finger and hematoma of her left arm. Review of the radiology report dated June 2, 2026, noted a soft tissue hematoma in Resident 1's dorsal distal (back) forearm and wrist measuring 4.2 cm (centimeters) by 3.1 cm by 10.0 cm. with suspected active bleeding, and an acute nondisplaced fracture of her fifth proximal phalanx (small finger bone closest to the main body) base. Review of the interdisciplinary team review of the incident dated June 3, 2026, revealed a staff member utilized the lift unattended and probably caught Resident 1's arm and hand between the bar and chair. A review of the facility's PB22 (Provider Bulletin 22 form, a standardized Pennsylvania Department of Health document used to report and investigate allegations of abuse, neglect, or misappropriation of property in long-term care facilities) investigation of the above incident noted that the facility substantiated the allegation of staff-to-resident neglect and terminated Employee 1's employment at the facility. Review of Employee 1's (nurse aide) witness statement noted, I was in doing morning care and she (Resident 1) was trying to hit me and bite me. I put my hand over her hand to stop her from hitting me. She was swinging at me during care. I got her out of bed with the lift. I used the lift by myself. Review of Employee 1's personnel file revealed the facility hired her on April 7, 2026. Employee 1 received abuse training and completed a competency on transfers on April 7, 2026. Further review of Employee 1's personnel file revealed a mechanical lift competency was completed April 16, 2026. The facility completed an investigation into Resident 1's injury of unknown origin and allegation of only being transferred using one person instead of the two required and sustaining a fracture. The facility interviewed all staff working in the time frame surrounding the incident and determined Employee 1 did not follow Resident 1's plan of care regarding the mechanical lift for transfers with two people, and Employee 1 admitted there was not a second person present. Employee 1 was terminated from the facility on June 3, 2026. The Director of Nursing and Employee 2 (assistant director of nursing and nurse educator) provided staff on the spot education on using the correct transfer status when providing residents with care and transfers to all nursing care staff starting June 8, 2026. Education of all nursing care staff working in the facility was completed on June 25, 2026. Interview with the Nursing Home Administrator and Director of Nursing on July 15, 2026, at 12:49 PM confirmed these findings. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(b)(d) Staff development

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility and a resident pantry area on two of seven nursing units (Nursing Units 300 and 700). Findings include: Initial tour of the facility's main kitchen with Employee 6, Culinary Manager, on April 7, 2026, at 8:45 AM revealed the following: There were two storage containers of serving ware located under the dishwasher conveyor that Employee 6 identified as clean. The serving ware was not protected from contamination from the ambient environment. There were debris noted in multiple blue cups. Clear serving bowls had debris accumulated in them and several were wet. There was a black discoloration to areas of the ceiling in the dishwasher area especially where the ceiling met with the wall. There was peeling paint also noted where the ceiling met the wall. There was a significant accumulation of dust on two observed air vents in the ceiling above the dishwasher area. Two large garbage receptacles had broken and cracked lids. A fire extinguisher receptacle protective cover was broken. Several broken and jagged pieces of the plastic covering were found at the bottom of the fire extinguisher receptacle. An ice machine had a plastic food storage container on the floor behind it. There was a significant accumulation of debris on the floor between the right side of the ice machine and the wall. The walk-in freezer contained two cardboard boxes of cookies and a box of broccoli cuts that were open to ambient air. The walk-in cooler contained the following: two large plastic tub containers being used to hold drinks. The containers held various beverages that included cans of soda, milk cartons, and nutritional drinks. These tub containers were partially filled with opaque water that the drinks were partially immersed in. There was a box of mushrooms open to ambient air and a bucket container of pickle chips that had a black colored mold-like accumulation on portions of the perimeter near the lid. There were three open containers of Worcestershire sauce on a rack that held various spices that were past their use by dates of December 3, 2025, March 20, 2025, and June 27, 2025. A stainless-steel prep table with a sink adjacent to the walk-in cooler and freezer had an area with electrical outlets. The area surrounding the electrical outlets held a significant accumulation of various debris. The food warmer appliance had a significant accumulation of food stains and debris on the bumpers that surrounded it at the base of the unit. The entire side of the food warmer was sticky to the touch. An oven held various baking racks that were being stored on the top of it. There was a significant accumulation of dust and debris accumulated on the top of the oven. A storage rack that held various adaptive equipment on blue trays, that Employee 6 identified as clean, had various debris and dried stains on multiple trays. A stack of nosey cups (adaptive feeding cups) had moisture accumulated between them. There was a fork on one of the blue trays that had dried food debris on the tongs. The suction unit in the main dining room adjacent to the main kitchen had two packaged filters that had expired (one on May 26, 2025, and the other on April 10, 2025). There was a container of unopened sterile water that had expired on April 4, 2026. The above information was reviewed in a meeting with the Director of Nursing on April 8, 2026, at 2:45 PM. A review of the tray line food temperatures provided by Employee 6 for March 2026 revealed the following missing temperature documentation: March 1, 2026: dinner temperature documentation missingMarch 6, 2026: dinner temperature documentation missingMarch 8, 2026: no documentation for breakfast, lunch, dinner temperaturesMarch 12, 2026: dinner temperature documentation missingMarch 15, 2026: no documentation for breakfast, lunch, dinner temperaturesMarch 16, 2026: no documentation for breakfast, lunch, dinner temperaturesMarch 17, 2026: dinner temperature documentation missingMarch 20, 2026: dinner temperature documentation missingMarch 22, 2026: dinner temperature documentation missingMarch 23, 2026: dinner temperature documentation missingMarch 25, 2026: dinner temperature documentation missingMarch 27, 2026: dinner temperature documentation missingMarch 28, 2026: no documentation for breakfast, lunch, dinner temperaturesMarch 31, 2026: no documentation for breakfast, lunch, dinner temperatures The missing temperatures were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 9, 2026, at 2:30 PM. There was no evidence to indicated food temperatures were checked prior to serving. Observation of the 700 Nursing Unit resident pantry on April 9, 2026, at 11:19 AM revealed a plastic container of coffee with a manufacturer's best if used by date of June 4, 2023. This was reviewed with the Nursing Home Administrator on April 10, 2026, at 11:49 AM. Observation of the 300 Nursing Unit resident pantry on April 10, 2026, at 11:53 AM revealed a two percent unopened milk carton, a nutritional drink single-serve carton, and a cup of an orange-colored drink that were sitting on top of the microwave. All three drinks were warm to touch. The nutritional drink printed directions on the carton instructed to keep refrigerated. There were no staff at the pantry area at the time of the findings. The findings were reviewed with Employee 7, licensed practical nurse, who revealed the drinks now needed to be thrown out and proceeded to discard them. The Nursing Home Administrator and Director of Nursing were informed of the findings for the 300 Nursing Unit on April 10, 2026, at 11:56 AM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risk areas for entrapment for five of six residents reviewed for accident hazards (Residents 2, 7, 12, 14, and 97). Findings include: Review of the facility policy titled, Enabler Bar Policy and Procedures, last reviewed without changes on November 20, 2025, revealed (in part) that immediately after placement of assist bar(s) maintenance will conduct a bed inspection for bed entrapment points using the bed measurement device following the manufacturer's test methods inspection each zone (1-4). Zones 5, 6, and 7 must meet the required measurements as noted in this procedure. Zone 5 is defined in the policy as between split bedrails; and Zone 5 must be noted as, Not Applicable, if there are no split bedrails. Zone 6 is defined in the policy as between the end of the rail and the side edge of the head or footboard. The policy further notes that Zone 6 must be marked as Pass or Fail if noted measurements are not met. Clinical record review for Resident 2 revealed a medical history that included a fall, abnormalities of gait and mobility, difficulty in walking, muscle weakness, and need for assistance with personal care. Review of the current physician orders for Resident 2 revealed an order dated December 6, 2024, that noted the resident may use left enabler bar on bed for increased mobility in bed. Review of the current care plan for Resident 2 revealed that the resident has an activities of daily living (ADL) self-care deficit and an intervention included that the resident may use left enabler bar on bed for increased bed mobility. Observation and concurrent interview with Resident 2 on April 8, 2026 at 8:40 AM revealed that the resident had an enabler bar attached to the bed on the resident's left side. The bed had a headboard attached. The resident reported he utilized the enabler bar for increased mobility when in bed. Review of the facility documentation for Resident 2 titled, Bed System Measurement Device Test Results Worksheet, dated November 7, 2025, revealed that Does Not Apply was circled for the Zone 6 measurement. There was no further documentation to indicate that Zone 6 was assessed for potential risk of entrapment. Clinical record review for Resident 97 revealed a medical history that included abnormalities of gait and mobility, difficulty in walking, weakness, and need for assistance with personal care. Review of the current physician orders for Resident 97 revealed an order dated September 9, 2022, that noted the resident to utilize bilateral enabler bars for bed mobility. Review of the current care plan for Resident 97 revealed that the resident has an ADL self-care performance deficit related to ambulatory dysfunction and an intervention included bilateral enabler bars for bed mobility. Observation and concurrent interview with Resident 97 on April 7, 2026, at 12:26 PM revealed that the resident had bilateral enabler bars attached to the bed. The bed had a headboard attached. The resident reported he utilized the enabler bar for increased mobility when in bed. Review of the facility documentation for Resident 97 titled, Bed System Measurement Device Test Results Worksheet, dated February 10, 2026, revealed that Does Not Apply was circled for the Zone 6 measurement. There was no further documentation to indicate that Zone 6 was assessed for potential risk of entrapment. An interview with Employee 5, maintenance staff, on April 9, 2026, at 12:48 PM confirmed that Zone 6 was marked as not assessed for Resident 2 and 97 and all sheets were marked as does not apply. The above information for Residents 2 and 97 was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 9, 2026, at 2:30 PM. Observation of Resident 7's room on April 7, 2026, at 1:13 PM revealed that her bed was equipped with a headboard, a footboard, and a left-sided assist device. Clinical record review for Resident 7 revealed a, Bed System Measurement Device Test Results Worksheet, dated February 6, 2026, that staff documented, Does Not Apply, for the Zone 6 assessment. There was no further documentation to indicate that Zone 6 was assessed for potential entrapment risks. Observation of Resident 14's room on April 7, 2026, at 11:42 AM revealed that her bed was equipped with a headboard, a footboard, and assist devices bilaterally at the head of her bed. Clinical record review for Resident 14 revealed a, Bed System Measurement Device Test Results Worksheet, dated February 6, 2026, that staff documented, Does Not Apply, for the Zone 6 assessment. There was no further documentation to indicate that Zone 6 was assessed for potential entrapment risks. Observation of Resident 12's room on April 8, 2026, at 11:20 AM revealed the left side of her bed against the wall and her bed was equipped with a headboard, a footboard, and an enabler device mounted to the right side of her bed. Clinical record review for Resident 12 revealed an active physician order dated February 24, 2026, for the use of a right enabler bar to her bed.A, Bed System Measurement Device Test Results Worksheet, dated February 6, 2026, documented an assessment that Zone 6, Does Not Apply, for Resident 12. There was no further documentation to indicate that Zone 6 was assessed for potential entrapment risks. Interview with Employee 5 on April 9, 2026, at 10:49 AM indicated that staff visually determined Zone 6 as large enough for Residents 7, 12, and 14; therefore marked, Does Not Apply. He confirmed that the residents reviewed have a headboard and an edge to an assistive device; therefore, that Zone 6 does apply to those residents and should have a documented assessment. The interview confirmed that the response, Does Not Apply, is correct for Zone 5 as no resident utilized a split rail system. The surveyor reviewed the concerns that the facility did not document an appropriate entrapment risk assessment for Zone 6 for Residents 7, 12, and 14, during an interview with the Nursing Home Administrator and the Director of Nursing on April 9, 2026, at 2:30 PM. 483.25(n)(1) Bed RailsPreviously cited deficiency 5/23/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an allegation of resident-to-resident physical abuse for one of 26 records reviewed (Resident 128).Findings include: The facility policy entitled Abuse Prevention/ Elder Justice Act Suspicious Crime Reporting, last reviewed without changes November 20, 2025, revealed all residents of the facility have the right to live without fear of abuse. All nursing staff are required to immediately report residents found to have a bruise, other unexplained new mark, skin tear, or wound. An incident report is completed to document and investigate the findings. Employees are required to timely report any reasonable suspicion of resident abuse, neglect, or misappropriation of property to their supervisor, the Director of Nursing, the Compliance officer, Nursing Home Administrator. If the events that cause reasonable suspicion do not result in serious bodily injury to the resident, the report must be made not later than 24 hours after forming the suspicion. The facility will make a written report through ERS (event reporting system) within 24 hours, an oral report to the Area Agency on Aging and local law enforcement immediately. The registered nurse supervisor will complete an incident report which will include the name of all the witnesses, a description of the event, and the extent of the resident's injuries. When abuse or neglect is suspected, immediate measures must be taken to protect the resident. Monitoring of the resident will be initiated. Individualized care plans may need to be revised. Clinical record review for Resident 128 revealed nursing documentation dated March 16, 2026, at 6:47 PM noting Resident 128 was sitting at the table eating supper when another resident became agitated, reached across the table, and hit Resident 128 across the face. The assessment revealed initially Resident 128's right cheek appeared slightly bruised and reddened. Review of the facility investigation dated March 16, 2026, revealed no witness statements. The interdisciplinary team review dated March 20, 2026, revealed this was an isolated incident with no injuries, and the residents were separated. Interview with the Director of Nursing and Nursing Home Administrator on April 9, 2026, at 2:30 PM confirmed that the facility did not report Resident 128's resident-to-resident physical abuse to the appropriate authorities. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(8) Personnel policies and procedures

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain policies and procedures that each resident is offered a pneumococcal immunization per current Centers for Disease Control (CDC) guidelines; and failed to ensure that the resident's medical record included required documentation related to pneumococcal immunizations for one of five residents reviewed for immunization concerns (Resident 14).Findings include: Review of the facility's policy entitled, Influenza, RSV, Pneumococcal and COVID-19 Vaccination, last reviewed on March 14, 2025, revealed that a resident may receive a Pneumovax23 or Prevnar13 (PCV13) pneumococcal vaccine (once per lifetime or after five years if age [AGE] years of age or less following the first immunization). Upon admission, the resident will be screened to determine if they are current on pneumococcal immunizations and consent for pneumococcal vaccination will be obtained from the resident/responsible party. Documentation of vaccinations and consent will be maintained in the resident's medical record. The pneumococcal immunization status of all residents will be determined on admission. A pneumococcal vaccination, Pneumovax23 (PPSV23), will be offered to all residents who cannot provide documentation of previous vaccination. The routine vaccination schedule indicated that for those age [AGE] years or older, one PPSV23 dose would be administered at least five years after the previous dose if the first dose was received before age [AGE]. Based on shared clinical decision-making, one dose of PCV13 would be administered if not previously received and at least one year elapsed since a previous vaccination. The immunization record of all residents in the facility will be reviewed each year in the fall. Current CDC website information notes that there are four pneumococcal vaccines available in the United States. Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20 (Prevnar20), and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). Each of these vaccines helps protect against specific serotypes, or strains, of pneumococcal bacteria. The number at the end of the vaccine name tells how many strains the vaccine includes. CDC Pneumococcal Vaccine Timing for Adults (https://www-new.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf) instructs that a complete series would be a PCV13 (Prevnar 13, pneumococcal conjugate vaccine) at any age, a PPSV23 (Pneumovax 23, pneumococcal polysaccharide vaccine) at greater than or equal to 65 years, and together with the resident, vaccine providers may choose to administer PCV20 (Prevnar 20, 20-valent pneumococcal conjugate vaccine) or PCV21 (CAPVAXIVE, 21-valent conjugate vaccine) to adults greater than or equal to [AGE] years old who have already received the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The CDC stipulates that, Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. The facility's pneumococcal immunization policy did not incorporate current CDC recommendations for pneumococcal immunizations. The surveyor reviewed the above concern regarding the pneumococcal immunization policy developed by the facility during an interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2026, at 8:55 AM. The surveyor requested that the facility provide instruction where to find in residents' medical records documentation that: the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal during interviews with the Director of Nursing on April 7, 2026, at 8:50 AM; April 8, 2026, at 2:45 PM; and April 9, 2026, at 2:30 PM. The interviews indicated that all documentation related to residents' immunization status should be scanned into the residents' electronic medical record. Clinical record review for Resident 14 revealed that she received her most recent pneumococcal immunization before her admission to the facility which was a Pneumovax (PPSV23) vaccine on October 23, 2023 (when she was [AGE] years old). There was no evidence available to indicate that the facility educated Resident 14 or her representative regarding the most current CDC guidelines related to pneumococcal immunizations (PCV15, PCV20, or PCV21), the risks and benefits of updating her pneumococcal immunization, or that Resident 14 or her representative declined or authorized the administration of a pneumococcal immunization. Interview with Employee 8 (licensed practical nurse/infection control prevention coordinator) on April 10, 2026, at 12:40 PM confirmed that the facility's active pneumococcal immunization policy did not incorporate current CDC recommendations. The interview indicated that she possessed documentation in a folder in her office that Resident 14 declined a pneumococcal immunization September 26, 2025 (more than six months earlier), however, this documentation was not included in either Resident 14's electronic or physical medical record available to facility staff. The surveyor reviewed the above concerns related to the facility's pneumococcal immunization policy and the documentation not available for the surveyor's review for Resident 14 per regulatory requirements during an interview with the Nursing Home Administrator on April 10, 2026, at 1:47 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f)(i)-(xi) 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 ensure an environment free from the potential spread of infection related to indwelling catheter equipment for one of two residents reviewed for catheter concerns (Resident 11), respiratory equipment for one of two residents reviewed for respiratory concerns (Resident 139), and laundry processing in the facility's main laundry facilities.Findings include: Interview with Employee 8 (licensed practical nurse/infection control prevention coordinator) on April 10, 2026, at 12:40 PM revealed that the facility had no established policy or employee competency guideline that addressed the appropriate steps to ensure indwelling urinary catheter equipment remained free of contamination when not in use. The interview confirmed that the facility provided care to residents who exchange a smaller urinary collection (e.g., leg) bag during the day with a larger urinary collection bag overnight. Clinical record review for Resident 11 revealed active physician orders dated February 17, 2026, for staff to implement a Foley catheter (thin tube that goes in through the urethra and up to the bladder to drain urine) due to obstructive uropathy related to benign prostatic hypertrophy (an enlarged prostate gland restricts the flow of urine out of the bladder through the urethra). An active physician order dated February 17, 2026, instructed staff to attach the Foley catheter to a leg bag when Resident 11 was out of bed. Observation of Resident 11's bathroom on April 8, 2026, at 10:59 AM with Employee 10 (nurse aide) revealed a large, open, plastic bag tied to an assist bar near the toilet that contained a large urinary collection bag and tubing. The end of the tubing (that would connect to Resident 11's Foley catheter) was not covered or capped to prevent potential environmental contamination. Observation of Resident 11's bathroom on April 10, 2026, at 12:23 PM with Employee 11 (nurse aide) revealed that staff continued to store Resident 11's large urinary collection bag and tubing in the open plastic bag without an intervention (e.g., cap) to prevent potential environmental contamination of the connector end when not in use. The surveyor reviewed the above concerns regarding Resident 11's Foley catheter equipment storage during an interview with the Nursing Home Administrator on April 10, 2026, at 1:47 PM. Observation of the facility's main laundry facility with Employee 9 (laundry/housekeeping) on April 10, 2026, at 1:11 PM revealed that staff utilized large yellow bins to transport clean laundry from the washers to the dryers and from the dryers to the sorting area. Employee 9 stated that they are, labeled, to ensure that the yellow bins are used only for clean laundry. Observation of the room that contained the facility's washers on April 10, 2026, at 1:18 PM revealed a yellow bin labeled, Clean, that contained residents' personal laundry. Interview with Employee 9 on the date and time of the observation revealed that the laundry was not processed yet (was dirty/soiled laundry) waiting for staff to load into the washer. Employee 9 confirmed that the laundry stored in the Clean, bin was not, in fact, cleaned. The surveyor reviewed the concerns identified in the facility's main laundry facility during an interview with the Nursing Home Administrator on April 10, 2026, at 1:47 PM. Observation of Resident 139's room on April 7, 2026, at 11:05 AM revealed a respiratory mask hanging, uncovered, from a drawer in her bedside stand. Observation of Resident 139's room on April 8, 2026, at 11:15 AM again revealed the respiratory mask hanging, uncovered, from a drawer in her bedside stand. Interview with Employee 1 (licensed practical nurse) on April 8, 2026, at 11:34 AM revealed that the respiratory mask was utilized for Resident 139's CPAP (machine takes in room air, filters and pressurizes it, before delivering it through a tube and mask to the resident) treatments, and that it should be in a black bag to protect it from potential environmental contaminants. Employee 1 placed the mask in a black bag hanging from Resident 139's oxygen room concentrator machine (medical device that takes in room air, concentrates the oxygen concentration, and delivers it back to the resident via tubing and a mask or nasal prongs) and stored the equipment on Resident 139's bedside stand (available for use). Employee 1 stated that a respiratory therapist provides Resident 139's equipment. A physician's order dated October 17, 2024, implemented the use of a CPAP with supplemental oxygen every evening and night shift until discontinued February 16, 2026. Review of Resident 139's Treatment Administration Record (electronic documentation completed by licensed staff to attest to the implementation of care) dated February 2026 revealed that Resident 139's CPAP treatment was no longer implemented after February 15, 2026. Interview with the Director of Nursing on April 9, 2026, at 8:49 AM confirmed that staff failed to remove, or store appropriately, Resident 139's CPAP equipment when her physician discontinued the treatment more than seven weeks earlier. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 5/23/26 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to implement treatment and assistive devices to maintain vision and hearing abilities for two of two residents reviewed for vision and hearing concerns (Residents 56 and 139).Findings include: Interview with Resident 56 on April 7, 2026, at 11:17 AM revealed that she had no professional eye appointments since her admission to the facility. Clinical record review for Resident 56 revealed that the facility admitted her on May 30, 2025. Review of Resident 56's diagnoses list indicated that she was diagnosed with essential hypertension (high blood pressure) and Parkinsonism (progressive neurological disorder that is characterized by degeneration of nerve cells in the brain). Both diagnoses risk damage to the eyes. Information available at https://www.parkinson.org/ (Parkinson's Foundation) included that Parkinson's can cause vision changes such as double vision, dry eyes, blurry vision, trouble reading, and difficulty opening the eyes. Some issues may be worsened by medications used to treat the condition. Management strategies include regular eye exams. Review of Resident 56's medication regime revealed the use of Sinemet 25-100 mg (Carbidopa-Levodopa, medication used to treat Parkinson symptoms such as muscle stiffness, tremors, spasms, and poor muscle control) three times a day since September 12, 2025. Information available at https://www.rxlist.com/sinemet-drug.htm (RX List) noted that blurred vision was one of the possible side effects from the use of Sinemet. Other adverse reactions that have been reported with Sinemet use include blepharospasm (involuntary, uncontrollable spasm or twitching of the eyelid muscles that can range from mild blinking to severe eyelid closure which may be taken as an early sign of excess dosage), oculogyric crises (an acute reaction in which the eyes deviate upward, usually in a sustained, involuntary fashion, often accompanied by discomfort or agitation), diplopia (double vision), blurred vision, and dilated pupils. The surveyor reviewed concerns of the lack of professional eye care while Resident 56 resided in the facility since May 30, 2025, during an interview with the Director of Nursing on April 8, 2026, at 2:45 PM. The surveyor requested evidence that Resident 56 declined professional eye care services or was provided professional eye care services since her admission to the facility. Documentation by medical records staff dated April 8, 2026, at 4:08 PM (following the surveyor's questioning) indicated the first conversation facility staff conducted with Resident 56 regarding professional eye care. Interview with the Nursing Home Administrator and the Director of Nursing on April 9, 2026, at 2:30 PM revealed that the facility has no contracted professional eye care provider. The interview indicated that staff who interview residents and/or their responsible parties on admission ask if there is a provider currently providing professional eye care services; however, may not offer the facility's services to arrange professional eye care. The interview confirmed that the facility staff who interviewed Resident 56 after the surveyor's questioning (medical records staff) would not have knowledge of Resident 56's risk factors for eye disease and would not have reviewed the risks and benefits of an eye exam at the time of the conversation. The facility had no evidence that Resident 56 declined professional eye care before the surveyor's questioning. Interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2026, at 8:55 AM confirmed that the facility had no policy regarding the provision of routine professional eye services. Interview with Resident 139 on April 7, 2026, at 10:48 AM revealed that Resident 139 was very hard of hearing, and she required multiple repetitions of questions in louder volumes to respond appropriately. Resident 139 stated that she did not know where her hearing aids were. Interview with Resident 139 on April 8, 2026, at 11:15 AM again indicated that she did not have her hearing aids and that she was very hard of hearing. Interview with Employee 1 (licensed practical nurse) on April 8, 2026, at 11:34 AM revealed that staff do not give Resident 139 her hearing aid unless she asks for it. Staff store the hearing aid in the nursing unit's treatment room. Task documentation (a list of resident care needs available to nurse aide staff that provide care) active for Resident 139 during the onsite survey revealed that Resident 139 required a hearing aid in her left ear that would be implemented by nurse aide, licensed practical nurse, and registered nurse staff. Review of plans of care developed by the facility to identify Resident 139's care needs and list interventions implemented to meet those needs included no reference to hearing aid use. Review of Medication Administration and Treatment Administration Records (electronic documentation completed by licensed staff to attest to the provision of care) dated April 2026 revealed no reference to Resident 139's hearing aid use. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 16, 2026, assessed Resident 139 with adequate hearing without the use of a hearing aid. The assessment indicated that the facility did not proceed to a care plan to address hearing concerns for Resident 139. Resident Assessment Instrument (RAI) instructions to complete Section B0200: Hearing of the MDS includes to, Ensure that the resident is using their normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. Staff failed to ensure Resident 139's use of a hearing aid during completion of the MDS assessment and failed to note any hearing difficulty to appropriately develop a plan of care to address her communication deficit and use of hearing aids. Nursing documentation dated April 2, 2026, at 11:52 AM noted that Resident 139 was hard of hearing but that she did not have her hearing aids present. Interview with the Director of Nursing and the Nursing Home Administrator on April 9, 2026, at 2:30 PM indicated that staff discontinued a physician order to ensure a right and left hearing aid was put in Resident 139's ears in the morning every day when she was hospitalized (March 29, 2026) and did not resume the treatment order upon her return to the facility (April 2, 2026). 28 Pa. Code 201.21(c) Use of outside resources 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop, revise, and ensure resident/resident representative participation in care plan decisions for four of 26 residents reviewed (Residents 11, 12, 82, and 139)Findings include: Clinical record review for Resident 11 revealed nursing documentation dated December 29, 2025, at 3:35 PM that Resident 11 was on his knees in front of a standard chair, his arms braced on the arms of the chair. Review of the facility's incident/accident investigation dated December 29, 2025, indicated that per the interdisciplinary team review, physical therapy would screen Resident 11 in response to his fall. A physical therapy response dated December 29, 2025, indicated that staff gave Resident 11 a, reacher (handheld assistive tool designed to help individuals pick up or reach objects without bending or stretching) to utilize in order to increase safety. Review of Resident 11's plans of care that included one to address his potential for falls related to immobility and ambulatory disfunction revealed that the facility did not revise his care plans to include the reacher intervention. Interview with Resident 139 on April 7, 2026, at 10:54 AM revealed that she had no recollection of attending care plan meetings. Clinical record review for Resident 139 revealed an MDS assessments (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) as follows that assessed her without cognitive deficits (BIMS, Brief Interview for Mental Status, scores of 13 to 15 out of 15): Quarterly MDS October 10, 2024, BIMS score 15Quarterly MDS January 2, 2025, BIMS score 14Annual MDS March 17, 2025, BIMS score 15Quarterly MDS June 9, 2025, BIMS score 13Quarterly MDS September 1, 2025, BIMS score 14Quarterly MDS November 24, 2025, BIMS score 15Annual MDS February 16, 2026, BIMS score 14 Care conference meeting documentation on the following dates and times noted that Resident 139 did not attend: February 25, 2026, at 1:00 PMDecember 3, 2025, at 1:06 PMSeptember 10, 2025, at 1:00 PMJune 18, 2025, at 1:19 PM Interview with the Director of Nursing and the Nursing Home Administrator on April 10, 2026, at 8:55 AM confirmed that the facility had no documentation in the medical record of the reasons (including the steps the facility took to include the resident) Resident 139 did not participate in her care plan meetings. Observation of Resident 139's room on April 7, 2026, at 11:05 AM and April 8, 2026, at 11:34 AM revealed a respiratory mask hanging from the drawer of her bedside stand. Interview with Employee 1 (licensed practical nurse) during the observation on April 8, 2026, at 11:34 AM revealed that the respiratory mask was utilized for Resident 139's CPAP (machine takes in room air, filters and pressurizes it, before delivering it through a tube and mask to the resident) treatments, and that it should be in a black bag to protect it from potential environmental contaminants. Employee 1 placed the mask in a black bag hanging from Resident 139's oxygen room concentrator machine (medical device that takes in room air, concentrates the oxygen concentration, and delivers it back to the resident via tubing and a mask or nasal prongs) and stored the equipment on Resident 139's bedside stand (available for use). Employee 1 stated that a respiratory therapist provides Resident 139's equipment. Review of a plan of care initiated by the facility on October 10, 2024, indicated that Resident 139 utilized a CPAP with supplemental oxygen at hour of sleep due to her fluctuating respiratory status related to COPD (chronic obstructive pulmonary disease, group of lung diseases that cause airflow blockage and breathing-related problems) and sleep apnea (condition that causes breathing to stop and start multiple times during sleep) since January 3, 2025. A physician's order for Resident 139 to utilize a CPAP with supplemental oxygen every evening and night shift was discontinued on February 16, 2026. Interview with the Director of Nursing on April 9, 2026, at 8:49 AM confirmed that the facility failed to revise Resident 139's plan of care when the physician discontinued the intervention. Interview with Resident 139 on April 7, 2026, at 10:48 AM and April 8, 2026, at 11:15 AM revealed that she had difficulty hearing. Resident 139 stated that she utilized hearing aids, but she did not know where they were during both interview occasions. Interview with Employee 1 on April 8, 2026, at 11:34 AM confirmed that Resident 139 had a hearing aid, however, staff did not provide it to her unless she requested it. Staff store the hearing aid in the locked treatment room. Review of plans of care developed by the facility to address Resident 139's treatment needs revealed no intervention that pertained to Resident 139's hearing loss, use of hearing aid device(s), or history of lost/broken hearing aids. Hospital History and Physical documentation dated March 27, 2026, noted, (Resident 139) also is extremely hard of hearing. Observation of Resident 82's room on April 7, 2026, at 12:19 PM revealed a pacemaker (medical device implanted under the skin that helps regulate the heart's rhythm by providing electrical impulses to the heart muscle) monitoring machine at his bedside. Clinical record review for Resident 82 revealed an active physician's order that Resident 82 had a scheduled appointment for a cardiac device check at the hospital on April 16, 2026. Review of Resident 82's plans of care revealed a plan of care initiated by the facility on March 25, 2026, to address Resident 82's altered cardiovascular status related to CHF (congestive heart failure, insufficient functioning of the heart that results in excessive fluid in the body), hypertension (high blood pressure), A-Fib (atrial fibrillation, abnormal heart rhythm that results in ineffective blood circulation out of the heart), and pacemaker. The plans of care available for Resident 82 did not include the use of the cardiac pacemaker monitoring machine. Interview with the Nursing Home Administer and the Director of Nursing on April 9, 2026, at 2:30 PM reviewed concerns regarding the available care plan information for Resident 82's pacemaker monitoring device. Interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2026, at 8:55 AM confirmed that the facility had not incorporated information regarding Resident 82's pacemaker monitoring machine into his plan of care until following the surveyor's questioning. Resident 82's available plan of care did not stipulate how the transmitter transmits (e.g., cell phone connection or Wi-Fi), what, if any interventions are implemented in the event of a power or Wi-Fi service interruption, or Resident 82's expected heart rate parameters (e.g., 70 to 90 beats per minute). Clinical record review for Resident 12 revealed an active physician order dated February 24, 2026, that staff ensure the application of supplemental oxygen at two liters per minute continuously. Observation of Resident 12's room on April 8, 2026, at 11:14 AM revealed a room concentrator running to administer supplemental oxygen to Resident 12. Clinical record review for Resident 12 revealed that she had no plan of care that indicated she used supplemental oxygen. Interview with the Director of Nursing on April 10, 2026, at 10:00 AM confirmed that the facility did not implement Resident 12's supplemental oxygen use in her plan of care until after the surveyor's questioning. 483.21(b)(2)(i-iii) Care Plan Timing and RevisionPreviously cited deficiency 5/23/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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 status for two of 26 residents reviewed (Residents 40 and 139).Findings Review of a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated October 26, 2025, revealed staff assessed Resident 40 as having no impairments of her lower extremities. Review of Resident 40's next quarterly MDS dated [DATE], staff assessed Resident 40 as having bilateral impairment to her lower extremities. Interview with Employee 4 (LPNAC) on April 10, 2026, at 10:55 AM revealed that Resident 40 did not have a decline in her range of motion. Employee 4 confirmed Resident 40's functional limitation in her range of motion was coded in error on the MDS dated [DATE]. The above findings for Resident 40 were reviewed with the Director of Nursing on April 10, 2026, at 11:32 AM. The facility failed to accurately assess Resident 40's MDS assessments as noted above. Interview with Resident 139 on April 7, 2026, at 10:48 AM revealed that she had difficulty hearing. Resident 139 stated that she utilized hearing aids, but she did not know where they were at that time. Clinical record review for Resident 139 revealed a physician order active October 16, 2025, to March 29, 2026, for staff to ensure a right and left hearing aid is put in Resident 139's ears in the morning every day shift for hearing aid use. An annual MDS dated [DATE], assessed Resident 139 with adequate hearing without the use of a hearing aid. The assessment indicated that the facility did not proceed to a care plan to address hearing concerns for Resident 139. Resident Assessment Instrument (RAI) instructions to complete Section B0200: Hearing of the MDS includes to, Ensure that the resident is using their normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. Hospital History and Physical documentation dated March 27, 2026, noted, (Resident 139) also is extremely hard of hearing. Staff failed to ensure Resident 139's use of a hearing aid during completion of the MDS assessment and failed to note any hearing difficulty to appropriately develop a plan of care to address her communication deficit and use of hearing aids. Interview with the Nursing Home Administrator and the Director of Nursing on April 9, 2026, at 2:30 PM confirmed the above findings for Resident 139. 28 Pa. Code 211.5(f)(ix) Medical records 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 that active physician orders incorporated resident wishes related to end-of-life care for two of four residents reviewed for advanced directives concerns (Residents 7 and 56). Findings include: Clinical record review for Resident 56 revealed an active physician order dated May 30, 2025, for staff to implement full treatment in the event of a medical emergency (Full Code, chest compressions and breathing assistance). Resident 56's clinical record also included an active physician order dated June 2, 2025, for staff to implement DNR (Do Not Resuscitate, do not provide chest compressions or assist with breathing) directives in the event of a medical emergency. There was no POLST (Physician Orders for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) form in Resident 56's medical record. Interview with Employee 1 (licensed practical nurse) on April 8, 2026, at 11:25 AM confirmed that there was no POLST form in Resident 56's physical or electronic medical record. Employee 1 stated, I know she's DNR because it's in the computer. Employee 1 then verified that there were two active physician orders related to code status for Resident 56: one to provide full treatment and one to provide no treatment. Physician documentation dated June 2, 2025, at 12:00 PM indicated that Resident 56 wished to be DNR. The facility failed to ensure that an updated end-of-life decision order was fully implemented; both physician orders were readily accessible to facility staff for Resident 56. Interview with the Nursing Home Administrator and the Director of Nursing on April 9, 2026, at 2:30 PM confirmed the above findings for Resident 56. Clinical record review for Resident 7 revealed an active physician order dated April 12, 2023, for staff to implement full treatment in the event of a medical emergency. There was no POLST in Resident 7's electronic or physical medical record. Interview with Employee 2 (licensed practical nurse) and Employee 3 (licensed practical nurse) on April 8, 2026, at 10:21 AM confirmed that Resident 7 did not have a POLST in either her electronic or physical medical record.The surveyor requested evidence that Resident 7 and/or her responsible party made the decision for full treatment in the event of a medical emergency during interviews with the Director of Nursing on April 8, 2026, at 2:45 PM and April 9, 2026, at 2:30 PM. Progress note documentation by Resident 7's physician dated April 9, 2026, at 5:11 PM (following the surveyor's questioning on April 8 and 9, 2026) noted a conversation with Resident 7's parents confirmed their wishes for full treatment. The facility failed to document the communication with the resident or resident's representative that evidenced the end-of-life care decision executed before the surveyor's questioning. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage at the observed facility trash dumpster.Findings include: Observation of the facility's main dumpster on April 7, 2026, at 9:00 AM revealed the following: There were multiple medical gloves in the grass area adjacent to the dumpster. There was various debris on the ground that included a crumpled cigarette pack, a discarded spoon, and additional debris. There was a mattress discarded on the ground in the grass area adjacent to the dumpster. The mattress top had water and dead leaves accumulated on the top of it. The above information was reviewed in a meeting with the Director of Nursing on April 8, 2026, at 2:45 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in one of one area reviewed (main lobby). Findings include: Observation of the main lobby of the facility on April 7, 2026, at 2:20 PM revealed a binder in a wall pocket that was titled, Department of Health Survey / Notice of Privacy Practices, that should contain the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Further review of the binder revealed that the most recent survey was dated July 28, 2023. These findings were reviewed with the Nursing Home Administrator on April 7, 2026, at 2:23 PM. A follow-up interview with the Nursing Home Administrator on April 7, 2026, at 2:31 PM revealed that the recent survey results were not printed and placed in the binder. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to immediately notify a resident's representative of a change in a resident's condition for one out of three residents reviewed (Resident CR1).Findings include: Closed record review for Resident CR1 revealed that the resident had a diagnosis list that included atrial fibrillation (an irregular heart rhythm). Physician orders for Resident CR1 revealed an order dated June 6, 2024, at 8:00 PM for Apixaban (Eliquis; an anticoagulant medication that is used to treat and prevent blood clots) oral table five milligrams (mg) given one table by mouth every 12 hours for atrial fibrillation. A review of the November 2025 medication administration record (MAR) for Resident CR1 revealed that staff were documenting the medication as administered per the physician order. Resident CR1's care plan revealed a care plan created on May 31, 2024, that indicated the resident was on anticoagulant therapy related to atrial fibrillation. Nursing documentation for Resident CR1 dated December 1, 2025, at 3:46 AM revealed that staff were assisting the resident from the wheelchair to the toilet. When standing the resident bent forward and hit her head on the wall and received a three-centimeter (cm) by three-centimeter hematoma (a collection of blood outside of a blood vessel) on the left side of the forehead and a skin tear to the right upper shin. Further review of nursing documentation for Resident CR1 dated December 1, 2025, at 3:55 AM revealed that the resident hit her head during a transfer onto the toilet and received a skin tear on the right shin and a three-centimeter hematoma to the right forehead. Neuro checks (assessments that evaluate an individual's brain function and mental status) were initiated but the resident was uncooperative to pupil checks and would not squeeze hands to check hand grasps. Medical provider documentation dated December 1, 2025, at 10:45 AM revealed that Resident CR1 was evaluated to follow-up on the right leg wound and AMS (altered mental status) noted above. The documentation noted the resident fell and hit head this morning, on Eliquis, and that the resident had a hematoma to the right upper forehead. The medical provider recommended transfer to ER for further evaluation and treatment. Nursing documentation dated December 1, 2025, at 10:54 AM for Resident CR1 again noted the resident has a hematoma on the forehead, is on Eliquis, and a new order was received to send the resident to the emergency room for evaluation and treatment and that staff spoke with the resident's family who agreed. Nursing documentation for Resident CR1 dated December 3, 2025, at 1:00 PM revealed that staff spoke with the resident's representative who was upset because they were not called when the resident hit her head causing a hematoma and should have been sent to the hospital ASAP (as soon as possible). There was no evidence to indicate Resident CR1's responsible party was notified of the incident that occurred on December 1, 2025, at 3:46 AM resulting in an injury which later required transfer to the hospital for further assessment until December 1, 2025, at 10:54 AM, when the resident was being transferred to the hospital, nearly seven hours after the incident/injury occurred. The facility failed to immediately notify the resident's responsible party of an accident involving the resident which resulted in injury and had the potential to require physician intervention. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 29, 2026, at 4:20 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 7 residents reviewed for accident hazards (Residents 14, 44, 85, 102, 113, and 230). Findings include: Review of the facility's current policy entitled Maintenance Enabler Bar Procedure last reviewed November 20, 2024, revealed it is the facility policy that maintenance will place assist bars on the resident's bed and immediately conduct a bed inspection for bed entrapment points using a bed measurement device following the manufacturer's test methods to inspect each zone. The zones were not specified. Observation of Resident 102's room on May 20, 2025, at 10:51 AM revealed an enabler bar attached to the right side of the resident's bed. Resident 102 stated it was put there to help her in bed because she had falls. Review of facility documents revealed facility staff completed an enabler bar entrapment evaluation for Resident 102 on March 14, 2025, which revealed facility staff assessed the resident's right side enabler bar indicating it passed for no potential entrapment for zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail, and four (between the top of the compressed mattress and the bottom of the rail at the end of the rail). There was no documentation that the facility assessed zone six (between the end of the rail and the side edge of the head or foot board) for potential entrapment. Observation of Resident 44's room on May 21, 2025, at 8:28 AM revealed an enabler bar placed on the right side of the bed. The resident indicated it helped her get out of bed. Review of an enabler bar entrapment evaluation for Resident 44 dated March 14, 2025, revealed facility staff assessed and passed the resident's right side enabler bar for entrapment risk in zones 1-4, but they did not assess the resident's risk for entrapment at zone 6. In an interview with Employee 2 , director of facilities management, on May 22, 2025, at 10:45 AM revealed the maintenance staff assess the resident's risk of entrapment when enabler bars are placed assessing zones 1-4 with the bed rail measurement device tool, but did not specifically assess zone 6, the area between top of the bed end of the rail to the headboard of the bed for risk of entrapment. Facility staff updated Resident 102's entrapment zone risk assessment to include zone 6 as passing for any entrapment risk after the above interview with Employee 2. The above information was reviewed during an interview with the Nursing Home Director and the Director of Nursing on May 22, 2025, at 2:30 PM. Clinical record review for Resident 14 revealed a current physician's order dated May 15, 2025, (same day as her readmission from the hospital) for bilateral enabler bars to her bed. Observation of Resident 14 on May 20, 2025, 11:30 AM revealed she was sitting in a chair in her room beside her bed. Her bed was noted to have bilateral enabler bars on it. Resident 14 indicated that she had the enabler bars for a long time, and she uses them to help move in bed and to help her get out of bed. Review of an enabler bar entrapment evaluation for Resident 14 dated March 14, 2024, revealed facility staff assessed and passed the resident's right and left side enabler bar for entrapment risk in zones 1-4, but they did not assess the resident's risk for entrapment at zone 6. Interview with Nursing Home Administrator on May 22, 2025, at 2:45 PM confirmed that the facility does not measure zone 6. 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 a 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. Observation of Resident 85's room on May 20, 2025, at 1:11 PM revealed assist bar devices located bilaterally at the head of his bed. Resident 85's bed was equipped with a headboard and footboard. Clinical record review of an active physician's order dated June 3, 2024, instructed that Resident 85 may have bilateral enabler bars on his bed. Review of a Bed System Measurement Device Test Results Worksheet dated March 14, 2025, indicated that facility staff assessed zones one through four for entrapment risks. Resident 85's clinical record did not indicate that the facility assessed the gap between the edge of the assist bar and Resident 85's headboard (zone six) for possible entrapment risks. Observation of Resident 113's room on May 21, 2025, at 8:56 AM revealed assist bar devices located bilaterally at the head of his bed. Resident 113's bed was equipped with a headboard and footboard. Clinical record review for Resident 113 revealed an active physician's order dated April 25, 2025, for bilateral enabler bars to Resident 113's bed. Review of a Bed System Measurement Device Test Results Worksheet dated April 26, 2025, indicated that facility staff assessed zones one through four for entrapment risks. Resident 113's clinical record did not indicate that the facility assessed zone six for possible entrapment risks. Observation of Resident 230's room on May 21, 2025, at 10:41 AM revealed assist bar devices located bilaterally at the head of her bed. Resident 230's bed was equipped with a headboard and footboard. Clinical record review for Resident 230 revealed an active physician order dated May 9, 2025, for bilateral enabler bars to her bed. Review of a Bed System Measurement Device Test Results Worksheet dated May 9, 2025, indicated that facility staff assessed zones one through four for entrapment risks. Resident 230's clinical record did not indicate that the facility assessed zone six for possible entrapment risks. The surveyor reviewed the above concerns regarding the assist bar assessments for Residents 85, 113, and 230 during an interview with the Nursing Home Administrator, the Director of Nursing, Employee 5 (assistant director of nursing), and Employee 1 (infection preventionist), on May 22, 2025, at 2:30 PM. The surveyor requested the identification of the facility's bed and assist bar manufacturer. The facility did not provide the manufacturer's identification information during the onsite survey. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff and resident interview it was determined that the facility failed to ensure the highest practicable care for three of 35 residents reviewed (Residents 40, 230, and 94). Findings include: The facility policy entitled, Verbal, Telephone, and Written Physician Orders, last reviewed November 21, 2024, revealed that a physician's verbal or telephone order will be given to a licensed nurse and be immediately recorded on the resident's medical record by that licensed nurse. Telephone orders for medical treatment will be accepted only under circumstances where it is impractical for the orders to be given in a written manner by the responsible practitioner, when the judgement of the professional nurse and the situation requires expedient action, or when the physician calls the facility and requests that a telephone order be accepted. The facility policy entitled, Skin Tears, Risk Reduction, last reviewed November 21, 2024, revealed that treatment of existing skin tears will be outlined in the Risk Reduction/Wound Care Protocol or as ordered by the physician. Weekly skin checks will be completed by the licensed nursing staff in concert with the resident shower/bath. Identified areas of concern will be reported to the registered nurse. Protocol Two, Skin Tears, Cuts, Abrasions, stipulated that treatment would include a wound cleanser and an Aquacel foam dressing (dressing that has a soft absorbent foam pad that gels on contact with wound drainage to maintain a moist wound environment, a silicone adhesive, and a waterproof/bacteria barrier). Clinical record review for Resident 40 revealed nursing documentation by the registered nurse (RN) dated May 18, 2025, at 7:57 PM that his daughter noted blood on his pant leg. Staff assessed two skin tears on Resident 40's left leg, calf area. The staff cleansed the wound with wound wash and applied a Tegaderm dressing (transparent film dressing that does not have a foam pad or materials that would gel on contact with wound drainage). The documentation did not indicate that the licensed nurse contacted Resident 40's physician or that Resident 40's physician provided an order for the wound treatment that prompted nursing staff to implement a dressing different from that stipulated in the wound care protocol noted above. Nursing documentation by Employee 3, licensed practical nurse (LPN), dated May 18, 2025, at 10:27 PM noted, N.O. (new order) Cleanse LLL (left lower extremity) skin tear with wound cleanser, pat dry, apply Tegaderm drsg. (dressing) Change drsg. Q (every) Friday 6-2 (6:00 AM to 2:00 PM) shift or prn (as needed) for soilage/dislodgement, check placement Q shift, measure Q Friday 6-2 shift. D/C (discontinue) when area healed. POA (power of attorney) aware of N.O. Nursing documentation by Employee 3 dated May 18, 2025, at 10:34 PM noted, N.O. Cleanse left calf skin tear with wound cleanser, pat dry, apply Tegaderm drsg. Change drsg. Q Friday 6-2 shift or prn for soilage/dislodgement, check placement Q shift, measure Q Friday 6-2 shift. D/C when area healed. POA aware of N.O. The documentation by Employee 3 did not indicate that the licensed nurse contacted Resident 40's physician. The documentation insinuated that Resident 40's physician provided an order for the wound treatment that prompted nursing staff to implement a dressing different from that stipulated in the wound care protocol noted above. Documentation by Resident 40's physician (Employee 4) dated May 19, 2025, at 8:17 AM noted that, Upon my return to work today, it appears that multiple messages were left on my work phone from RN (registered nurse) Supervisor regarding this resident from this past weekend. This number is to be used only if I am on call or with specific permission, neither of which were the circumstances this weekend. There was an on-call provider available. I will investigate further. Nurse leaving messages not in today. The physician order recorded by Employee 3 dated May 18, 2025, at 10:31 PM for Resident 40's left calf skin tear treatment was electronically signed by Employee 4 on May 19, 2025, at 4:09 PM. The physician order for Resident 40's left lower extremity skin tear treatment was created by Employee 3 on May 18, 2025, at 10:25 PM as a verbal order from Employee 4 and was electronically signed by Employee 4 on May 19, 2025, at 4:09 PM. Interview with the Director of Nursing on May 22, 2025, at 11:20 AM confirmed that the facility had no evidence that either the RN or LPN spoke with a physician before implementing a treatment to Resident 40's skin tear sites. The interview indicated that licensed staff may implement a treatment per the facility's wound care protocol without speaking with a physician; however, the interview confirmed that the wound care protocol included a different dressing than the Tegaderm implemented for Resident 40 on May 18, 2025. Clinical record review for Resident 230 revealed that the facility admitted her on May 6, 2025. Diagnoses listed for Resident 230 upon her admission to the facility included the presence of a cardiac pacemaker (surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). Review of Resident 230's baseline plan of care dated May 6, 2025, noted that Resident 230 had a pacemaker related to dysrhythmias (abnormal heart rhythms). The listed interventions included instructions to perform pacemaker checks; however, there was no intervention related to a pacemaker machine or method used to perform pacemaker checks. Interview with Resident 230 on May 21, 2025, at 10:42 AM revealed that she has had the cardiac pacemaker for three or four years. Resident 230 reported that she had one incident while she resided at her home when she went to bed when not feeling well and received a telephone call from her pacemaker monitoring company to inquire if she felt well. The pacemaker monitoring company instructed her to call emergency medical response services (911). Resident 230 stated that she was evaluated in the emergency room and diagnosed with a problem with her heart rate. Resident 230 confirmed that she had a machine in her home that is used to monitor her cardiac pacemaker. Resident 230 confirmed that she has not had this machine since her admission to the facility. Resident 230 stated, I didn't say anything, I just prayed a lot. The surveyor reviewed the concern regarding Resident 230's pacemaker monitoring during an interview with the Director of Nursing, the Nursing Home Administrator, Employee 1 (infection preventionist), and Employee 5 (assistant director of nursing), on May 21, 2025, at 2:30 PM. Nursing documentation dated May 21, 2025, at 4:29 PM (following the surveyor's questioning) revealed that Employee 5 spoke with Resident 230 regarding her home monitor for her cardiac pacemaker. Resident 230 verified that she had a machine at home and that she didn't think to bring it. Resident 230 suggested that Employee 5 call her daughter to bring the machine to the facility. Nursing documentation dated May 21, 2025, at 6:21 PM revealed Resident 230's family brought the cardiac pacemaker monitor to the facility. The surveyor reviewed the concern regarding Resident 230's baseline care plan and omission of a pacemaker monitoring machine during an interview with the Director of Nursing on May 22, 2025, at 11:20 AM. Clinical record review for Resident 94 revealed that she was admitted to the facility on [DATE], with hospice services related to her terminal diagnosis of senile degeneration of the brain/dementia (a group of thinking and social symptoms that interfere with daily functioning). Review of Resident 94's current care plan revealed that the facility failed to implement an integrated plan of care with hospice services. The plan of care did not include evidence of all services that hospice will provide for the management of Resident 94's terminal illness. Resident 94's current care plan failed to identify the hospice entity providing services, the hospice disciplines that would provide her care and services, and how often. . The findings were reviewed with the Director of Nursing during a meeting on May 22, 2025, at 2:45 PM. 483.25 Quality of Care Previously cited deficiency 6/20/24 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.3(a)(e)(2) Verbal and telephone orders 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, 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 obtaining verbal or telephone physician orders for one of one employee reviewed (Employee 3; Resident 40). 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 current Facility Assessment (noted as fourth quarter, April 2025) noted that staff receive yearly education and are assigned additional courses as needed. The Staff Development Coordinator maintains the current staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. Additional competencies are developed as needed. The list entitled, LPN (licensed practical nurse) Staff Competencies, included, Documentation/Order writing, as one of the competencies completed by the facility for LPN staff. The facility policy entitled, Verbal, Telephone, and Written Physician Orders, last reviewed November 21, 2024, revealed that a physician's verbal or telephone order shall be given to a licensed nurse and shall be immediately recorded on the resident's medical record by that licensed nurse. Telephone orders for medical treatment should be accepted only under circumstances where it is impractical for the orders to be given in a written manner by the responsible practitioner, when the judgement of the professional nurse and the situation requires expedient action, or when the physician calls the facility and requests that a telephone order be accepted. Clinical record review for Resident 40 revealed nursing documentation by the registered nurse (RN) dated May 18, 2025, at 7:57 PM that his daughter noted blood on his pant leg. Staff assessed two skin tears on Resident 40's left leg, calf area. The staff cleansed the wound with wound wash and applied a Tegaderm dressing (transparent film dressing). The documentation did not indicate that the licensed nurse contacted Resident 40's physician or that Resident 40's physician provided an order for the wound treatment. Nursing documentation by Employee 3, licensed practical nurse (LPN), dated May 18, 2025, at 10:27 PM noted, N.O. (new order) Cleanse LLL (left lower extremity) skin tear with wound cleanser, pat dry, apply Tegaderm drsg. (dressing) Change drsg. Q (every) Friday 6-2 (6:00 AM to 2:00 PM) shift or prn (as needed) for soilage/dislodgement, check placement Q shift, measure Q Friday 6-2 shift. D/C (discontinue) when area healed. POA (power of attorney) aware of N.O. Nursing documentation by Employee 3 dated May 18, 2025, at 10:34 PM noted, N.O. Cleanse left calf skin tear with wound cleanser, pat dry, apply Tegaderm drsg. Change drsg. Q Friday 6-2 shift or prn for soilage/dislodgement, check placement Q shift, measure Q Friday 6-2 shift. D/C when area healed. POA aware of N.O. The documentation by Employee 3 did not indicate that the licensed nurse contacted Resident 40's physician. The documentation insinuated that Resident 40's physician provided an order for the wound treatment. Documentation by Resident 40's physician (Employee 4) dated May 19, 2025, at 8:17 AM noted that, Upon my return to work today, it appears that multiple messages were left on my work phone from RN (registered nurse) Supervisor regarding this resident from this past weekend. This number is to be used only if I am on call or with specific permission, neither of which were the circumstances this weekend. There was an on-call provider available. I will investigate further. Nurse leaving messages not in today. Interview with the Director of Nursing on May 22, 2025, at 11:20 AM confirmed that the facility had no evidence that either the RN or LPN spoke with a physician before documenting a treatment order for Resident 40's skin tear sites. The surveyor requested evidence of Employee 3's competency evaluations regarding obtaining and documenting verbal or telephone physician orders during an interview with the Nursing Home Administrator and Director of Nursing on May 22, 2025, at 2:30 PM. Documentation provided by the facility dated August 29, 2018, indicated that Employee 3 completed the facility's test regarding, Competency Test for Writing Orders. The facility failed to provide evidence that Employee 3 received any education after August 29, 2018, related to obtaining/documenting verbal or telephone physician orders although this competency was identified through the Facility Assessment as necessary to provide the level and types of care needed for the resident population. Cross Refer F684 28 Pa Code 201.20(a)(6)(d) Staff development

Based on clinical record review and staff interview, it was determined that the facility failed to revise the comprehensive care plan for one of 35 residents reviewed (Resident 11). Findings include: Observation of Resident 11 on May 21, 2025, at 9:10 AM revealed a urinary collection bag hanging from the left side of his bed. Clinical record review for Resident 11 revealed an active physician's order dated May 19, 2025, for the use of a Foley catheter (flexible tubing inserted through the penis into the bladder to drain urine) due to urinary retention related to bladder cancer. The order instructed staff to change the Foley as needed for obstruction, leaking, or if the closed system is compromised. Review of active plans of care for Resident 11 (including a care plan to address Resident 11's risk for urinary retention, incontinence, chronic kidney disease, and urinary tract infection) during the onsite survey revealed no plan of care that included the intervention of an indwelling Foley catheter. The surveyor reviewed the above concerns regarding Resident 11's care plans during an interview with the Director of Nursing on May 23, 2025, at 10:15 AM. 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 an individualized person-centered care plan to address dementia and cognitive loss displayed by two of four residents reviewed (Residents 86 and 89). Findings include: Clinical record review for Resident 86 revealed that the facility admitted her on November 25, 2024, with diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 86's significant change minimum data set (MDS, a form completed at specific intervals to determine care needs) assessment dated [DATE], indicated that the facility assessed Resident 86 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 86's care plan entitled, Impaired cognitive function/dementia or impaired thought processes r/t (related to) Vascular Dementia initiated on December 3, 2024, failed to identify individualized person-centered interventions to address Resident 86's dementia and cognitive loss. Clinical record review for Resident 89 revealed that the facility admitted her on November 10, 2022, with a diagnosis of Dementia added on January 12, 2023. A review of Resident 89's annual MDS assessment dated [DATE], indicated that the facility assessed Resident 89 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 89's care plan entitled, Impaired cognitive function/impaired thought processes, moderately impaired per BIMS (brief interview for mental status, determines level of cognition); dementia with psychosis, dated August 7, 2023, failed to identify individualized person-centered interventions to address Resident 89's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 22, 2025, at 2:55 PM. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to obtain routine dental services for one of three residents reviewed for dental concerns (Resident 67). Findings include: The facility policy entitled, Dental Exams, last reviewed November 21, 2024, revealed that each resident will receive, at a minimum, an annual oral examination with a dentist or his/her choice. In addition to the minimum oral examination, each resident will be offered dental services every six months as his/her insurance will allow. Any resident or resident's responsible party may elect to have the annual oral examination done with the contract dentist. Interview with Resident 67's daughter on May 20, 2025, at 10:10 AM revealed that Resident 67 has natural teeth; however, Resident 67's daughter did not know the last time Resident 67 received professional dental services. Resident 67's daughter stated that she, .would love to see that happen. Clinical record review for Resident 67 revealed that the facility admitted her on May 3, 2023, with Medicare as her primary payer source. Resident 67 began to pay privately for her care on June 1, 2023. Resident 67's primary payer source converted to Medicaid on May 1, 2024. A Dental Services form (document the facility utilized to obtain consent for contracted dental services) signed by Resident 67's daughter on May 3, 2023, (while Resident 67 did not receive Medicaid payment for services) indicated that Resident 67's daughter declined dental care. Annual MDS assessments (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 2, 2024, and May 3, 2025, assessed Resident 67 with obvious or likely cavities or broken natural teeth. The Care Area Assessment for Dental Care indicated that the facility would proceed to a care plan in May 2024; however, the facility decided to not proceed to a care plan in May 2025. Review of Resident 67's plans of care revealed no evidence that the facility developed a care plan to address the likelihood that Resident 67 had decayed or broken teeth or attempted an intervention for professional dental services following either the May 2, 2024, or May 3, 2025, MDS assessments. Care Conference Meeting documentation dated November 6, 2024, at 10:00 AM indicated that Resident 67's daughter attended the meeting. Care Conference Meeting documentation dated January 15, 2025, at 10:43 AM indicated that Resident 67's daughter attended via telephone. Care Conference Meeting documentation dated May 14, 2025, at 12:57 PM indicated that staff emailed updates to Resident 67's daughter because she was unable to attend. Resident 67's clinical record contained no evidence that the facility afforded Resident 67's daughter the opportunity to accept dental services provided under the Medicaid benefit in the year since her mother's payment source changed. The surveyor reviewed the above information regarding concerns related to Resident 67's dental needs during an interview with the Nursing Home Administrator and the Director of Nursing on May 21, 2025, at 2:30 PM and the Director of Nursing on May 22, 2025, at 11:20 AM. Nursing documentation dated May 22, 2025, at 11:32 AM (following the surveyor's questioning) revealed that staff contacted Resident 67's daughter regarding dental services now that Resident 67 is approved for medical assistance (Medicaid). Resident 67's daughter stated that she would be interested in services for her mother from the facility's contracted dental provider and asked that the forms be mailed to her for signature. 28 Pa. Code 211.15 Dental services 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 medications for two of five residents reviewed (Residents 72 and 86). Findings include: Clinical record review revealed the facility admitted Resident 72 on January 24, 2025. Review of a consultant pharmacist recommendation dated April 12, 2025, revealed as needed Ativan (an antianxiety medication) is the most effective intervention for reducing Resident 72's anxiety. The pharmacist recommended Ativan 0.5 milligrams (mg) every 12 hours as needed for anxiety for 30 days with a re-evaluation of Resident 72's Ativan use in 30 days to determine if ongoing use is indicated. Review of Resident 72's clinical record revealed a physician's order dated April 16, 2025, for Ativan 0.5 mg, one tablet every 12 hours as needed for agitation. Further clinical record review revealed that Resident 72's order for Ativan did not have a 14 day stop date and there was no physician's progress note that provided a rationale for the medication extending past 14 days. Interview with the Director of Nursing on May 22, 2025, at 2:50 PM confirmed the above noted findings related to Resident 72's Ativan. Clinical record review for Resident 86 revealed a physician's order dated April 18, 2025, for Ativan 0.5 mg every six hours as needed for anxiety/agitation. Further clinical record review revealed that Resident 86's order for Ativan did not have a 14 day stop date and there was no physician's progress note that provided a rationale for the medication extending past 14 days. Interview with the Director of Nursing on May 21, 2025, at 2:47 PM confirmed the above noted findings related to Resident 86's Ativan. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of six residents reviewed, which resulted in actual harm (Resident 38). Findings include: Resident 38's clinical record revealed the resident had a diagnosis of Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) and unspecified dementia (a condition with memory loss, poor judgment, and confusion) and vascular dementia (dementia caused by impaired blood loss to the brain). Review of Resident 38's care plan dated September 14, 2019, identified the resident as being at risk for pressure injuries/ulcers and impaired skin integrity due to facial cancer with an intervention added, for the RN (registered nurse) to assess the skin weekly. Resident 38's care plan identified bowel incontinence (inability to control bowel movements resulting in soiling) as a problem on March 21, 2022. Resident 38's care plan identified a Stage IV pressure ulcer/injury (full thickness tissue with exposed bone, tendon, or muscle to the sacrum on December 27, 2022. Review of Resident 38's skin assessment dated [DATE], revealed that the resident had four surgical wounds on his abdomen. There was no documentation of a pressure ulcer/injury. Clinical record review for Resident 38 revealed an order dated September 23, 2022, for the staff to cleanse the sacrum (lower back) and buttocks with Remedy Wash (cleansing solution) then apply Calmoseptine ointment (a skin protectant containing zinc oxide that is used to treat diaper rash) every day and evening shift. Review of Resident 38's weekly Skin check completed by the LPN (licensed practical nurse) dated October 4, 2022, revealed the resident's bottom was red and remained so after 30 minutes of pressure reduction, and Calazime (another name for Calmoseptine ointment) was applied. Clinical record review for Resident 38 revealed that there was no corresponding RN assessment of the resident. Review of an RN progress note for Resident 38 dated October 7, 2022, at 1:24 PM revealed as per the LPN the resident was noted to have a sacral (bottom of the spine) slit (a long narrow open area) and a new physician's order was obtained to apply Optifoam (a foam dressing that is waterproof and has a high fluid-handling capacity) and change it on Tuesdays and Fridays and PRN (as needed) for dislodgement. The nurse was to check the placement of the dressing every shift. Clinical record review for Resident 38 revealed there was no documented assessment of the resident's sacral wound performed by an RN. The above progress note by the RN indicated that the information was relayed per LPN. Review of a Wound consultation (physician ordered wound care specialist that visits the facility to provide care and recommendations) for Resident 38 dated October 13, 2022, revealed the consultant assessed and provided treatment, and recommendations for the resident's surgical wound to his right abdomen. There was no mention of the provider evaluating or treating the sacral wound. The only assessment of the sacral slit was provided 13 days later on October 20, 2022, and described below. Review of a Wound consultation for Resident 38 dated October 20, 2022, revealed the consultant provided an initial evaluation of the resident's buttocks wounds. The staff reported the wound started as a coccyx (tailbone) slit. The wounds were assessed, and treatment recommendations were as follows: An unstageable (unable to identify staging or severity) pressure ulcer/injury of the right buttocks secondary to slough (dead tissue that needs to be removed for healing to occur) measured 3.0 cm (centimeters) length x 2.0 cm width x 0.2 cm depth. There was 20% granulation tissue (healing tissue) and 80% slough. The nurse was to cleanse the area with NSS (normal saline solution, similar to body fluid) or wound cleanser (special solution designated for wounds), apply Medihoney (a wound healing ointment that has antibacterial and anti-inflammatory properties that aides in removing dead tissue) to the wound base daily, cover with a bordered foam dressing, off-load pressure to affected areas, continue repositioning the resident, monitor for signs of infection such as bogginess, drainage, and erythema (redness). An unstageable pressure ulcer/injury due to a DTI (deep tissue injury, unable to see severity at this stage) of the left buttocks measured 1.5 cm x 1.5 cm x 0.0 cm. The nurse was to cleanse the affected area with NSS or wound cleanser, apply Skin prep (a protective barrier to help preserve the skin), cover with bordered foam dressing, off-load pressure, and continue to reposition the resident. Clinical record review of the TARs (forms for documenting treatments provided) dated October 2022 and November 2022, for Resident 38 revealed that the treatments to the buttocks recommended by the wound consultant was never implemented and the Optifoam dressing was applied though November 15, 2022. Review of a Wound consultation for Resident 38 dated November 10, 2022, revealed the right and left buttocks wounds merged and measured 3.0 cm x 2.5 cm x 0.2 cm, with 10% granulation and 90% slough. The wound was classified as unstageable. The treatment recommendations were changed to cleansing the affected area with NSS or wound cleanser, apply Medihoney to wound base daily, cover with bordered foam dressing, monitor for signs of infection, off-load pressure to affected areas, and continue to reposition in accordance to assessed needs. (The TAR dated November 2022 revealed this treatment was not applied.) Review of a Wound consultation for Resident 38 dated November 17, 2022, revealed the sacral wound measured 3.5 cm x 2.5 cm x 0.2 cm with 100% slough. The wound was classified as unstageable. The peri wound (the area surrounding the wound) was with erythema (redness). The consultant analysis was that the wound had larger measurements, the resident had poor mobility, and erythema to the peri wound. The Medihoney treatment was discontinued and Bactroban (antibiotic ointment) was ordered with a foam dressing daily. The consultant indicated that barriers to wound healing that can delay or impede wound healing were altered mobility, bowel and bladder incontinence, diabetes mellitus, and indicated the resident is at high risk for slow wound healing and secondary wound infection. (There was no documented evidence by the consultant that acknowledged that the previously ordered wound treatments were not provided as recommended for 26 days). Clinical record review of a TAR dated November 2022 for Resident 38 revealed that the Optifoam treatment was provided through November 15, 2022, and on November 16, 2022, the sacrum was cleansed with wound cleanser and Medihoney and a bordered dressing was applied. The sign-off area to complete this treatment for November 16 and 17, 2022, was blank indicating no documented evidence that the treatment was provided before being discontinued on November 18, 2022. Review of the November 2022 TAR revealed Mupirocin (generic name for Bactroban) was administered from November 18, 2022, through December 1, 2022. Clinical record review for Resident 38 revealed no weekly documented evidence of sacral wound assessments from November 17, 2022, until December 8, 2022 (two weeks without assessments). Review of a Wound consultation for Resident 38 dated December 8, 2022, revealed the sacral wound was larger in size, at 5.0 cm x 5.5 cm x 1.0 cm, with undermining (wound extends under the skin in all directions) from 8-12 o'clock, and 20% granulation tissue and 80% slough. The recommendation was to change the treatment to cleansing the area with NSS or wound cleanser, apply nickel thick size of Santyl (debriding agent to remove slough) to wound base, and gently packing the cavity with 1/4 strength Dakin's (debriding agent) moistened gauze, and cover with bordered foam dressing. Review of the TARs indicated that this treatment was implemented through March 18, 2023. Review of a Wound consultation for Resident 38 dated December 15, 2022, revealed the sacral wound measured 7.0 cm x 6.0 cm x 3.0 cm, with undermining from 8-12 o'clock from 0.5 cm, and 20% granulation tissue and 80% slough. A foley catheter (tubing inserted in the bladder that drains urine into a collection bag, keeping the skin dry) was implemented to aide in wound healing. Clinical record review for Resident 38 revealed weekly Wound consultations with assessments of the sacral wound, and on January 12, 2023, the sacral wound measured 6.0 cm x 5.0 cm x 2.5 cm with undermining from 8-12 o'clock for 2.5 cm. A sacral Xray was recommended to rule out osteomyelitis (bone infection). Review of a Sacrum/coccyx Xray completed for Resident 38 on January 15, 2023, revealed no acute abnormalities and no definite evidence of osteomyelitis (bone infection). Should a clinical concern persist then consider follow up with a more sensitive CT scan (computer tomography, uses computer and x-rays). Review of a CT pelvis with contrast for Resident 38 completed on March 8, 2023, revealed the resident had Sacrococcygeal (sacral and coccyx area) osteomyelitis with tiny fluid collection/abscess. Clinical record review for Resident 38 revealed weekly Wound consultations with assessments of the sacral wound with their last consultation on March 9, 2023. The wound measured 4.5 cm x 4.5 cm x 2.5 cm. During a meeting with the Director of Nursing on July 27, 2023, at 11:30 AM the surveyor requested additional documentation of Resident 38's sacral wound as there was no documented evidence of wound assessments after March 9, 2023, to current. The Director of Nursing indicated that the resident's responsible party wanted to change consultants. Resident 38 was seen in the new Wound consultation office, and she indicated the facility had problems obtaining the written consultations. The new Wound consultations were provided to the surveyor after requested. Review of these documents revealed they were faxed to the facility on [DATE]. The first consultation by the Wound Center for Resident 38 was on March 2, 2023, and revealed a Stage IV (full thickness tissue with exposed bone, tendon, or muscle) pressure ulcer that measured 4.5 cm x 3.5 cm x 2.8 cm with 4 cm of undermining from 11-3 o'clock. The consultant indicated that the bone was exposed, and chronic osteomyelitis was suspected. A CT (computer tomography, uses computer and x-rays) scan was ordered. Review of a CT pelvis with contrast for Resident 38 completed on March 8, 2023, revealed the resident had Sacrococcygeal (sacral and coccyx area) osteomyelitis with tiny fluid collection/abscess. Review of a deep wound culture of Resident 38's sacral wound dated March 16, 2023, revealed Pseudomonas aeruginosa and Escherichia coli (both bacteria found in stool). Review of a physician's order for Resident 38 dated March 21, 2023, revealed the nurse was to administer Cefepime Hcl (hydrochloride; an antibiotic) 2 gram/100 milliliters intravenously twice daily for six weeks for sacral osteomyelitis. Review of Wound Center consultations revealed that Resident 38 was provided additional consultations on March 16 and 23, April 11, May 2 and 23, June 6, 27, and July 18, 2023. Review of a physician's order for Resident 38 dated June 7, 2023, to current, revealed that Z-guard (zinc ointment, protective barrier) was to be applied to the sacral peri wound with each dressing change twice daily. Review of a physician's order for Resident 38 dated June 27, 2023, revealed the current treatment ordered for the sacral wound was to wash the area with soap and water, pat dry, apply moistened Puracol plus (a collagen healing solution), cover with gauze and ABD (large abdominal size dressing), use Hypafix tape to sacrum, change every other day and PRN for soiling/dislodgement for sacral ulcer. Review of Wound Center consultation for Resident 38 dated July 18, 2023, revealed the Stage IV sacral wound was stable and smaller. The wound was debrided and measured 3.5 cm x 1.5 cm x 1.5 cm with undermining of 2.5 cm. During an interview with the Director of Nursing on July 28, 2023, at 8:20 AM it was confirmed that there were no weekly assessments done on the sacral wound from March 3, 2023, to current other that the dates assessed by the Wound Center as above. Observation of a sacral dressing change by Employee 1, LPN, on July 26, 2023, at 2:00 PM revealed the resident's sacral wound had scant active bleeding after the old dressing with brown drainage was removed. Employee 1 indicated that she did not need as much gauze to pack it. Employee 1 administered the treatment containing Puracol plus as ordered but did not apply Z-guard to the peri wound. During an interview with the Director of Nursing on July 28, 2023, at 8:20 AM the surveyor questioned how Z-guard could be applied to the sacral peri wound as the current dressing change was to be performed every other day and the dressing covers the peri wound and the Z-guard is ordered twice daily. The Director of Nursing indicated that she would clarify this order. Review of a nursing note dated July 28, 2023, at 12:15 PM revealed that the facility received a return call from the wound center and a new order was received to discontinue z-guard to peri wound BID with dressing change. The facility's failure to initially assess and treat Resident 38's buttocks wound resulted in harm. The facility failed to assess the reddened buttocks on October 4, 2022, which worsened to a sacral slit on October 7, 2022. The sacral slit was not assessed until 13 days later and then was classified as an unstageable pressure ulcer/injury. A new treatment recommendation was not provided for 26 days resulting in an infection requiring topical antibiotics. The pressure ulcer/injury enlarged to a Stage IV pressure ulcer/injury with undermining that resulted in osteomyelitis. The resident required intravenous antibiotics for six weeks and remains with a foley catheter to prevent urinary incontinence for optimal wound healing. Bone was observable in the sacral pressure ulcer/injury. These issues were discussed with the Director of Nursing on July 28, 2023, at 8:20 AM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of select facility policies, clinical record review and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards and provide adequate supervision to prevent serious injury for one of 5 residents reviewed (Resident 78). Findings include: The facility policy entitled, Incident and Accident Reports, last revised October 2015, revealed that the data contained in the incident/investigation form is compiled and analyzed by the facility to maintain high quality of care standards. By identifying and addressing potential areas or systems of concern in a timely manner, the facility might lessen the possibility of a similar or repeat occurrence. Review of Resident 78's clinical record revealed documentation dated April 8, 2014, that indicated Resident 78's physician deemed her unable to comprehend and that her, memory waxes and wanes. Review of Resident 78's current impaired cognition plan of care indicated that she has periods of confusion, forgetfulness, and needs redirection. Documentation dated April 30, 2016, indicated that the nursing staff sent a request to occupational therapy to assess Resident 78's feet because they were falling off her wheelchair platform. Occupational therapy documentation dated May 4, 2016, indicated that the nursing staff was incorrectly placing Resident 78 in her chair due to, staff not positioning her well. Interview with Employee 1, the Director of Rehabilitation, on July 11, 2016, 12:10 PM revealed that occupational therapy initiated Dycem (a non-slip material used to create traction) on Resident 78's wheelchair platform, but indicated the staff must position Resident 78 correctly for the Dycem to be effective. Employee 1 indicated that occupational therapy was providing education to the nursing staff regarding Resident 78's positioning in her motorized wheelchair. Review of Resident 78's, on the spot in service documentation dated May 2016, revealed that the nursing staff should be checking Resident 78's sitting posture in her motorized wheelchair throughout each shift. Resident 78's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated May 24, 2016, that indicated Resident 78 had a [DIAGNOSES REDACTED]. The assessment revealed that the facility assessed her as needing extensive assistance of one staff member for moving to and from different areas of the facility. Nursing documentation dated June 7, 2016, indicated that the activity staff witnessed Resident 78 back up over another resident's left foot with her motorized wheelchair. Review of the facility's investigation dated June 7, 2016, indicated that the staff would implement a therapy screen for assistance in preventing similar incidents. Interview with Employee 1, on July 11, 2016, at 12:15 PM revealed that therapy did not receive any communication about a screen to assess Resident 78 and the safe use of her motorized wheelchair. Interview with the Director of Nursing on July 11, 2016, at 2:00 PM confirmed that the facility did not assess Resident 78's safe use of her motorized wheelchair after she ran over another resident's foot. Review of the information dated July 6, 2016, submitted by the facility revealed that Resident 78 returned from the facility's courtyard through a door in the activities room at 4:15 PM. Resident 78 asked the recreation aide to assist her in placing her right foot back on the baseboard of her motorized wheelchair. The aide noted a puddle of blood under Resident 78's foot. The registered nurse noted that Resident 78's right great toe was partially amputated. Upon staff questioning the, noncapable resident as to if she recalled how the injury occurred, Resident 78 could not recall any injury. According to the staff that were present at the time of the incident, her left shoe was on her left foot and the staff found the right shoe in the courtyard. The facility transferred Resident 78 to the hospital where she had to undergo surgery to repair her right second toe and to have her right great toe completely removed. There was no documented evidence in Resident 78's incident investigation to indicate that the nursing staff properly placed her in her motorized wheelchair or that the staff were checking her positioning throughout each shift per therapy recommendations. There was no documented evidence in Resident 78's incident investigation to indicate that the facility investigated how this injury occurred. Observation of the activity room's courtyard door on July 11, 2016, at 10:00 AM revealed an unsecured door to the facility's large courtyard. The courtyard door had an alert system (a system used to stop residents who are wearing a special bracelet) but was open to all other residents who tried to exit without alerting staff. There was no documented evidence that the facility thoroughly investigated Resident 78's incident to rule out other potential accident hazards in the courtyard. There was no evidence in Resident 78's clinical record to indicate that the facility assessed her to ensure that she was safe to be alone in the courtyard. An interview with the Director of Nursing on July 11, 2016, at 2:00 PM confirmed the above information. 483.25 (h) Free of Accident Hazards/Supervision/Devices Previously cited 6/17/16, 3/3/16, 1/8/16 28 Pa. Code 201.18 (e)(1) Management Previously cited 6/17/16, 3/3/16, 1/8/16 28 Pa. Code 211.11 (d) Resident care plan Previous cited 6/17/16 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 6/17/16, 3/25/16, 3/11/16, 1/8/16, 12/19/14 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 6/17/16, 3/25/16, 3/11/16, 3/3/16, 1/8/16, 12/19/14

Based on clinical record review, observation, staff interview, and review of select facility policies, it was determined that the facility failed to ensure an environment free from accident hazards for one of 24 sampled residents (Resident 52). The facility also failed to ensure an environment free from the potential for accident hazards on three of seven nursing units (400, 600 and 800 Nursing Unit) and the resident's personal laundry. Findings include: The Incident and Accident Reports, policy reviewed without changes on December 1, 2015, revealed that the facility would complete an incident/investigation form whenever there is an occurrence not consistent with the routine of the facility. The Director of Nursing (DON) or designee will obtain either a written signed statement or verbal statement from the employee(s). Observation of the resident's personal laundry area on January 6, 2016, at 11:05 AM with Employee 3, Director of Support Services, revealed that the lint trap had approximately one inch of lint covering the entire lint trap surface area, potentially causing a fire hazard. Concurrent interview with Employee 3 confirmed the above observation. Interview with the Nursing Home Administrator (NHA) on January 6, 2016, at 12:10 PM confirmed the above observation. Clinical record review for Resident 52 revealed that the facility completed a quarterly Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) on March 23, 2015. It revealed that staff completed her cognition assessment and determined that her cognition was moderately impaired. Nursing documentation dated April 2, 2015, at 10:45 AM revealed that Resident 52 returned from the beauty shop and staff found a red mark on the back of her neck measuring 7.0 cm (centimeters) by 3.0 cm. On April 3, 2015, at 7:59 AM, staff documented that Resident 52 did not have any redness on the back of her neck. The facility investigation dated April 2, 2015, revealed that at 10:30 AM staff found the above noted red marks on the back of Resident 52's neck, and applied cool compresses to the area. The interdisciplinary team identified that the beauty shop staff would keep a towel on the back of Resident 52's neck to keep direct heat off the back of her neck. Employee 9, registered nurse (former assistant director of nursing), noted that she spoke with Employee 7, beautician, and made her aware of the above intervention. There was no documentation available indicating that the facility assessed or monitored the beauty shop hair dryers for the potential for resident injury after the April 2, 2015, incident, and prior to the April 16, 2015, incident. Nursing documentation dated April 16, 2015, at 12:25 PM revealed that on the way back from the dining room, staff observed a 15 cm by 12 cm red area on the back of Resident 52's neck and two 1 cm by 1 cm red areas on the top of her right ear. On April 16, 2015, at 12:24 PM and 2:24 PM staff determined that the redness on the back of Resident 52's neck and the top of her right ear was a first degree burn. On April 17, 2015, at 6:44 AM staff documented that Resident 52's first degree burn continued and measured 14.0 cm by 2.0 cm, with red blotches extending in a line on the back of her neck and upper back area. On April 23, 2015, at 6:50 AM staff documented that the redness on the back of Resident 52's neck and top of her right ear was healed. Review of a facility investigation dated April 16, 2015, revealed that at 12:00 PM, staff found the above noted burns to the back of Resident 52's neck and right ear, and applied a cool compress. Upon investigation, Employee 10, nurse aide, revealed that the red areas on the back of Resident 52's neck and on her right ear were not present during her morning care. The facility concluded that Resident 52 was under the (stationary hair) dryer too long. The beauty shop staff received education to not place Resident 52 under a stationary (hair) dryer, to use a hand held dryer on Resident 52's hair, to check to see if more frequent checks are needed depending on the hair dryer temperatures, and to continue to place a towel behind every resident's neck while under a stationary or hand (held) dryer. Review of the beauty shop staff education dated April 17, 2015, revealed that Employee 6, beauty salon owner, acknowledged the above education. Review of a facility work order dated May 4, 2015, at 10:02 AM revealed that Employee 9 requested that maintenance check the temperatures on all of the stationary dryers in the beauty shop. Employee 9 indicated that they stationary dryers should be on a medium setting and checked every five minutes for a total of 35 minutes, with the temperature(s) not to exceed 165 to 170 degrees Fahrenheit. Review of a work order maintenance report dated May 5, 2015, revealed that every five minutes between 6:50 AM to 7:20 AM maintenance staff checked five stationary dryers in the beauty shop. There was no determination as to what the heat setting the stationary dryers was set at, except for the fifth dryer. After the 6:55 AM temperature reading, staff indicated that they set the fifth dryer to the high setting. At 7:25 AM, maintenance staff placed all five stationary dryers to the highest possible setting and continued to check them every five minutes until 7:40 AM. The first stationary dryer, from left to right when facing the dryers, revealed that the temperatures ranged from 93 degrees Fahrenheit at 6:50 AM to 104 degrees Fahrenheit at 7:20 AM. It stayed at 104 degrees Fahrenheit from 7:25 AM to 7:40 AM on the highest setting. The second stationary dryer revealed that the temperatures ranged from 106 degrees Fahrenheit at 6:50 AM to 108 degrees Fahrenheit at 6:55 AM, then back to 106 degrees Fahrenheit at 7:20 AM. While on the highest setting, it ranged from 126 degrees Fahrenheit at 7:25 AM up to 138 degrees Fahrenheit at 7:40 AM. The third stationary dryer revealed that the temperature ranged from 99 degrees Fahrenheit at 6:50 AM to 114 degrees Fahrenheit at 7:20 AM. While on the highest setting, it went from 126 degrees Fahrenheit at 7:25 AM to 135 degrees Fahrenheit at 7:40 AM. The fourth stationary dryer ranged from 92 degrees Fahrenheit at 6:50 AM to 103 degrees Fahrenheit at 7:20 AM. When placed on the highest setting, it ranged from 107 degrees Fahrenheit at 7:20 AM to 134 degrees Fahrenheit at 7:40 AM. The fifth stationary dryer ranged from 84 degrees Fahrenheit at 6:50 AM to 86 degrees Fahrenheit at 6:55 AM. At 6:55 AM, it was placed on the highest setting, where it ranged from 103 degrees Fahrenheit at 7:00 AM to 105 degrees Fahrenheit at 7:20 AM. While on the highest setting, it ranged from 114 degrees Fahrenheit at 7:20 AM to 122 degrees Fahrenheit at 7:40 AM. There was no documentation that the facility checked the temperatures on the beauty shop stationary hair dryers after Resident 52's incident on April 16, 2015, and prior to completion of the facility work order request on May 5, 2015. Review of a witness statement dated January 8, 2016, revealed that Employee 9 interviewed Employee 6 after the above noted incident(s) with Resident 52. Employee 6 stated that they discussed how to correct the situation and received education that the beauty shop would no longer put Resident 52 under the hair dryers. There was no documentation available of staff witness statements that were completed, dated, and/or signed at the time of the April 2, 2015, or April 16, 2015, incidents. Review of Resident 52's annual MDS assessment dated [DATE], revealed that staff completed the cognition assessment, and determined that she is severely cognitively impaired. Observation on January 7, 2016, at 9:47 AM revealed that Resident 52 was at the facility's beauty shop waiting for hair care. There were five residents under hair dryers, with towels around their necks and three beauticians at the sinks performing hair care. Observation at 10:20 AM revealed that Resident 52 was under the second stationary hair dryer from left to right, with a towel around her neck and curlers in her hair. At 10:35 AM, Employees 3 and 6, Employee 5, beautician, and this surveyor checked the temperature of the stationary hair dryer where Resident 52 was located. The facility's infrared thermometer indicated that the dryer's air temperature was 126 degrees Fahrenheit. The air blowing from the dryer was warm and the plastic covered metal rim was warm to the touch. Employee 5 indicated that the stationary hair dryer where Resident 52 was located was set on high. Employee 6 indicated that the dryer was set on high due to just turning it on. Resident 52 was placed back under the same hair dryer, with a towel around her neck, as her hair was still wet, per Employee 5. At 10:58 AM, staff removed Resident 52 from under the stationary hair dryer. Concurrent observation revealed that Resident 52's neck was not red. Her right ear was slightly reddened and her skin was flushed and warm. Resident 52 was sleeping and had her head down and tilted to the left while under the dryer and during this observation. She was unable to respond when questioned if her ear felt hot or if it hurt. Review of the facility provided manufacturer's guidelines for a Highland Machine Model 1500 (Stationary) Hair Dryer revealed that staff is to not direct hot air toward eyes or heat sensitive areas. There was no documentation available indicating that the dryer was not to exceed 165 degrees Fahrenheit or 170 degrees Fahrenheit as determined by Employee 9 in the above noted facility work order. Review of the National Institute of Standards and Technology, Fire Dynamics website revealed that at 118 degrees Fahrenheit human skin receives a first degree burn. At 131 degrees Fahrenheit, human skin receives a second degree burn. Interview with the DON on January 7, 2016, at 11:15 AM and 2:30 PM and on January 8, 2016, at 9:50 AM, confirmed the above information and confirmed that beauty shop staff should have used a hand held hair dryer for Resident 52 during the observation on January 7, 2016, as per their staff education dated April 17, 2015. Observation of the 400 Nursing Unit (dementia unit), on January 7, 2016, at 11:27 AM revealed that during lunch time, staff stored hot silver pellets (known as hot plates, which staff use to keep plates of food warm) directly in reach of the resident's. The plates were hot to touch, and staff placed them on an open three tiered mobile cart and on the shelf at the nursing station making it possible for any resident walking by to touch them and burn themselves. Interview with Employee 2, therapeutic recreation aide, on January 7, 2016, at 3:00 PM, who was serving residents their meals on the above noted date and time, confirmed this finding. Observation of the 800 Nursing Unit during the initial tour of the facility on January 5, 2016, at 10:38 AM revealed that staff stored the following products in an unlocked soiled utility closet: skin cream phytoplex, CarraScent air freshener, calazime with zinc skin cream, and antifungal cream. Review of the Material Safety Data Sheet, (documentation that indicates how staff should use the product and whether or not it is safe if ingested), for each of the above noted products indicated that they were harmful if ingested orally, or if comes in contact with the eyes. Interview with Employee 8, licensed practical nurse, on the above noted date and time, confirmed the above noted findings. Observation of the 600 Nursing Unit during the initial tour of the facility on January 5, 2016, at 10:50 AM revealed that staff stored the following products in an unlocked Janitor's closet: Bathroom cleaner, glass cleaner, and Eco Lab disinfectant chemicals. Review of the Material Safety Data Sheet for each of the above noted products indicated that they were harmful if ingested orally, or if comes in contact with the eyes. Observation on January 6, 2016, at 12:20 PM revealed that the janitor's closed was still unlocked with the bathroom cleaner, Eco Lab disinfectant chemicals, and glass cleaner still accessible to residents. Interview with the Administrator on January 6, 2016, at 2:45 PM confirmed that staff should store the above noted products in a locked room. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/19/14 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 12/19/14

Based on clinical record review, staff interview, and review of select facility policies, it was determined that the facility failed to implement, assess, and monitor interventions to ensure acceptable parameters of nutrition for two of 24 sampled residents (Residents 136 and 73). Findings include: The policy entitled, "Weights," last reviewed November 2011, revealed that staff is to monitor weights and verify weight changes for all residents to aid in the assessment of nutritional and medical status. The dietitian is to address significant weight changes. The policy did not indicate what nutritional interventions would be utilized for residents exhibiting significant weight losses. Clinical record review for Resident 136 revealed that the facility admitted her on May 29, 2008, with dementia with behavior disturbances and dysphagia (difficulty swallowing). A Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs), dated September 20, 2011, revealed that Resident 136 requires staff assistance when eating meals. Review of Resident 136's weights revealed that her weight was 126.8 pounds on March 1, 2011. Resident 136's weight was 112.2 pounds on October 4, 2011. This is a 14.6 pound 11.5 percent severe weight loss. Current physician orders [REDACTED]. Dietary does not provide any high calorie, high protein nutritional supplements to help prevent weight loss. Clinical record review for Resident 136 revealed that Employee 4, Registered Dietitian, documented in her dietary notes on the following dates without implementing any nutritional interventions to prevent further weight loss: June 28, 2011, June 29, 2011, July 28, 2011, October 21, 2011, November 11, 2011, December 12, 2011, and January 9, 2012. There is no documentation by Employee 4 indicating that dietary reviewed food preferences to aid in increased meal intakes. There is no documentation in Resident 136's medical record that Employee 4 assessed her [MEDICAL CONDITION] risk due to this weight loss or the medical consequences of this weight loss. Review of Resident 136's weights reveal that staff last weighed her on January 3, 2012. Resident 136's weight was 103.4 pounds on that day. Review of the dietary notes on January 11, 2012, revealed that there was no documentation indicating that Employee 4 has assessed or implemented any nutritional intervention for Resident 136 to prevent further weight loss. Interview with the Director of Nursing and the Administrator on January 10, 2012, at 2:15 PM, revealed that they could provide no documented evidence indicating that the facility implemented any nutritional interventions to prevent weight loss for Resident 136. Clinical record review for Resident 73 revealed that staff assessed her weight as 171.8 pounds on April 4, 2011. Staff next assessed her weight as 161.8 pounds on May 2, 2011 (a 10 pound, 5.8 percent, severe weight loss in one month). Review of Employee 4's documentation dated May 5, 2011, at 1:19 PM, revealed that he acknowledged her severe weight loss; however, made the determination that she was well nourished based on her BMI (body mass index, a mathematical equation used to measure body fat based on an individual's weight and height, is not an indicator of protein stores or nutritional status) of 30.3. Staff assessed Resident 73's weight on May 11, 2011, as 156 pounds (a 5.8 pound weight loss in nine days). Employee 4's documentation dated May 13, 2011, at 10:24 AM, assessed Resident 73 as having, "ample energy stores," based on her BMI of 30. Employee 4 confirmed that Resident 73's meal intake average equaled 16 percent; however, Employee 4 did not make any recommendations to Resident 73's physician to address her poor appetite (i.e. appetite stimulant, frequent small meals, increasing food preferences, increasing nutritional content of foods consumed/fortified foods). Resident 73 continued to exhibit weight loss on May 18, 2011, (155.8 pounds) and May 25, 2011, (154.2 pounds). Staff assessed Resident 73's weight on June 1, 2011, as 152.2 pounds (a 5.9 percent, 9.6 pound weight loss in one month; 19.6 pound, 11.4 percent severe weight loss in two months). Review of Employee 4's documentation dated June 2, 2011, at 2:33 PM, acknowledged Resident 73's weight loss continues; and noted weight loss is expected secondary to chronic poor meal intake and diuretic treatment (medication used to remove excess water from the body, Resident 73's dose had not changed over the period). The only recommendation Employee 4 made to Resident 73's physician was to discontinue routine weights. Resident 73 continued to exhibit weight loss on June 8, 2011, (151.8 pounds), June 15, 2011, (149.2 pounds), and June 22, 2011, (147.4 pounds). Review of Employee 4's documentation dated June 29, 2011, at 10:07 AM, noted his first discussion of weight loss with Resident 73. Resident 73 stated, "I'm not trying to lose weight." Resident 73 also confirmed that her appetite is not very good. Employee 4 recommended, and Resident 73 agreed to try, a supplement between meals; however, Resident 73 cautioned that she was not used to eating between meals. Employee 4 did not make any additional recommendations to Resident 73's physician (i.e. appetite stimulant, fortified foods, identify resident preferences, laboratory studies to determine nutritional status, etc.) except to add Resource 2.0 twice daily between meals. Staff assessed Resident 73's weight on August 17, 2011, as 136.2 pounds (a 7.4 pound, 5.1 percent, severe weight loss in one month). Employee 4's documentation dated August 25, 2011, at 11:34 AM, noted, "No significant weight changes over the period," however, notes Resident 73's weight as 137.2 pounds on August 24, 2011 (a 17 pound, 11 percent, severe weight loss in three months). Employee 4 made no recommendations to Resident 73's physician to address her continued weight loss. Employee 4's documentation dated September 2, 2011, at 11:00 AM, noted, "Per CNA, resident dislikes the Resource 2.0 and does not want it anymore, recommend d/c (discontinue) Resource 2.0." Although Employee 4 recommended discontinuing the only nutritional supplement Resident 73 received, he made no alternate suggestions to Resident 73's physician to improve Resident 73's nutritional intake. Resident 73 continued to exhibit weight loss on October 4, 2011 (130.8 pounds) and October 5, 2011 (130 pounds). Employee 4's documentation dated October 6, 2011, at 1:08 PM, noted that Resident 73 had a five percent weight loss the past month; however, the only recommendation he made to Resident 73's physician was to discontinue routine weight assessments. Interview with Employee 4 on January 10, 2012, at 10:00 AM, confirmed that he recommended no other intervention to Resident 73's physician than the Resource 2.0 twice daily, which was at the end of June 2011, three months after the weight loss. Employee 4 stated that Resident 73 was on "comfort measures," however, agreed that this did not preclude the facility from requesting laboratory testing, implementing preferred foods, implementing fortified foods, or implementing an appetite stimulant since the resident and facility staff identified her appetite was poor. Interview with the Director of Nursing on January 11, 2012, at 9:45 AM, revealed that Resident 73's weight was assessed as 120.8 pounds that morning (a 22.8 pound, 15.8 percent severe weight loss in six months). Interview with the Nursing Home Administrator and Director of Nursing on January 10, 2012, at 2:15 PM, confirmed that the facility could not provide evidence that any intervention other than the Resource 2.0 twice daily was implemented for Resident 73 over a nine month period that reflected a 51 pound, 29.6 percent severe weight loss. 28 Pa. Code 211.6 (d) Dietary services. 28 Pa. Code 211.12 (d)(5) Nursing services.