Every finding on record at Wallingford Skilled Nursing and Rehabilitation Cen

Based on review of pest control documentation, observations, resident and staff interviews, it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment outside the therapy room and for the following resident rooms on the second floor (First and Second floors).Findings include:Review of pest control documentation revealed pest control had been at the facility on August 6, 2026.Interview with Resident 1on August 11, 2026, at approximately 9:35am revealed they had seen mice in the room.Interview with Employee 3 and Employee 4 on August 11, 2026, at 9:51 am stated that they have seen mice. Observed housekeeping on the south wing on August 11, 2026, at 9:55am.Observations made of Resident 2 and Resident 3 rooms on August 11, 2026, at 10:00am revealed evidence of small black specks indicative to mouse droppings at the head of resident beds and next to trash can. This observation was shared with the Nursing Home administrator on August 11, 2026, at approximately 11:14am.Interview with Resident 6 on August 11, 2026, at 10:05am revealed that they have seen mice in the room.Observations made of Resident 4, Resident 5 and Resident 6 rooms on August 11, 2026, at approximately 10:06am revealed evidence of small black specks indicative to mouse droppings at the head of resident beds. This observation was shared with the Nursing Home administrator on August 11, 2026, at approximately 11:17am.Observation made outside the therapy room next to the side door entrance of the building on August 11, 2026, at 10:22am revealed evidence of small black specks indicative to mouse droppings on the floor. This observation was shared with the Nursing Home administrator on August 11, 2026, at approximately 11:25am and confirmed the above findings.28 Pa. Code 201.18(b)(3)(e)(2) Management.28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical records review and staff interview, it was determined that the facility failed to follow the wound care physician's order for one of two residents reviewed (Resident CL1). Findings: A review of Resident CL1's wound physician's notes dated January 15, 2026, revealed residents had a right heel DTI (Tissue Pressure Injury- Persistent non-blanchable deep red, maroon or purple discoloration) measuring 2.5 x 3.5 cm (centimeters), and a left heel DTI measuring 2.5 x 2.3 cm. An order was made to cleanse both heels with soap and water, apply skin prep, and leave them open to air daily. A review of Resident CL1's January 2026 Treatment Administration Record (TAR) revealed that the skin prep order for both heels was followed. A review of Resident CL1's wound physician's notes dated January 22, 2026, revealed that the right heel DTI had worsened with a measurement of 3.7 x 6.0 cm. The left-heel DTI had a measurement of 0.3 x 0.3 cm. A new wound treatment was made to apply Betadine (brownish solution used to prevent infections)-soaked gauze to the right heel and cover with a dressing. A new order was also made to apply the left heel with Betadine and leave it open to air. A review of Resident CL1's January 2026 TAR revealed that the right heel treatment was followed. However, further TAR review reveal that left heel DTI treatment was not done from January 23, 2026, until February 8, 2026. An interview was conducted with the Director of Nursing (DON) on March 31, 2026, at 1:00 p.m. The DON confirmed that the left heel DTI order from the wound physician was missed and was therefore not followed. The facility failed to ensure Resident CL1's left heel DTI treatment order was followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based upon review of nurse aide staff documentation, it was determined that the facility failed to ensure annual performance reviews were completed for five of five staff members reviewed. (Employees E5, E6, E7, E8, and E9)Findings include: Review of employee files for Employes E5, E6, E7, E8 and E9 failed to reveal evidence of annual performance reviews.Interview with the Director of Nursing on December 18, 2025, at 10:42 a.m. confirmed that no employee annual performance reviews were completed for the five staff members reviewed. 28 Pa. Code 201.19(2) Personnel Policies and Procedures

Based on a review of facility documentation and staff interview, it was determined that the facility failed to inform residents of charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for two of two residents reviewed (Residents 18 and 59). Findings include: Review of facility documentation revealed that Resident 18's last covered day under Medicare was July 21, 2025. Further review of the facility documentation revealed no evidence that the facility provided the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident. Review of facility documentation revealed that Resident 59's last covered day under Medicare was December 22, 2025. Further review of the facility documentation revealed no evidence that the facility provided the SNF ABN to the resident. Interview with the Director of Nursing on December 18, 2025, at 10:00 a.m. confirmed that the SNF ABN forms were not provided to the residents.28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.18(3)(e)(1) Management.

Based on clinical record review and employee interviews it was determined that the facility failed to ensure physician orders were followed for two of 33 residents reviewed (Resident 98 and 173). Findings include: Review of Resident R98's physician's orders revealed an order dated January 5, 2023, for PEG (percutaneous endoscopic gastrostomy) site care to be completed every night shift, including application of a drainage sponge and daily dressing changes. Review of Resident R98's progress notes revealed a nurse note dated September 3, 2025, which stated Resident was observed with purulent drainage (thick, cloudy fluid from pus-like fluid) and active bleeding at stoma site for Peg Tube. C/O of pain and bleeding. Date noted on gauze was 8/29/25. Unit manager notified and observed resident. Site was cleaned with [normal saline solution] and new gauze applied. Review of Resident R98's medication administration record (MAR) revealed PEG site care was documented as completed on August 30, August 31, September 1, and September 2, 2025. An interview conducted with the Director of Nursing (DON) on December 18, 2025, revealed that nursing staff documented completion of PEG site care for Resident R98 on the MAR; however, the DON stated the care was not actually performed. Review of Resident 173's clinical record revealed that resident was admitted on [DATE], with a left foot transmetatarsal amputation (TMA - surgical procedure to remove part of the foot that includes the metatarsals [five long bones in the midfoot]) and wound vac placement (non-invasive treatment method used to promote wound healing). Review of Resident 173's physician's orders included an order for wound vac to left foot wound, cleanse with NSS (normal saline solution), then apply nonadherent dressing (adaptic) over area and place sponge over adaptic. Change every day shift Monday, Wednesday, and Friday. Review of Resident 173's August 2025 Treatment Administration Record revealed that there was no evidence that the treatment was completed on August 8, August 25, and August 27, 2025. Interview with the Director of Nursing on December 18, 2025, at 1:00 p.m. confirmed that there was no documentation that the treatment was completed as ordered. Quality of Care 483.25 Previously cited 12/12/24 28 Pa. Code 201.18(b)(1) Management Previously cited 12/12/24 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 8/5/25, 12/12/24 28 Pa. Code 211.5(f) Clinical records Previously cited 12/12/24

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of nine residents reviewed for nutrition (Resident 17 and Resident 24).Findings include:Review of Resident 17's diagnosis list revealed diagnoses including moderate protein-calorie malnutrition. (condition where there is a deficiency in both protein and calories in the diet)Review of Resident 17's clinical record revealed recorded weights on June 02, 2025, the resident weighed 145.6 pounds; July 03, 2025, 132 pounds; July 9, 2025, 119 pounds. This indicated a weight loss of 13 pounds (9.848%).Further review of Resident 17's clinical record failed to reveal evidence of a reweight after July 9, 2025, was obtained.Further review of Resident 17's clinical record failed to reveal evidence that the facility dietitian was notified of Resident 17's weight loss.Review of Resident 24's diagnosis list revealed diagnoses including vitamin d deficiency, unspecified. (condition where the body lacks sufficient vitamin D).Review of Resident 24's clinical record revealed recorded weights on May 6, 2025, 170.1 pounds; June 9, 2025, 152.8 pounds; June 13, 2025, 153.2 pounds. This indicated a weight loss of 16.8 pounds (9.9%).Further review Resident 24's clinical record failed to reveal evidence that the facility dietitian was notified of Resident 24's weight loss.Interview with Director of Nursing at 12 pm on December 18, 2025, confirmed that further dietary interventions should have been implemented to address Resident 20's weight loss.483.25 Nutrition/Hydration Status Maintenance previously cited 12/12/2428 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observation, interview, policy and clinical record review, it was determined that the facility failed to provide respiratory care and services in accordance with professional standards of practice for one of two residents reviewed (Resident 13).Findings include:Review of Resident 13's diagnoses include chronic obstructive pulmonary disease (lung damage which results in difficulty breathing). Observation of Resident 13 on December 15, 2025 at approximately 10:00 AM revealed that the resident was receiving oxygen at 8 liters per minute via nasal cannula (a device that delivers extra oxygen through a tube into the nose) from an oxygen concentrator (a device that pulls in room air and delivers oxygen for people with respiratory issues).Observation of Resident 13 on December 15, 2025 at approximately 1:20 PM revealed the resident was receiving oxygen at 10 liters per minute via nasal cannula. She was wearing an additional nasal cannula with tubing attached to a portable oxygen tank attached to her wheelchair. The portable oxygen tank was empty.This observation was confirmed by licensed nursing staff (E4) who stated that Resident 13 is only supposed to use the portable oxygen tank when she leaves the room.Review of facility policy 10.5 Oxygen Therapy via Nasal Cannula dated 12/01/06 states Oxygen therapy via nasal cannula will be administered as ordered by a physician and will include correct flow rate, mode of delivery, and frequency.Review of Resident 13's Medication Administration Record reveals the following order: Resident may have up to 3 tanks of 02 (oxygen) when out of her room and has a concentrator to use in her room.Interview with Registered Respiratory Therapist (E3) on 12/18/2025 at approximately 11:00AM revealed that resident did not have an order for oxygen that reflected a correct flow rate, mode of delivery, or frequency. 28 Pa. Code 211.10(c) Resident Care Policies

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to administer non-pharmacological interventions (NPI) and document pain level in accordance with physician orders for one of two residents reviewed for pain management (Residents R11).Findings include:Review of facility policy titled Pain Management, revised March 24, 2025, An individualized, interdisciplinary, person-centered care plan will be developed and include non-pharmacological and pharmacological approaches. And patients receiving interventions for pain will be monitored for the effectiveness and/or side effects/adverse drug reactions. Document non-pharmacological interventions and effectiveness.Clinical record review revealed Resident R11 was admitted to the facility March 9, 2023, with the following admitting diagnosis: unspecified sequelae of cerebral infarction (stroke), COPD (Chronic Obstructive Pulmonary Disorder-a progressive lung condition causing airflow blockage and breathing difficulties, primarily from damage to airways and air sacs), chronic pain syndrome, displaced intertrochanteric fracture of right femur (thigh bone), and multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing.Review of Resident R11's physician's order, dated September 23, 2025, with an end date of December 5, 2025, and a revised order with a start date of December 5, 2025, revealed an order for Oxycodone (opiod for severe pain) 5 mg (milligrams) give 1 tablet by mouth every 8 hours as needed for severe pain for pain level of 8-10 (on a pain scale of 1-10 with 1 being the least pain and 10 the most severe pain).Review of Resident R11's physician order, dated June 25, 2025, revealed an order for non-pharmacological interventions document Q shift Record Non-Pharm intervention in Supplementary Documentation. Document Effectiveness. If having pain follow providers direction which may include pain medication.Review of one month of Resident R11's medication administration record revealed Oxycodone 5 mg was administered on the following dates without a pain rating:-December 3, 2025, at 10:00 a.m.-December 5, 2025, at 07:54 p.m.-December 6, 2025, at 10:28 a.m.-December 10, 2025, at 10:06 a.m.-December 10, 2025, at 8:51 p.m.-December 12, 2025, at 10:00 a.m.-December 13, 2025, at 10:58 a.m.-December 15, 2025, at 10:22 p.m.-December 15, 2025, at 08:23 a.m.-December 17, 2025, at 10:19 p.m.Additional review of Decembers medication administration record revealed no non-pharmacological interventions were utilized prior to the administration of the above medication.Interview on December 18, 2025, at 12:37 p.m. with Director of Nursing, confirmed the facility staff administered Resident R11's pain medication without attempting non-pharmacological interventions and documenting pain level.28 Pa Code 211.10(c) Resident care policies28 Pa Code 211.12 (d)(5) Nursing services

Based on review of facility policy, clinical record review and staff interviews it was determined the facility failed to ensure the physician addressed all recommendations for one of five residents reviewed (Resident 2).Findings include:Review of facility policy Medication Regimen Review and Reporting, undated, revealed that the consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly. Resident-specific Medication Regimen Review recommendations and findings are documented and acted upon by the nursing care center and/or physician. Review of Resident 2's clinical record revealed the pharmacist made recommendations on January 10, 2025, March 14, 2025, April 4, 2025, June 26, 2025, and November 26, 2025.Further review of Resident 2's clinical record failed to reveal evidence of the physician and/or facility response to the pharmacy recommendations for the dates indicated. Interview with the Director of Nursing on December 18, 2025, at 9:55 a.m. confirmed that the above-mentioned pharmacist recommendations were not addressed.28 Pa. Code 211.10(c) Resident care policiesPreviously cited 12/12/2428 Pa. Code: 211.12 (d)(1)(3) Nursing services.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of two medication rooms (Two South and Two North) and two of four medication carts (Two South Long Hall and Two South Short Hall). Review the facility policy, Storage of Medications dated, indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. Review of the U.S. FDA approved prescribing information for Lantus (a type of insulin, an injectable medication to treat diabetes) dated 05/2019, indicated that in-use injection pens must be used within 28 days. Review of the U.S. FDA approved prescribing information for insulin lispro (a type of insulin) dated 05/2015, indicated that in-use injection pens must be used within 28 days. During an observation of the Two South nursing unit medication room on [DATE], at approximately 3:30 p.m., the following was observed: (1) Debridement tray [DATE].(1) Package oxygen tubing, [DATE](3) Safety needles, 03/2019.(1) Extension tubing with connector [DATE].(5) Transport swabs [DATE].(3) Urinary catheter securement devices 02/2020.(4) Urinary catheter securement devices [DATE].(1) Urinary catheter securement device [DATE].(1) Urinary catheter securement device [DATE].(1) Urinary catheter [DATE].(1) Urinary catheter [DATE].(2) Urinary catheter insertion kits [DATE].(1) Pair sterile gloves [DATE].(6) Pair sterile gloves 07/2024.(1) Needleless connector [DATE].(1) Luer access device [DATE].(2) Dressing change trays [DATE].(1) Dressing change tray [DATE].(6) Pair sterile gloves 07/2024.(1) Bottle ostomy lubricating deodorant 05/2024. During an interview on [DATE], at approximately 4:00 p.m., the DON and Registered Nurse (RN) Employee E1 confirmed the above medical supplies were expired. During an observation of the Two North nursing unit medication room on [DATE] at approximately 5:20 p.m., the following was observed: (6) Luer lock access devices [DATE](1) Package oxygen tubing, [DATE](5) Safety needles, 09/2018(1) Transfer straw kit 09/2020(1) Tuberculin syringe [DATE](1) IV catheter 04/2009(1) Syringe with connector [DATE].(5) Blood collection needles [DATE].(1) Tissue infusion sets [DATE].(1) Tissue infusion sets [DATE].(1) Dressing change tray [DATE].(1) Luer access device 08/2017.(1) Luer access device [DATE].(2) 2023-2024 season Fluzone High Dose influenza vaccines.(1) Vial tuberculin solution (Tubersol) with an open date of 12/2(3) Transdermal scopolamine patches Feb/25. During an interview on [DATE], at 5:35 p.m., Licensed Practical Nurse (LPN) Employee E2 confirmed the above medications and medical supplies were expired. During an observation of the Two South Long Hall medication cart on [DATE], at 5:45 p.m., the following was observed:One partially used Lantus injection pen with a written open date of [DATE], and a written expiration date of [DATE]. One partially used Lantus injection pen, undated. One partially used lispro injection pen, with [DATE], written on the pen lid, and [DATE], written on the dating sticker. During an interview on [DATE], at 5:48 p.m. LPN Employee E3 confirmed the above injection pens were undated and/or expired. During an observation of the Two South Short Hall medication cart on [DATE], at 5:50 p.m., the following was observed:Two partially used Lantus injection pens, undated. During an interview on [DATE], at 5:53 p.m., RN Employee E4 confirmed the above injection pens were undated. During an interview on [DATE], at approximate 12:00 p.m., the DON and the Administrator in Training confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility documents, policy review, observations, and staff interviews, it was determined that the facility failed to properly restrain hair and failed to properly store food items to prevent possible cross-contamination in the Main Kitchen. Findings include: Review of the facility dietary policy, Personal Hygiene dated 5/1/25, indicated Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. Review of the facility policy, Refrigerated/Frozen Storage dated 5/21/25, indicated that food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner. All foods are labeled with the name of product and the date received and use by date once opened. Prepared foods are labeled and dated with the name of the product, date opened, and use by date. During an observation of the Main kitchen on 7/31/25, at approximately 4:05 p.m., the following was observed: Dietary Employee E5 admitted the surveyor to the kitchen. When the surveyor retrieved a hairnet immediately upon entering the kitchen and stepped to the hall to place it on, Dietary Employee E5 retrieved a hairnet and placed it on. Observation of the food preparation area revealed both the industrial food mixer and the slicing machine to be uncovered. In the main cooler:-One package of deli meat, wrapped in plastic wrap, without a date.-Six packages of sliced or shredded cheese, wrapped in plastic wrap, without a date.-One package of unknown meat strips, wrapped in plastic wrap, without a date.-One pan of gray-colored pureed food, not dated.-One package of butter, partially used, with the paper wrapping folded back over it, not dated. -One large pan of three uncut meat roasts, wrapped in foil, not dated.-One pan of yellowed pureed food, not dated. -One plastic container of premade omelets, covered with plastic wrap, not dated. -One plastic jug of white beans, without an open date, with a preprinted use-by date of 7/12/25. -Five packages of tubes of unsliced deli meat, wrapped in plastic wrap, not dated. -Two unopened packages of bologna, with a preprinted use-by date of 7/19/25.-Three packages of partially sliced ham, wrapped in plastic wrap, not dated.-A large pan of red gelatin, with a sticker on it that indicated it was made on 7/23/25, and was to be used by 7/27/25.-The fan located at the ceiling was observed to be leaking condensed water onto the bags of potatoes and multiple boxes of food items. In the freezer:-One open box of fish filets, with the inside plastic liner opened, exposing the food to air, not dated.-A Styrofoam cup with a personal drink on the shelf.-Boxes of food items stacked directly on the floor of the freezer. During an observation on 7/31/25, at 4:22 p.m., Dietary Employee E6 was observed to have a beard, without a facial covering over it. Dietary Employee E6 confirmed that the beard nets were locked in the Dietary Manager's office. During an interview on 7/31/25, at 4:25 p.m., the Administrator in Training confirmed the observation of open, undated foods, the presence of expired foods, the mixer and the slider not being covered, the compressor fan in the cooler leaking water onto food items, and two of three dietary staff present not wearing hair and/or beard restraints. During an interview on 8/4/25, at 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to properly restrain hair and failed to properly store food items to prevent possible cross-contamination in the Main Kitchen. 28 Pa. Code: 211.6(c) Dietary services.

Based on review of facility documents and staff interviews it was determined that the facility failed to document grievance resolutions for four of six residents (Resident R4, R5, R6, and R7). Findings include: Review of the facility policy Grievances/Concern dated 1/8/25, stated The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient. Review of facility grievance forms revealed that the form section titled Resolution of Grievance/Concern included areas to document the following:If the grievance was resolved.Date of resolution.Date that written resolution was provided, if necessary.Method used to notify resident or representative of grievance resolution, if not written.Signature and title of staff member resolving the grievance.Signature and title of the grievance officer. Review of a grievance filed on 5/13/25, on behalf of Residents R4 and R5, failed to include documentation including if the grievance was resolved, the date of the resolution, and notification to resident or representative of the resolution. Review of a grievance filed on 5/25/25, on behalf of Resident R6, failed to include documentation of what staff member received the grievance and the resolution date. Review of a grievance filed on 6/23/25, on behalf of Resident R7, revealed the section titled, Resolution of Grievance/Concern to be blank. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to institute corrective actions and resolve resident grievances for four of six residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for failing to implement policies and procedures to report allegations of abuse and/or neglect for six of ten residents (Resident R4, R5, R7, R8, R9, and R10). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility policy, Abuse Prohibition dated 5/21/25, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the facility will perform the following. -Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury.-Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/4/25, included diagnoses of respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C indicated a BIMS score of 10. Review of Section H: Bladder and Bowel indicated Resident R4 was always incontinent of bladder and bowel. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C indicated a BIMS score of 04. Review of Section H: Bladder and Bowel indicated Resident R5 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and history of a stroke. Review of Section C indicated a BIMS score of 03. Review of Section H: Bladder and Bowel indicated Resident R8 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and muscle weakness. Review of Section C indicated a BIMS score of 05. Review of Section H: Bladder and Bowel indicated Resident R9 was frequently incontinent of bladder and always incontinent of bowel. Review of a staff-submitted grievance filed on Resident R4 and R5's behalf dated 5/13/25, indicated When I came in the morning, did my rounds, I noticed [Resident R4 and R5's] brief soaked. I told 11-7 (11:00 p.m. - 7:00 a.m.) assigned CNA (nurse aide) but she stated she just changed them and she is about to leave. Then when 7-3 (7:00 a.m. - 3:00 p.m.) CNA came in they also reported that [Resident R8 and R9] were soaked as well and still in their previous clothes. Review of reports submitted to the local state field office did not include a report of allegations of neglect for Residents R4, R5, R8, and R9. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of amyotrophic lateral sclerosis (ALS, a progressive neurological disorder which results in weakened muscles and deformity) and neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination). Review of Section C indicated a BIMS score of 15. Review of a grievance filed on Resident R7's behalf dated 6/23/25, indicated Resident R7 was crying because her nurse would not provide her as needed medications: Zofran (medication for nausea, Gas-x (medication to treat excess digestive gas) and Flexeril (medication used to treat muscle spasms and pain). Additionally, the grievance stated, Come on man, I don't have time for this. If you are going to keep asking about your medication, I am (missing information). Review of reports submitted to the local state field office did not include a report of allegations of neglect or verbal abuse for Resident R7. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and excoriation (skin-picking) disorder. Review of Section C indicated a BIMS score of 12. Review of a grievance filed by Resident R10 dated 7/2/25, indicated Resident R10 reported to Social Worker Employee E10 that he was verbally abused by Registered Nurse (RN) Employee E11. Supporting documents attached to the grievance indicated that Resident R10 was interviewed on 7/8/25, at 12:02 p.m., and confirmed that RN Employee E11 yelled at him about picking his wound. He still feels that she will do or say something so he can't go back home. He prefers not to have to deal with her. Review of reports submitted to the local state field office did not include a report of possible verbal abuse for Resident R10. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed that facility failed to implement policies and procedures to report allegations of abuse and neglect for six of ten residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to fully investigate allegations of neglect for four of six residents (Resident R4, R5, R8, and R9).Findings include: Review of the facility policy, Abuse Prohibition dated 5/21/25, defined indicated the facility will Initiate an investigation within 24 hours of an allegation of abuse that focuses on:- whether abuse or neglect occurred and to what extent;- clinical examination for signs of injuries, if indicated;- causative factors; and- interventions to prevent further injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/4/25, included diagnoses of respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C indicated a BIMS score of 10. Review of Section H: Bladder and Bowel indicated Resident R4 was always incontinent of bladder and bowel. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C indicated a BIMS score of 04. Review of Section H: Bladder and Bowel indicated Resident R5 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and history of a stroke. Review of Section C indicated a BIMS score of 03. Review of Section H: Bladder and Bowel indicated Resident R8 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and muscle weakness. Review of Section C indicated a BIMS score of 05. Review of Section H: Bladder and Bowel indicated Resident R9 was frequently incontinent of bladder and always incontinent of bowel. Review of a staff-submitted grievance filed on Resident R4 and R5's behalf dated 5/13/25, indicated When I came in the morning, did my rounds, I noticed [Resident R4 and R5's] brief soaked. I told 11-7 (11:00 p.m. - 7:00 a.m.) assigned CNA (nurse aide) but she stated she just changed them and she is about to leave. Then when 7-3 (7:00 a.m. - 3:00 p.m.) CNA came in they also reported that [Resident R8 and R9] were soaked as well and still in their previous clothes. Review of the resolution of the grievance indicated that the nurse aide who was alleged not to have provided care was from a nursing agency and would not be allowed to return to the facility for work. The facility was unable to provide an investigation into an allegation of neglect based on the above grievance. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing (DON) and the Administrator in Training (AIT) confirmed that that an investigation was not completed to ascertain if the licensed nurse supervising the above nurse aide had concerns about her job performance, if other residents on the above nurse aides assignment were provided care, nor was their documentation that skin checks were completed to ensure no skin injuries were incurred due to Residents R4, R5, R8, and R9's extended time left in soiled briefs/clothing. The DON and AIT further confirmed that the facility failed to failed to fully investigate allegations of neglect for four of six residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

Based on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program on two of four nursing units (One North and Two South nursing units). Findings include: Review of the facility preventive maintenance policy, Infection Control Practices dated 5/21/25, indicated the facility will provide a pest free environment. During an interview on 7/31/25, at approximately at approximately 1:30 p.m., the Nursing Home Administrator confirmed that there had been a bat in the facility, but it had been disposed of by staff. During an interview on 8/1/25, at approximately 11:54 a.m., Resident R11 stated that she had seen mice in her room. During an observation on 8/1/25, at approximately 11:58 a.m., of Resident R12, R13, and R14's room, fruit flies were observed. During an interview on 8/1/25, at approximately 12:00 p.m., Resident R18 stated that he has seen mice in his room. During an interview on 8/1/25, at approximately 12:04 p.m., Resident R16 stated that she has seen field mice in her room. During an interview on 8/1/25, at approximately 12:10 p.m., Resident R17 stated that he has often seen field mice. Resident R17 was interviewed in the unit dining room. Resident R17 gestured to the PTAC unit (packaged terminal air conditioner, a type of self-contained heating and air conditioning system) and stated that there was a hole there, and the mice would come in. Resident R17 also stated that he has seen mice run from beneath the soda machine. During an interview on 8/1/25, at approximately 12:15 p.m., Resident R14 stated that he saw a mouse yesterday (7/31/25). During an interview on 8/1/25, at approximately 12:20 p.m., when asked if he has seen mice in the facility, Resident R15 Sure, all the time. This whole place is full of mice. I had two in my room. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed that the facility failed to maintain an effective pest control program on two of four nursing units. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 207.2 Administrator's responsibility.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from abuse for one of six residents (Resident R10).Review of the facility policy, Abuse Prohibition dated 5/21/25, defined verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that they will never be able to see their family again. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), autism disorder, and excoriation (skin-picking) disorder. Review of Section C indicated a BIMS score of 12 (8-12 moderate cognitive impairment, 13-15 cognitively intact). Review of a grievance filed by Resident R10 dated 7/2/25, indicated Resident R10 reported to Social Worker Employee E10 that he was verbally abused by Registered Nurse (RN) Employee E11. Review of statement written by Social Worker Employee E10 indicated, At 1630 (4:30 p.m.) EDT (Eastern Daylight Time) 7/2/25, resident asked to see undersigned. In mtg. (meeting), resident tearful. Resident stated: 'Today when [RN Employee E11] was doing treatment on my back, I guess I may have scratched it again, but she was very mean to me. She started yelling at me, and she said to me' You better stop picking at your wounds or you will never go back home. I have another care meeting next Friday July 11th with the group home staff. I'm afraid [RN Employee E11] is going to say or do something and I will never be able to go back home. She was so mean to me. She was so mad at me.' Review of an employee statement dated 7/2/25, written by RN Employee E11, indicated, [Resident R10] has a large trauma wound on his left shoulder/back. He has increased his picking causing his wound to have extreme delay in healing. On this day [Resident R10's] dressing was removed by him x2 and he picked his wound and caused moderate bleeding and removing tissue from the wound. I have educated him several times that his picking can cause the wound to become infected and delay his discharge. I had to replace his dressing for the third time on 7/2/25 and I did raise my voice to the resident and tell him he needed to stop picking at his wound and that his group home will not take him back until his wound is healed and they do not give that level of care. Resident was seen by psych and his trazodone has now been increased to TID (three times daily). Review of supporting documents attached to the grievance indicated that Resident R10 was interviewed on 7/8/25, at 12:02 p.m., and confirmed that RN Employee E11 yelled at him about picking his wound. He still feels that she will do or say something so he can't go back home. He prefers not to have to deal with her. During an interview on 8/5/25/25, at approximately 12:00 p.m., the Director of Nursing (DON) and the Administrator in Training confirmed that that RN Employee E11 spoked negatively to Resident R10 about a symptom of a diagnosed medical condition, and confirmed that RN Employee E11 raising her voice and verbalizing what was perceived to Resident R10 as a threat to not be able to return to his group home constituted verbal abuse. The DON further confirmed that the facility failed to implement policies and procedures to protect residents from abuse for one of six residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

Based on review of facility policies, clinical record review, and staff interviews, it was determined that the facility failed to obtain the required dental services for three of five residents. (Resident R1, R2, and R3)Findings include: Review of the facility policy, titled Dental Services dated May 21, 2025, revealed the facility will provide, or obtain from an outside resource, routine and emergency dental services to meet the needs of each patient. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated June 4, 2025, included diagnoses of Anemia (too little iron in the body causing fatigue) and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Section L: Oral/Dental Status revealed Resident R1 had experienced, Mouth or facial pain, discomfort or difficulty with chewing within the lookback period (5/28/25 through 6/4/25). Review of Resident R1's plan of care failed to reveal goals and interventions related to dental services or mouth pain until June 2, 2025. Review of a nurse practitioner progress note created on April 15, 2025, at 7:18 p.m., indicated She is being seen today at [resident] request due to complaint of tooth pain. Upon exam, no obvious tooth abnormality or deformity noted, but patient reports pain in right upper back tooth. No increased redness or edema noted. [Resident] denies any other pain or discomfort at this time. The progress further noted: Assessment & Plan:#Tooth pain-acute-new order given to consult dentist.-new order given for Tylenol (acetaminophen, non-narcotic pain medication) 650 mg PO TID (by mouth, three times daily) x5 days. Review of Resident R1's physician note dated April 21, 2025, at 1:03 p.m., revealed Resident R1 C/o (complains of) tooth pain which [he/she] has 2 weeks, relieved by Tylenol. No abscess seen. Dental to see at facility. The progress further noted: Plan:*Tooth Pain-Dental referral placed-d/w (discussed with) nursing-Tylenol for pain prn (as needed). Review of a nurse practitioner progress note dated May 27, 2025, at 3:34 p.m., revealed, No dental consult completed, order placed on 4/21, d/w nursing to schedule. The progress further noted:*Tooth Pain--still pending consult---Dental referral placed-d/w nursing,-Tylenol for pain prn, Review of a change in condition progress note dated June 2, 2025, at 3:30 pm., revealed Resident R1 was experiencing pain and required a dental consult related to pain and tooth cracked. Review of a nurse practitioner progress note dated June 2, 2025, at 3:26 p.m., revealed Resident R1 was seen related to a toothache. Pt (patient) is reporting severe pain L (left) upper side of mouth. On exam, there are no abscesses noted. R (right) upper quadrant tooth 5 or 6 appears chipped/cracked. The progress further noted:#Toothache, acute, labile-Pt c/o R upper quadrant toothache-Order APAP (acetaminophen) 1 gm q 8 x 7 days then PRN (1 gram every 8 hours for seven days, then as needed).-Order Anbesol (topical anesthetic that numbs the skin or mouth for pain relief) qid (four times daily) as prn.-Refer to dentist. Review of Resident R1's progress note dated June 10, 2025, at 4:36 p.m., revealed Resident R1 returned from his/her dental appointment, with temporarily Bridge 2-3-4-5 that is broken in 2 places. Recommendation: needs permanent bridge 2 thru 5. New order Amoxicillin (antibiotic medication). Review of a follow-up note dated June 11, 2025, at 2:08 p.m., revealed Pt initially referred to dentist for L[eft] sided toothache. Reviewed paperwork from appt. Pt with broken temporary bridge 2-5. Recommendations to f/u for permanent bridge as well as course of Amoxicillin. Pt examined today post visit. [Resident] reports [he/she] continues to have pain in L upper quadrant of mouth thought it has improved with APAP. Review of Resident R1's progress note dated June 18, 2025, at 3:06 p.m., revealed Resident R1 was transferred to the hospital for tooth pain/swollen jaw. Review of Resident R1's nurse practitioner progress note dated June 18, 2025, at 3:59 p.m., revealed Pt seen today by request of unit manager for evaluation of swollen face and pt crying in pain. Pt was examined while sitting up in chair. Pt is in obvious distress. [Resident] is crying reporting pain in [his/her] mouth. [Resident] is unable to provide further details only repeating [he/she] needs to see a doctor. On exam, pt with flat red, blotchy area on skin from chin on R side of face. Upper and bottom lips are swollen. Unable to examine inside of pt's mouth as [he/she] is unable to open mouth wide enough presumably due to pain. Review of hospital documentation dated June 18, 2025, revealed Resident R1 was treated in the emergency room for dental pain and a dental infection. Review of Resident R1's progress note dated June 19, 2025, at 2:38 a.m., indicated Resident returned to the facility at 0230 (2:30 a.m.). N/O (new order) to start Augmentin (antibiotic medication) and to schedule a dental appointment ASAP (As Soon As Possible). Review of a follow-up progress note dated June 19, 2025, at 6:31 p.m., revealed, Pt seen today for f/u (follow up) of facial swelling and tooth pain. Pt transferred to ED yesterday after crying in pain and noted with swelling redness on face and lips. Pt was transferred back to facility with Rx (prescription) for Augmentin and recs (recommendations) to f/u with dentist ASAP. Pt examined today while sitting up in chair. [Resident] is a poor historian. [He/she] continues to report pain in tooth. Currently on scheduled APAP with no relief. Was also previously on IBU (ibuprofen, non-narcotic pain medication) with no relief. Review of a progress note dated June 20, 2025, at 2:45 p.m., indicted, Pt seen today in hallway after [he/she] was noted to be at the nurse station crying in pain. Pt is unreliable historian and cannot elaborate on the pain. [He/she] is holding [his/her] face on the R side crying and repeatedly saying [he/she] needs to see a doctor. Pt returned from ED on June 18, 2025 and returned with recs to complete abx and f/u with dentist. The progress further noted:Assessment & Plan:#Dental infection, acute, labile#Broken temporary bridge#Facial swelling- Pt returned from ED with Rx for Augmentin x 10 days- Pt recently completed course of amoxicillin on 6/16, was noted to have facial/lip swelling on 6/18- Augmentin switched to doxycycline (antibiotic medication) 100mg bid x 10 days through 6/29- Ordered tramadol 25mg q8 prn for severe pain- Pt again at nurses station crying in pain. Nurse reports pt just recently received tramadol. Instructed nurse to notify provider if tramadol ineffective for pain control- Continue APAP 1gm q(every) 8 hours. Review of Resident R2's clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses Dementia and gastroesophageal reflux disease (GERD, condition where stomach contents flow back up into the esophagus, causing irritation and other symptoms). Review of a physician's progress note dated April 2, 2025, at 7:01 p.m., indicated, [Resident] is requesting for eye glasses and also to get dental check. The progress note further noted:New order:refer to Opto (optometry)Refer to Dental Review of Resident R2's physician's order dated April 2, 2025, revealed, consult Optometry and dental for Eye glasses and poor dentation. One time only for dentation and poor eye sight for 60 Days. Review of the order details revealed that completion of this order was to be documented on the MAR (medication administration record). Review of Resident R2's MAR from April 2, 2025, through the order completion date of June 1, 2025, revealed this order was completed on April 2, 2025, at 8:57 p.m. Further review of Resident R2's clinical record failed to reveal a dental visit had been scheduled or completed. Review of Resident R3's clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses Dementia and history of a stroke. Review of Resident R3's nurse practitioner note created April 15, 2025, at 1:23 p.m., revealed, Pt was seen by dentist on February 11 at facility. Uploaded consult note reviewed however difficult to read. It appears pt is recommended to follow up in office for extraction of #6. Unclear if this was ever arranged. Will need to f/u with nursing/HUC (unit clerk). Further review of Resident R3's clinical record failed to reveal a dental follow-up had been scheduled or completed. During an interview on August 5, 2025, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to obtain the required dental services for three of five residents. 28 Pa. Code: 211.15(a) Dental services.

Findings include: Review the facility policy, Storage of Medications dated, indicated, Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used extremally such as lotions, creams, ointments, and suppositories. During an observation on 7/31/25, at approximately 5:37 p.m., the treatment cart stored in the Two North Medication room was observed. Upon opening the top drawer, it was noted that the treatment supplies were placed haphazardly in the drawer, with no separation of medications/biologicals based on resident or route of administration. A partial list of what was noted in the cart:Santyl ointmentsCollagenase ointmentsZinc oxide paste.Voltaren cream.Multiple types of gauze and dressing suppliesWound measuring tools.Anti-dandruff shampoo.Medi-honey.Antifungal sprays.Prescription antifungal powder.Multiple rolls of tape.Iodosorb.Vashe wound cleanser.A non-functional thermometer.A watch. Disposable shavers. Upon opening the second drawer, it was noted that the treatment supplies were placed haphazardly in the drawer, with no separation of medications/biologicals based on resident or route of administration. A partial list of what was noted in the cart:Santyl ointmentsZinc oxide paste.Voltaren cream.Multiple types of gauze and dressing suppliesAquafor.Anti-dandruff shampoo.Facial tissue.Antifungal cream.Bandages.Body cleansing wipes.Multiple rolls of tape.Dakin's Solution.Wound cleanser. During an interview on 7/31/25, at approximately 5:40 p.m., Licensed Practical Nurse Employee E2 confirmed the treatment cart was actively in use daily, confirmed the above observations, and confirmed that not storing medications and biologicals for different residents created the potential for cross-contamination between residents. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to maintain infection control practices during medication storage for one of two treatment carts. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e )(1) Management. 28 Pa Code: 211.10 (d ) Resident care policies.

Based on clinical record review, observations, and interviews with residents and staff it was determined that the facility failed to maintain personal dignity for two of six residents observed (Resident R1, R2) Findings Include: Facility policy titled Residents Rights Under Federal Law , revised 2023, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included fracture of upper end of left humerus, schizophrenia (mental health condition that affects how people think, feel, and behave), and muscle weakness. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 06, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of Resident R1's MDS assessment, dated June 10, 2025, revealed under section GG- functional abilities, Resident R1 is dependent (helper does all the work) on upper and lower body dressing (the ability to dress and undress) Observation on 1st floor unit 2 wing on June 21, 2025 at 11:02 a.m. revealed Resident R1's door open. Resident R1 was observed to be exposed with only a brief on. Interview with Resident R1 on June 21, 2025 at 11:04 a.m. revealed Resident R1 felt uncomfortable that his/her door was open while he was laying in bed with only a brief on. Resident R1 stated staff did not close the door when exiting the room. Clinical record review revealed Resident R2 was admitted to the facility on [DATE] with a diagnosis that congestive heart failure (chronic condition that affects the hearts ability to pump blood well), rhabdomyolysis (serious condition where the muscles break down and release toxins into your blood and kidneys), and muscle weakness. Review of Resident R2's MDS assessment, dated May 08, 2025, revealed Resident R2 had a BIMS score of 13 indicating cognitively intact. Review of Resident R2's MDS assessment, dated May 20, 2025, revealed under section GG- functional abilities, Resident R2 requires supervision or touching assistance (helper provides verbal cues and/or touching/ steadying assistance as resident completes activity) on upper and lower body dressing. Observation on 2nd floor unit 4 wing on June 21, 2025 at 11:13 a.m. revealed Resident R2's door open. Resident R2 was observed sitting on his/her bed with lower body exposed and no brief on. Interview with Resident R2 on June 21, 2025 at 11:14 a.m. revealed Resident R2 needed assistance with lower body dressing. Interview with Certified Nursing Assistant, Employee E1, on June 21, 2025 at 11:17 a.m. confirmed Resident R2 requires assistance with dressing and Resident R2's door should be closed for privacy. Residents R1 and R2 both had their doors and privacy curtains open, revealing their body to anyone who walked past their rooms. 28 Pa. Code: 201.18(b)(2) Management. 28 Pa. Code: 201.29(j) Resident's rights.

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for four out of 35 residents reviewed (Resident 11, Resident 59, Resident 64, and Resident 164). Findings include: Review of facility policy titled Enhanced Barrier Precautions, revision date January 8, 2024, states Enhanced Barrier Precautions (EBP) is based on the Centers of Disease Control & Prevention (CDC) guidance, Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs). Review of Resident 11's clinical record revealed the resident was admitted [DATE], with an admitting diagnosis of sepsis (occurs when your immune system has a dangerous reaction to an infection, resulting in tissue damage and organ failure). Additional review of Resident 11's clinical record revealed an active order for indwelling foley catheter due to: neurogenic bladder (a condition where a problem in the brain, spinal cord, or central nervous system causes loss of bladder control), with a start date of July 5, 2024. Review of Resident 11's clinical record failed to reveal an order for enhanced barrier precautions. Observations conducted on December 11, 2024, and December 12, 2024, revealed that Resident 11 did not have any EBP signage or PPE located in or outside of his room. Interview conducted with the Director of Nursing (DON) on December 12, 2024, at 10:37 a.m. confirmed the facility failed to establish enhanced barrier precautions for Resident 11. Clinical records review revealed Resident 59 had an order for a GT (Gastrostomy tube- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth) feeding for diagnosis of protein calorie malnutrition. Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 59's room. Clinical records review revealed Resident 64 had an order for a GT feeding . Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 64's room. Clinical records review revealed Resident 164 was admitted on [DATE], with a diagnosis of small bowel cancer. The resident had an admission order for a PICC line (Peripherally Inserted Central Catheter- a thin, flexible tube inserted into a vein in the vein near arm and threaded into a large near the heart) to the left upper arm, a foley catheter for urinary retention and a GT attached to a collection bag for abdominal decompression. Observation and interview with the Resident 164 confirmed that presence of a PICC line to the left upper arm, indwelling foley catheter, and GT attached to a collection bag. Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 164's room. An interview with licensed nurse Employee E6 conducted on December 12, 2024 at approximately 10:00 a.m., revealed that residents requiring EBP needed to have a signage by the door for communication and PPE set up outside of the resident's room. Employee E6 acknowledged the absence of the signage and PPE set up for Resident 64 and 164 and reported that she/he just notified the staff responsible in placing the signage and PPE's for the resident mentioned above. An interview with the Regional nurse Employee E9 and Director of Nursing on December 12, 2024, at 1:00 p.m., confirmed EBP process was not implemented for Resident 59, 64, and 164. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263) Findings include: Review of facility policy and procedure titled Assessment: Nursing last revised March 2022, revealed A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. Assessments will be reviewed and certified as completed by an RN within 24 hours and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment, he/she completed. Review of Resident 263's clinical record revealed the resident was admitted to the facility on [DATE] from the hospital. Review of Resident 263's documentation from the hospital revealed the resident went to the hospital and was admitted after a near syncope (fainting) episode during which she was hypotensive (low blood pressure) and had difficulty getting into her house. Further review of the hospital documentation revealed the resident was discharged with a diagnosis of Hypotension and Syncope. Review of Resident 263's physical therapy documentation while in the hospital revealed the resident was determined to be at risk for falls and to have ambulation deficits, balance deficits, bed mobility deficits, strength deficits, transfer deficits and safety awareness deficits. Review of Resident 263's facility diagnosis list revealed diagnosis of Hypotension (low blood pressure), Syncope (sudden, temporary drop in the amount of blood that flows to the brain), and collapse. Review of Resident 263's Vital Signs revealed a blood pressure on December 17, 2023 at 9:32 P.M. of 102/45 (normal 120/80). Review of Resident 263's admission assessment dated [DATE] revealed the resident was determined to have no risk factors for falls related to history or fear of falls or factors such as current diagnosis or medications that would increase the risk for falls and there was no risk for falls due to the resident's presence or history of gait, strength, or balance factors. Review of Resident 263's progress notes revealed a nursing entry dated December 18, 2023 at 2:53 a.m. that indicated CNA (Certified Nursing Assistant) heard a noise and went into the room to check on patient and found her on the floor face down next to the bed. R (right) facial laceration at smile line measuring 4 cm (centimeters) and one of R eye measuring 1.5 cm. Peri orbital (eye) swelling noted on right side. EMS (Emergency Medical Services) called at 0233 (2:33 a.m.). Review of Resident 263's care plan revealed there was no care plan developed for risk for falls or interventions in place prior to the fall of December 18, 2023. Resident 263 was inaccurately assessed at the time of admission as not being at risk for falls and there were no interventions in place to prevent falls leading to a fall with major injury that required hospitalization on [DATE]. This information above was relayed to the Nursing Home Administrator on June 24, 2024 at 1:15 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to ensure residents were free from physical abuse by Resident 88 who previously demonstrated physical aggression towards other residents, which resulted in harm requiring emergency medical treatment of Resident 141. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. Findings include: Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed. Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Review of Resident 88's clinical record revealed an admitted [DATE], which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities). Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to the local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member. Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her. Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others. Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents. Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation. Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified. Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first. Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated. Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty. Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher. Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents. Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88. Review of Resident 88's clinical record revealed a progress note dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her. Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead. Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment. Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable). Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates. The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy. An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and an Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023. Upon supervisory review dated August 25, 2023 it was determined the facility placed residents in Immediate Jeopardy of abuse on August 17, 2023 concurrently with Immediate Jeopardy of Supervision. The facility was notified on August 25, 2023 at 10:00 a.m. of the supervisory review and presented with the Immediate Jeopardy template for failure to ensure residents on the secured nursing unit were safe from Resident 88 who had a known physical aggression history. The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review. The action plan was accepted on August 17, 2023, at 6:09 p.m. On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. The facility failed to ensure Resident 88 with known physical aggression history from physical abuse towards other residents resulting in an injury to Resident 141 which required emergency hospital treatment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records

Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration to the forehead requiring emergency hospital treatment. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. The facility failed to ensure interventions were in place to prevent falls for two residents (Residents 67 and 68) reviewed resulting in actual harm to Resident 68 who sustained a fracture. Findings include: Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed. Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Review of Resident 88's clinical record revealed an admitted [DATE], which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities). Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member. Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her. Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others. Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents. Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation. Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified. Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first. Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated. Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty. Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher. Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents. Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88. Review of Resident 88's clinical record revealed a progress notes dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her. Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead. Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment. Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable) . Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates. The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy. An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023, regarding the facility's failure to ensure the residents were free from threat of physical violence when staff failed to provide supervision for a resident with a history of violent and aggressive behavior. The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review. The action plan was accepted on August 17, 2023, at 6:09 p.m. On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. Review of Facility policy and procedure titled Falls Management, revised June 15, 2022 revealed Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Adjust and document individualized intervention strategies as patient condition changes. Review of Resident 68's demographic sheet revealed the resident was admitted to the facility on [DATE]. Review of Resident 68's Admission Evaluation, dated April 8, 2023 revealed in the section titled Fall Risk Factors Resident 68 was identified as having worries about falling or feeling unsteady when standing or walking as well as having incontinence as risk factors for falls. Resident 68 was indicated as requiring a care plan for risk for falls. Further review of the document failed to reveal fall prevention interventions to be included on the care plan. Review of Resident 68's clinical record failed to reveal subsequent fall risk assessments completed until May 20, 2023. Review of Resident 68's Admission Minimum Data Set (MDS- periodic assessment of resident needs) dated April 14, 2023 revealed the resident had a fall in the last 2-6 months prior to admission and triggered for a falls care plan. The assessment was coded as being completed on April 20, 2023. Review of Resident 68's admission care plan failed to reveal a care plan for the prevention of falls. Review of Resident 68's Progress Notes revealed a nursing entry dated April 26, 2023 at 6:23 p.m. stating resident was found on the floor next to her bed five or six feet from her wheelchair at 3:45 p.m. states 'my foot slipped' when asked what happened. No injuries were noted and denies pain anywhere. Further review of Resident 68's progress notes revealed a note dated April 26, 2023 at 6:54 p.m. indicating, Resident had just finished up with visit from her daughter, resident trying to go out of the dinning room and back to her room. Resident had a previous fall and was being closely monitored. CNA (certified nurse aide) on shift was pushing resident in wheelchair back into the dinning room when resident removed her feet from the leg rest and tried to stop the chair. Resident placed her feet on the floor to stop the wheelchair and fell front. When falling the resident did strike the left side of her head. Resident had a small bruise to the chest area along with an abrasion to the left side of her head. MD (medical doctor) gave order to send resident out for cat (Computed Tomography-diagnostic cross-sectional X-ray images of the body) scan and to be evaluated. Further review of Resident 68's progress notes revealed a nursing entry dated April 27, 2023, at 1:22 a.m. indicating resident returned to the facility after being sent to the hospital for a fall with a diagnosis that included a fracture of the left clavicle (collar bone). Review of Resident 68's current care plan revealed a care plan for falls wasn't developed until April 28, 2023. Interview with the Nursing Home Administrator and the Director of Nursing on August 2, 2023 at 12:30 p.m. confirmed there was no comprehensive assessment of Resident 68's falls risk and no care plan developed upon admission to prevent falls. The facility failed to comprehensively assess Resident 68 and develop interventions to prevent falls for Resident 68 resulting in actual harm to Resident 68 when Resident 68 had two falls on April 26, 2023 requiring evaluation and treatment for a fractured clavicle at the hospital. Observation of Resident 67 on July 31, 2023 at approximately 11:00 a.m. revealed the resident was nonverbal with bilateral contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) to both the upper and lower extremities. Review of Resident 67's clinical record revealed a diagnosis of Anoxic Brain Injury (brain injury from lack of oxygen). Review of Resident 67's care plan revealed the resident was identified as requiring assistance for mobility with an intervention added March 25, 2022, for the resident to have two staff person assistance with repositioning in bed. Review of Resident 67's progress notes revealed a nursing note dated July 20, 2023, which indicated; [Staff person] was changing resident and since the bed was saturated she was trying to change the sheets. Resident kicked and when she kicked she rolled out of bed and hit the floor. When she hit the floor she hit her head on either the dresser or the floor resulting in bleeding. Further review of Resident 67's progress notes revealed the resident was sent to the hospital and returned a few hours later when the CT scan showed no injuries, and the resident did not require sutures. Review of facility documentation including incident report dated July 20, 2023 revealed there was only one staff person assisting Resident 67 to turn in bed. Interview with the Director of Nursing on August 3, 2023, at 10:30 a.m. confirmed Resident 67 should have had two staff people present when repositioning in bed. F 0689 Free of Accidents/Hazards/Supervision/devices was previously cited on November 16, 2022 at scope and severity level J. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited on 11/16/22 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited on 04/04/23; 11/16/22 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.10 (d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited on 4/4/23, 11/16/22, 2/10/22, 8/23/21, 7/8/21, and 4/20/21

Based on observations, clinical record review, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions, supervision, and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident assessed with history of elopement and exit seeking behavior. This failure placed residents at the facility in an Immediate Jeopardy situation for one of four residents reviewed who were identified as at risk for elopement (Resident R1). Findings include: Review of the facility's policy titled Courtyard Monitoring Guidelines, undated, revealed residents with cognitive impairment, impaired communication, require extensive assistance with mobility, or have poor decision-making skills are not permitted to go outside unless accompanied by a staff or family member. Review of Resident R1's diagnosis list includes Aphasia (language disorder that affects a person's ability to communicate), Major Depressive Disorder, Cocaine Dependence In Remission, Other Seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), and Schizophrenia (mental health disorder characterized by significant alterations in perception, thoughts, mood, and behavior). Review of Resident R1's clinical record revealed a document titled Court of Common Pleas of Philadelphia County, Pennsylvania Orphans Court Division dated November 14, 2017, indicating resident was adjudged a totally incapacitated person. Further review of document revealed Resident R1 was assigned a guardian due to impaired capacity to receive and evaluate information effectively and to make and communicate decisions to such a degree that he/she is totally unable to meet the essential requirement for his/her physical and safety. Review of Resident R1's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated October 13, 2022, revealed a BIMS (Brief Interview for Mental status) score of 15, indicating the resident's cognition was intact. The same MDS also revealed that the resident required supervision with locomotion on and off the unit. Review of Resident R1's current care plan initiated on September 17, 2018, revealed a plan of care for wandering, pacing, and restlessness. An intervention developed revealed, allow to front lobby only during hours it is monitored by staff. A care plan for exit-seeking and elopement risk was developed on May 5, 2019, an intervention includes the placement of an alert bracelet. Additional review revealed resident was care planned for physical/verbal aggression and was non-compliant with care and treatments. Review of Resident R1's clinical record revealed the resident was placed on the secure nursing unit upon admission, date of March 14, 2018. Review of facility documentation, and incident report dated January 25, 2021, revealed [Resident R1] was found on a nearby road by a staff member. Additional review of clinical record revealed that the resident was able to leave the building by taking off his/her alert bracelet and watching staff enter the door's security code. The resident was returned to the facility safely. Additional review concerning the elopement of January 25, 2021 was unable to be completed as the documents were unavailable for review. Additional review of Resident R1's care plans failed to reveal any interventions to address elopement of January 25, 2021. Review of Resident R1's clinical records including the most recent, Behavioral assessment dated [DATE]; indicated the resident was exit seeking. Review of a NP Progress note dated August 8, 2022, revealed that on August 22, 2022, the resident was seen for excessive behaviors which includes pacing and talking to himself. The resident admitted to feelings of anxiety, stating his/her mind was racing and was having trouble sleeping. Laboratory works were ordered; medication dosage was changed. Review of nursing progress notes dated November 9, 2022, (12:15 p.m.), revealed Resident R1 requested to go downstairs, accompanied by agency staff member who requested the elevator pass code from the front desk staff. Review of the progress notes dated November 9, 2022, (4:23 p.m.), revealed at approximately 1:00 p.m., this nurse was notified that Resident R1 was missing. The note revealed that the floor nurse reported accompanying the resident downstairs and turned him/her over to the receptionist. The note indicated that it was a common thing for Resident R1 to go to the courtyard daily. As soon as the resident was identified missing, a search was initiated, police were notified, responsible party and physician were notified. Review of the facility investigation, including the facility's surveillance camera footage revealed on November 9, 2022, at 11:56 a.m., Resident R1 was allowed entrance into the outside courtyard unaccompanied by front desk staff. At 12:10 p.m., the resident was seen on the video footage looking in the glass door, a passing housekeeper opened the door, but the resident did not reenter the building. At 12:39 p.m., another resident observed entering the courtyard but indicated no other persons observed in the courtyard at time of entrance. At 1:20 p.m., a missing resident protocol was initiated. Observation of the courtyard was conducted on November 15, 2022, at 10:00 a.m., in the presence of the Nursing Home Administrator (NHA). The courtyard is connected to the front lobby, requiring a security code to enter. The courtyard was secured with an estimated eight foot fences. The gate had a padlock observed to be intact. The Administrator reported that during the investigation it was noted where the right-side of fence (concrete base with wrought iron spike top) anchors the attached gate to the brick was loose but the gap was not wide enough to allow Resident R1's body size (large) to pass. Per Nursing Home Administrator, police investigators postulated the resident climbed the fence. During the observation, the right side of the fence was fixed and properly secured. Review of the facility surveillance camera on November 15, 2022, at 11:30 a.m., in the presence of the Assistant Administrator, Employee E3, revealed that at 11:55 a.m., on the day of the incident, Resident R1 was admitted to the courtyard unaccompanied by the front desk staff, identified as Employee E4. Further review of camera footage revealed at 12:10 p.m., a passing staff member opened the door, spoke to the resident, then closed the door leaving Resident R1 in the courtyard by himself/herself. Additional review of outside camera footage revealed that at 12:18 p.m., the resident was seen leaving the courtyard area and walking towards the street. Interview with licensed nurse Employee E5 conducted on November 15, 2022, at 11:45 a.m. revealed, on the morning (around 8:30 a.m.- 09:00 a.m.) of November 9, 2022, the resident was frustrated due to inability to leave the secure dementia unit earlier due to the unavailability of the staff to escort him to the front lobby. Employee E5 reported that at around 11:30 a.m., she/he accompanied the resident to the front lobby after Employee E5 requested the security code of the elevator. Employee E5 reported leaving Resident R1 in the front lobby after informing receptionist, Employee E4 regarding the presence of the resident. Employee E5 stated, at that time, I have transferred the responsibility to her. Interview with receptionist, Employee E4 conducted on November 15, 2022, at 11:50 a.m. revealed, Resident R1 had been going to the courtyard alone since approximately October 2021. Employee E4 indicated, he/she was not informed the resident required staff supervision when going to the courtyard. Employee E4 reported not being able to see residents in the courtyard especially when she/he is sitting at the desk. Employee E4 stated, I don't have a responsibility for them (residents) unless they needed to go back in, I also make sure they don't smoke. Interview with non licensed, Employee E6 conducted on November 15, 2022, at 1:00 p.m., revealed Resident R1 goes to the courtyard by himself /herself to get fresh air daily depending on the weather. Employee E6 reported that Resident R1 spends most of the day pacing in the hallway, standing by the exit doors, and observing staff getting in and out of the unit. Employee E6 reported that these were normal behaviors for Resident R1. The above information was conveyed to the NHA and DON on November 15, 2022, at 2:00 p.m. Resident R1 was assessed as an elopement risk with a history of actual elopement while in the facility. The resident continued to exhibit exit seeking behaviors, after successful elopement on January 25, 2021. The facility failed to follow the resident's plan of care, implement appropriate supervision interventions, and provide effective safety measures to prevent Resident R1 from leaving a safe area, walking out of the building with the potential to experience negative outcomes. Resident R1's whereabouts are still unknown as of November 15, 2022. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on November 15, 2022, at 4:10 p.m., and the IJ template was provided. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure the implementation of appropriate supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On November 15, 2022, at 11:11 p.m., an acceptable immediate action plan was approved which included the following interventions: Head count of current residents conducted on November 9, 2022, after identifying that Resident R1 was missing. Missing resident protocol, including an internal and external search of the facility was initiated but the resident was unable to be located. The police (including transit police) were notified, as well as the attending physician and Guardian were notified. Education for facility staff was initiated regarding supervision of residents and Courtyard Monitoring. The facility staff were educated in person and via phone regarding supervision of residents. Upon Resident R1 return, the facility will review physician orders and assessments for accuracy, and will check wander guard for function and placement. The elopement care plan will be updated to include 1:1 supervision intervention. All residents will be or were assessed for elopement risk, and orders will be reviewed and updated. All wander guards will be checked on residents assessed as an elopement risk for functionality and placement. All residents assessed to be at risk for wandering will have the care plan reviewed for appropriateness and accuracy. The care plan will be audited by the DON/designee weekly for four weeks then monthly for two. Audit results are to be reviewed at the QA (Quality Assurance) meeting. Current residents at risk for wandering were reviewed on November 10, 2022, to validate appropriate orders and care plans. Full house review of residents at risk who are independently mobile, cognitively impaired, and/or have a court-appointed guardian will be reviewed for appropriate supervision needs to be completed on November 16, 2022. The center will conduct Courtyard monitoring and security audits three times a week on each shift for two weeks weekly, then monthly each month for two months. All residents assessed to be at risk for wandering will have their care plan reviewed for appropriateness and accuracy. Care plans will be audited by the DON/designee. All audit results will be reviewed at the QA meeting. Elopement policy and courtyard monitoring/supervision were reviewed but deemed no changes needed. The outside courtyard fence and gate were repaired and an additional lock was placed on the gate. The facility placed signs on all exit doors for staff and visitors to prohibit residents from leaving unsupervised. Random audits of residents with exit-seeking behaviors will be completed five times a week for one week, weekly for three weeks, then weekly for two months. Staff education to include an emphasis on ensuring proper supervision for any resident identified with cognitive impairment, to include court order capacity; ongoing as needed. The QAPI committee will meet and determine further actions and audits based on trends and analysis. The facility continues to search and coordinate and contact the police, Septa, former residences, and local hospitals to obtain regular updates and any additional information. On November 15, 2022, at 10:50 a.m., a Department of Health surveyor entered the facility to verify the immediate action plan was implemented. Through observations, staff interviews, facility documentation, and audits, it was confirmed that the facility's immediate action plan was implemented, and Immediate Jeopardy was lifted on November 16, 2022, at 4:17 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services Previously cited 2/10/22, 8/23/2021, 7/8/21 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 2/10/22, 8/23/2021, 7/8/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/10/22, 8/23/2021, 7/8/21, 4/20/2021

Based on policy and clinical record review, and staff interview, it was determined that the facility failed to notify the practitioner timely of a change in condition for one of 29 residents reviewed, which resulted in actual harm to Resident 112, who experienced a delay in being sent to the hospital for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy, Change in status, identifying and communicating, long-term care, last revised August 19, 2022, revealed that the facility must consult with the resident's physician when there is a significant change in the resident's physical status and a need to alter treatment significantly. Further review of facility policy revealed, According to the American Medical Directors Associations (AMDA) clinical practice guidelines -Acute changes in condition in the Long Term Care setting: Immediate notification is recommended for any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms or unrelieved by measures already prescribed. Review of Resident 112's clinical record revealed, the resident was admitted to the facility on [DATE], with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 112's progress notes revealed a physician's note dated January 28, 2022 at 5:04 p.m., which indicated the resident had crackles in the lungs (noises heard in the lungs with a stethoscope, indicative that there is fluid in the lungs.) The physician ordered a stat (immediate) chest x-ray. Further review of Resident 112's progress notes revealed a nursing note on January 29, 2022 at 6:41 a.m. which stated that the facility received the x-ray results, which were faxed to the physician on this shift. Review of Resident 112's chest x-ray results from January 29, 2022 revealed moderate pleural effusions (fluid in the lungs). Review of Resident 112's clinical record including a respiratory assessment conducted by registered nurse, Employee E5 documented in a respiratory progress note dated January 30, 2022 (01:54 AM) revealed, lung sounds: Right upper lobe crackles, Right lower lobe crackles, Left upper lobe crackles, and Left lower lobe crackles. Additional review of Resident 112's progress notes revealed a respiratory assessment by the registered nurse, Employee E6 who documented in a respiratory progress note dated January 30, 2022 (14:09/2:09 PM) which revealed, lung sounds: Right upper lobe crackles, Right lower lobe crackles, Left upper lobe crackles, and Left lower lobe crackles. Review of Resident 112's progress notes dated January 31, 2022, revealed a progress notes from the certified registered nurse practitioner (CRNP) Employee E4, which stated the resident was admitted on [January 27, 2022] and found to be SOB [short of breath] and have abnormal lung exam. She was given one dose of [[MEDICATION(S)] - water pill] and stat XRay was ordered which was done on [January, 29, 2022]. Results per notes were faxed to the office but on call was not notified. I reviewed results today and XRay shows moderate pleural effusion. Further review of CRNP Employee E4's progress note revealed the resident was experiencing swelling in the right arm, so a venous doppler (ultrasound which checks the circulation of large veins) was ordered. Review of Resident 112's venous doppler from February 1, 2022, revealed the resident had a DVT ([CONDITION(S)] - blood clot.) Review of Resident 112's progress notes revealed the resident was transferred to the hospital on February 1, 2022, for [CONDITION(S)] (low oxygen), [CONDITION(S)] (elevated heart rate), and DVT. Review of Resident 112's hospital records from February 1, 2022 through February 9, 2022 revealed the resident presented with shortness of breath, [CONDITION(S)], and [CONDITION(S)] and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was treated with IV [MEDICATION(S)] (blood thinning medication) and an IVC filter (small device that is placed in the inferior vena cava to prevent blood clots from moving through the blood into the lungs.) Interview with CRNP Employee E4 on October 6, 2022, at 11:00 a.m. revealed that the stat chest x-ray was ordered on January 28, 2022, which was a Friday night. The results were obtained January 29, 2022, Saturday morning. There is no one at the physician's office on the weekend to receive fax results, so the earliest the results would have been reviewed were Monday morning, three days after the XRay was ordered. Further interview with the CRNP confirmed Resident 112's XRay results should have been communicated to the on-call physician as soon as they were received by the facility so that the resident could have been treated appropriately and in a timely manner. The above information was conveyed to the Nursing Home Administrator on October 6, 2022, at 11:35 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review, resident, physician, and staff interview, it was determined that the facility failed to follow a physicians order for four residents (Resident 9, 13, 99, and 409) and failed to notify the physician of an abnormal blood test result in a timely manner. The failure to notify the physician resulted in actual harm of a hospitalization for one of 31 residents reviewed (Resident 76). Findings include: Review of Resident 76's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 76's clinical record revealed a physician's progress note dated June 17, 2021, at 3:27 p.m., indicating the resident had a constant small amount of loose stool mixed with blood, generalized abdominal pain mostly on the right lower quadrant area, complaint of nausea but no vomiting. The same progress note revealed that blood results were pending. Review of the laboratory blood results revealed the blood specimen was collected on June 17, 2021, at 5:00 a.m. The final report was dated and printed on June 17, 2021, at 2:20 p.m. The blood result revealed the following: WBC (White Blood Count- also called Leukocytes, cells responsible for fighting infections by attacking bacteria, viruses, and germs that invade the [NAME]) 19.1 (normal range was 3.5-11.0); and NA (Sodium- used as part of an electrolyte panel for a routine health exam) 124 (normal range was 135-145 mMOL/L) The hardcopy blood test result was located on the resident's hard copy chart on August 24, 2021. Review of resident 76's progress notes dated June 17, 2021, through June 21, 2021, failed to reveal that the physician was notified of Resident 76's abnormal blood result. Review of the Nurse Practitioner's (NP) progress notes dated June 21, 2021, at 3:04 p.m., revealed, [Resident 76] was seen for follow up, staff reported that the resident had several pasty stools with frank blood in them, refused to eat anything 'today', and did not participate in rehab. The resident also complained of diffused abdominal pain and feeling very weak. The NP notes revealed, I reviewed labs from 6-17-21, results of which were abnormal and never reported to us: WBC 19.1, NA 3.2, K 3.2. The NP notes also revealed an Assessment and Plan: Leukocytosis (A condition in which the white blood cell is above the normal range in the blood, usually a sign of infection). Worsening leukocytosis, worsening diffuse abdominal discomfort. Reviewed abnormal labs from June 17, 2021, 'not reported to us', will send to ER (emergency room ) for evaluation due to slow process in the nursing home; [CONDITION(S)], NA was 124 on June 17, 2021, 'not reported', she is currently on [MEDICATION(S)] 40 mg (medication used to treat fluid build-up due to heart failure), the patient is symptomatic, weak, and very tired. A review of the nursing progress notes dated June 21, 2021, at 6:21 p.m., revealed Resident 76 will be transferred to the hospital as ordered by the physician for Leukocytosis, diffuse abdominal pain, and [CONDITION(S)] (Extreme abnormal lab result drawn last Thursday). A review of the nursing progress notes dated June 22, 2021, at 4:28 a.m., revealed that Resident 76 was admitted to the hospital for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital records dated June 21, 2021, at 6:48 p.m., revealed Resident 76's chief complaint was for an evaluation of abnormal chemistry results, decreased sodium. Blood test result dated June 21, 2021, at 7:11 p.m., revealed a critical result of 118. The resident was admitted to the Telemetry unit (units where patients are under constant electronic monitoring) for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Resident 76's physician on August 23, 2021, at 10:00 a.m., confirmed that the abnormal blood test results drawn on June 17, 2021, was not communicated to the physician until the nurse practioner conducted a follow-up visit on June 21, 2021, resulting in the resident being transferred to the hospital for further evaluation. An interview with the Director of Nursing and licensed nurse Employee E7 on August 23, 2021, at 11:30 a.m., revealed that the nurse on the unit and the nursing supervisor was responsible for checking for the blood test result and communicating with the physician. Employee E7 reported the blood test results were relayed to the facility through fax, online checking, or a phone call from the laboratory (for critical results). An interview with the nursing supervisor, licensed nurse Employee E8 on August 23, 2021, at 12:30 p.m., revealed that blood drawn in the morning usually has results communicated to facility approximately 2:00 to 5:00 p.m. Employee E8 reported that the nurse on the unit is responsible for checking blood test results through several ways: check for results via fax; check result via on-line, or call the laboratory. Employee E8 reported that the facility procedure was to flag out normal laboratory results for the physician/NP to review on their next visit. Abnormal laboratory results should be relayed to the Physician/NP immediately. Employee E8 denied that the nursing supervisor was responsible for checking the resident's laboratory results unless the nurse on the unit was busy and ask the supervisor for assistance with laboratory test result checking. Employee E8 stated, I do not go floor to floor to check lab (laboratory) results. Employee E8 reported that on June 17, 2021, she/he cannot remember being informed of an abnormal blood result by the nurse on the unit. An interview with the DON on August 23, 2021, at 1:00 p.m., revealed that Resident 76's nurse on June 17, 2021, was a PRN (as needed) employee and unavailable for interview. The facility failed to notify Resident 76's physician of a low Sodium level in a timely manner resulting in actual harm to the resident hospitalized and admitted for [CONDITION(S)]. A review of Resident 9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 9's clinical record revealed June 2021, MAR (Medication Administration Record) revealed that the [MEDICATION(S)] medication was administered to the resident on the following dates: June 4, 2021, at 9:00 a.m., for a BP of 122/78; June 4, 2021, at 5:00 p.m., for a BP of 128/80; June 7, 2021, at 9:00 a.m., for a BP of 129/77; June 10, 2021, at 9:00 a.m., for a BP of 125/60; June 10, 2021, at 5:00 p.m., for a BP of 122/64; June 16, 2021, at 9:00 a.m., for a BP of 128/76; June 20, 2021, at 9:00 a.m., for a BP of 122/71; June 20, 2021, at 5:00 p.m., for a BP of 126/70; June 21, 2021, at 5:00 p.m., for a BP of 122/72; June 24, 2021, at 9:00 a.m., for a BP of 137/96; June 29, 2021, at 9:00 a.m., for a BP of 128/78; and June 30, 2021, at 9:00 a.m., for a BP of 126/62. Interview with the Director of Nursing on August 24, 2021, at 11:30 a.m., confirmed that the [MEDICATION(S)] was administered to Resident 9 outside of the ordered parameters. The DON also confirmed that the physician was not notified of the medication administered outside of the ordered parameters. The facility failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 13's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 13's Weight Summary Report revealed that the resident's weight on July 6, 2021, was 368 lbs. and 376 lbs. on July 8, 2021, an 8 lbs. weight gain in two days. A review of the same report revealed that on July 29, 2021, the resident's weight was 378.2 lbs. and was 387.4 pounds on July 30, 2021, a 9.2 lbs. weight gain in one day. A review of Resident 13's clinical records failed to reveal that the MD/NP was notified of above 5 lbs. weight gain in less than five days until August 23, 2021. An interview with the Director of Nursing on August 23, 2021, at 1:00 p.m., confirmed that the physician was not informed of Resident 13's above 5 lbs. weight gain in less than a week. The facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . weight gain in a week. Review of Resident 99's progress notes revealed a note written by the nurse practitioner on May 10, 2021, which stated: Notified by patient that he had not been receiving his [MEDICATION(S)] (medication used to prevent nausea, vomiting, and dizziness), and he is experiencing [CONDITION(S)] (dizziness). He was previously receiving 12.5 mg [(milligrams)] PO [(by mouth)] TID [(three times daily)], but on 4/23/21, he was changed to a 3 day trial of 25 mg PO TID to combat increased [CONDITION(S)]. He was to return to previous dose of 12.5 mg PO TID after the 3 day trial. Review of chart and administration record indicated that the [MEDICATION(S)] order was entered incorrectly at that time, and patient received 3 day trial of [MEDICATION(S)] 25 mg PO TID, followed by 12.5 mg PO TID for 3 days only, instead of continuing every day. Review of Resident 99's orders revealed that the order written by the same nurse practitioner on April 23, 2021 stated Increase [MEDICATION(S)] dose to 25 mg PO TID x 3 days, then return to 12.5 mg x 3 days - same times as currently ordered. Review of Resident 99's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator on August 20, 2021, at 12:55 p.m., confirmed that the nurse practitioner wrote Resident 99's [MEDICATION(S)] order incorrectly and nursing failed to clarify the order. A review of Resident 409's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 409's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated August 18, 2021, revealed that the resident was cognitively intact. A review of the Resident 409's Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 unit; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301- 350 = 8 units; 351-400 = 10 units; 401 + = 12 units and notify the physician, subcutaneously (Administering medication via needle into the tissue layer between the skin and the muscle) before meals and at bedtime. Medication time was at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. An observation of the medication administration on August 19, 2021, at 8:53 a.m., with licensed nurse Employee E10 was conducted. Employee E10 reported that she/he took the resident's blood sugar before breakfast, the resident's blood sugar was 253. Employee E10 was observed injecting six units of Insulin [MEDICATION(S)] to resident's left arm at 8:55 a.m. An interview with Resident 409 on August 19, 2021, at 8:58 a.m., revealed that he/she had consumed the breakfast meal a few minutes prior but unable to state the exact time. An interview with Employee E10 on August 19, 2021, at 9:00 a.m., confirmed that Resident 409 was administered with six units of Insulin [MEDICATION(S)] after the resident had consumed his/her breakfast. Employee E10 confirmed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The above was conveyed to the Director of Nursing (DON) on August 20,2021, at 1:00 p.m. The facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #409 before meals. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 7/8/21,12/5/2019, 10/30/2019 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 7/8/21, 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019, 8/16/2019 28 Pa. Code 210.18(b)(3)(e)(1) Management Previously cited 7/8/21, 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019 28 Pa. Code 211.12(c) Nursing services Previously cited 7/8/21, 11/5/2020, 12/5/2019 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 7/8/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/8/21, 4/20/2021, 11/5/2020, 5/21/2020, 12/5/2019

Based on clinical record review and staff interview, it was determined that the facility failed to obtain a urology consult in a timely manner for a resident with a foley catheter for one of two residents reviewed for urinary tract infections resulting in actual harm to Resident 10 who was hospitalized for a urinary tract infection. Findings include: Review of Resident 10's clinical record on August 18, 2021, revealed the resident was hospitalized at the time with a urinary tract infection. Further review of the resident's clinical record revealed the resident had a chronic foley catheter. Review of Resident 10's care plan revealed a plan of care dated September 13, 2020, for the resident's use of a foley catheter due to urinary retention and [CONDITION(S)] with an intervention added on the same date to change the resident's catheter per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 10's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 10's urology consults failed to reveal a urology appointment following July 16, 2021. Review of Resident 10's progress notes revealed a progress note dated August 4, 2021, which stated, Patient [appointment] for Urology had to be canceled due to Transportation issues. Scheduling is working on rescheduling [appointment.] Further review of Resident 10's progress notes revealed a progress note dated August 15, 2021, which stated, Patient is being sent to the [emergency room ] for evaluation, for change of mental status, hematuria, and lethargy, per on call physician. Further review of the resident's progress notes revealed the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 10's discharge instructions upon readmission from the hospital on August 19, 2021, revealed the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator on August 20, 2021, at 12:56 p.m. revealed there was no explanation for the delay in obtaining Resident 10's urology appointment when it was ordered to be done ASAP. Further interview revealed no explanation as to the transportation issues that led to the cancelation of Resident 10's urology appointment. Further interview with the NHA on August 23, 2021, at 11:46 a.m. confirmed there was a delay in treating Resident 10's catheter associated urinary tract infection. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. code 211.10(a)(d) Resident care policies

Based on a review of facility policy, facility documentation, and clinical records and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed (Resident CL1) was free of neglect during care which resulted in actual harm of a laceration to the head, which required a visit to the emergency room and three staples. Findings include: Review of facility policy entitled, Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention, dated November 2016, revealed that, neglect is 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. Review of Resident CL1's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident CL1's quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated February 24, 2021, revealed that the resident had severe cognitive impairment. The same MDS also revealed that the resident required extensive two person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Review of Resident CL1's care plan identified the resident as having, ADL Self care deficit as evidenced by inability to complete by self related to physical limitations, intellectual disabilities and failure to thrive, B/L [bilateral] hand contractures with an intervention created on October 28, 2018, for the resident to have an assist of two staff persons for incontinence care. Review of Resident CL1's progress notes revealed a nurses' note dated April 2, 2021, at 11:04 p.m. which stated, Resident fell from the bed and hit his head on the floor resulted on serious injury. This happened during patient incontinent care, when [Nurse Aide Employee E3] was given care. During assessment, he was found stable upon vital assessment with exception of Spo2 [measure of oxygen in the blood - normal is above 95%] which fell below 90 with 2 liter of oxygen. Dr. was notified and [911] was called in, [resident] was later taken to the [emergency room ] @ 10:50 pm. Further review of Resident CL1's progress notes revealed a nurses' note dated April 3, 2021, at 7:35 a.m. which stated, resident returned to the facility at 0300am. [Hospital] said they performed a ct scan [a type of X-ray scan] no abnormal findings. Resident received 3 staples on the right side of his head. Review of Resident CL1's emergency department record revealed that the resident was, presenting after a fall from bed at nursing home. CT scans of head and neck were negative for any traumatic findings apart from laceration and swelling. 3 staples were placed in the right scalp after which bleeding was controlled. Review of facility investigation revealed a witness statement from Nurse Aide (NA) Employee E3 dated April 2, 2021, which stated, I was changing the resident when I turned him on his side he continued to roll over and fell on the floor. Further review of facility investigation revealed a follow up interview with NA Employee E3 conducted by the Director of Nursing (DON) and Human Resources dated April 5, 2021, which stated, During interview, [NA Employee E3] admitted that she did not have assistance when she was performing care to resident. Stated she did not check [Kardex] [(task sheet nurse aides use to follow the resident's plan of care)] or nurse that states resident is to have 2 person assist when performing [incontinence] care. Further review of facility investigation revealed NA Employee E3 was terminated on April 3, 2021, for, poor patient care. The facility concluded their abuse investigation on April 7, 2021, and they substantiated neglect for NA Employee E3's failure to follow Resident CL1's care plan. Interview with the Nursing Home Administrator and the DON on July 8, 2021, confirmed that the facility substantiated the neglect and terminated NA Employee E3 for failing to follow Resident CL1's plan of care, which resulted in actual harm to Resident CL1 from falling out of bed and sustaining a laceration to the head, requiring hospital services of three staples to the head. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 12/5/2019, 10/30/2019 28 Pa. Code 201.18(b)(1)(e)(1) ManagementPreviously cited 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019, 8/16/2019 28 Pa. Code 210.18(b)(3)(e)(1) ManagementPreviously cited 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019 28 Pa. Code 211.12(c) Nursing servicesPreviously cited 11/5/2020, 12/5/2019 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited 4/20/2021, 11/5/2020, 5/21/2020, 12/5/2019

Based on review of facility policy, facility documentation and clinical records, and staff interview, it was determined that the facility failed to provide the proper assistance indicated on the resident's plan of care in regard to their ADL's (Activities of Daily Living) which resulted in actual harm of a fall with laceration requiring a transfer to the emergency room and three staples to the head for one of four residents reviewed (Resident CL1). Findings include: Review of facility policy entitled, Bed Making, initiated October, 2020, revealed, Obtain assistance from another staff member, if needed to maintain patient safety, when making an occupied bed. Review of Resident CL1's clinical record revealed diagnoses that included [CONDITION(S)] (loss of ability to understand or express speech, caused by brain damage), contractures of the left and right hand, adult failure to thrive, unspecified intellectual disabilities, abnormalities of gait and mobility, muscle weakness, and expressive language disorder. Review of Resident CL1's quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated February 24, 2021, revealed that the resident had severe cognitive impairment. The same MDS also revealed that the resident required extensive two person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Review of Resident CL1's care plan identified the resident as having, ADL Self care deficit as evidenced by inability to complete by self related to physical limitations, intellectual disabilities and failure to thrive, B/L [bilateral] hand contractures with an intervention created on October 28, 2018, for the resident to have an assist of two staff persons for incontinence care. Review of Resident CL1's progress notes revealed a nurses' note dated April 2, 2021, at 11:04 p.m. which stated, Resident fell from the bed and hit his head on the floor resulted on serious injury. This happened during patient incontinent care, when [Nurse Aide Employee E3] was given care. During assessment, he was found stable upon vital assessment with exception of Spo2 [measure of oxygen in the blood - normal is above 95%] which fell below 90 with 2 liter of oxygen. Dr. was notified and [911] was called in, [resident] was later taken to the [emergency room ] @ 10:50 pm. Further review of Resident CL1's progress notes revealed a nurses' note dated April 3, 2021, at 7:35 a.m. which stated, resident returned to the facility at 0300am. [Hospital] said they performed a ct [a type of X-ray] scan no abnormal findings. Resident received 3 staples on the right side of his head. Review of facility investigation revealed a witness statement from Nurse Aide (NA) Employee E3 dated April 2, 2021, which stated, I was changing the resident when I turned him on his side he continued to roll over and fell on the floor. Further review of facility investigation revealed a follow up interview with NA Employee E3 conducted by the Director of Nursing (DON) and Human Resources Director dated April 5, 2021, which stated, During interview, [NA Employee E3] admitted that she did not have assistance when she was performing care to resident. Stated she did not check [kardex] [(task list nurse aides use to follow the resident's plan of care)] or nurse that states resident is to have 2 person assist when performing [incontinence] care. Interview with the Nursing Home Administrator and the DON on July 8, 2021, at approximately 3:00 p.m. confirmed that NA Employee E3 did not follow Resident CL1's plan of care to include the assistance of a second staff person while turning the resident in bed, which resulted in a fall from the bed and actual harm to the resident of a laceration to the head requiring hospital services and three staples to the head. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 12/5/2019, 10/30/2019 28 Pa. Code 201.18(b)(1)(e)(1) ManagementPreviously cited 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019, 8/16/2019 28 Pa. Code 210.18(b)(3)(e)(1) ManagementPreviously cited 11/5/2020, 5/21/2020, 12/5/2019, 10/30/2019 28 Pa. Code 211.12(c) Nursing servicesPreviously cited 11/5/2020, 12/5/2019 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited 4/20/2021, 11/5/2020, 5/21/2020, 12/5/2019

Based on clinical record review and staff interview, it was determined that the facility failed to properly assess and obtain an X-ray in a timely manner for one resident with a bruise of unknown origin of 26 residents reviewed, which resulted in actual harm to Resident M4. Findings include: Review of Resident M4's nursing record dated July 23, 2016, revealed that the resident was identified with, three nickel sized bruises on upper right arm and each hand with a complaint of pain of left wrist. Further review of the above-mentioned nursing note revealed that the, resident did not complain of pain on right arm but did at times guard (protect) left wrist. Review of Resident M4's July 2016 physician's orders [REDACTED]. Review of Resident M4's July 2016 Medication Administration Record [REDACTED]. Review of Resident M4's nursing notes dated August 2, 2016, revealed that Resident M4's daughter stated that Resident M4 was complaining of pain to the, left wrist and forearm when manipulated. Further review of the above-mentioned nursing note revealed, upon inspection, left wrist appears swollen as compared to the right wrist, daughter reports bruising was noted a week ago with unknown origin and daughter requesting X-ray of left wrist and forearm to r/o (rule out) fracture. Review of Resident M4's nursing notes dated August 3, 2016, revealed X-ray results which indicated that the resident sustained [REDACTED]. An interview with the Director of Nursing on November 4, 2016, at approximately 11:00 a.m. revealed that an X-ray of Resident M4's left wrist and forearm was not obtained until August 3, 2016, twelve days after Resident M4 was noted with bruising of the arms and hands and guarding (protecting) of the left wrist. The facility failed to properly and timely assess Resident M4's left wrist which appeared with unknown bruising for a one week period and required the administration of pain medication. This contributed to a delay in obtaining an X-ray of the resident's left wrist that revealed a left wrist fracture which resulted in actual harm to Resident M4. 42 CFR 483.25 Provide Care/Services for Highest Well Being Previously cited 03/23/15, 12/15/15, 09/20/16 28 Pa. Code 201.18(b)(1) Management Previously cited 11/20/15, 12/15/15, 07/18/16, 10/17/16 28 Pa. Code 201.18(b)(3) Management Previously cited 11/20/15, 10/17/16 28 Pa. Code 211.5(f) Clinical records Previously cited 11/20/14, 03/23/15, 3/31/15, 11/20/15, 12/15/15, 09/20/16, 10/17/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/20/14, 10/17/16 28 Pa. Code 211.12(c) Nursing services Previously cited 11/20/14, 12/15/15, 07/18/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/20/14, 03/23/15, 03/31/15, 11/20/15, 12/15/15, 09/20/16, 10/17/16

Based on review of facility policies and procedures, clinical record review, staff interview and observation, it was determined that the facility failed to follow physician orders [REDACTED]. Further, the facililty to follow policies or provide asssessment or needed care and services as ordered by the physicans for six of 26 sampled residents. ( Residents CL2, H4, J9, M7, U1, S7). Findings include: Review of current facility policy for the treatment of [REDACTED]. The procedures included that nursing staff was to assess the resident's clinical status by using airway, breathing and circulation. To be prepare to activate emergency services and transportation if the resident's condition deteriorated or did not improve. The physician was to be notifying of the resident clinical condition including vital signs and blood glucose level and the resident was not to be left unattended. The resident's blood glucose level was to be monitoring every 15 minutes until results were within normal limits for the resident or per physician's orders [REDACTED]. Review of Resident CL2's [DATE] physician's orders [REDACTED]. The resident was ordered to receive an injection of Humalog 100 unit/ ml (a mealtime insulin used to treat diabetes) according to blood sugar levels and per sliding scale as follows: ,[DATE]= 0 units, ,[DATE] = 2 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units, ,[DATE] =12 units, ,[DATE] =14 units, ,[DATE] = 16 units at 8:00 a.m., 12:00 p.m. and 5:00 p.m. Review of Resident CL2's [DATE] medication administration record revealed that on [DATE], 14, and 18, 2013 there were no documentation of the blood sugar levels taken at 5:00 p.m. or the units administered. Further, on [DATE] the resident's blood sugar level was documented at 286 at 12:00 p.m. There was no documentation of the insulin dose administered to the resident. On [DATE] at 12:00 p.m. the blood sugar level was recorded at 400. There was no documentation of the amount of insulin administered. On [DATE] the resident's blood sugar level was documented at 163 at 5:00 p.m There was no documentation of the insulin dose administered. On [DATE] at 12:00 p.m. Resident CL2's blood sugar was was recorded at 396 (per sliding scale, 16 units of Humalog 100 units/ml was to be administered). It was documented that 14 units of Humalog 100/ml was administered. The facility failed to administer to correct units of insulin in accordance to the resident's blood sugar level. On [DATE] at 8:00 a.m. Resident CL2's blood sugar level was assessed and a HI (high) reading was recorded on the glucometer (machine to record blood sugar from a blood sample. There was no numerical value given by the glucometer to indicate how high the resident's blood sugar level was at. Nurses notes related that the physician was notified and an order was obtained for the resident to receive 20 units of Humalog subcutaneous. Further review of the medication administration record revealed that on [DATE] at 12:00 p.m. the glucometer again gave a HI blood sugar reading. The facility notified the physician and an order was obtained for Humalog 20 units subcutaneous. There was no documented evidence that the resident blood sugar level continued to be monitor every 15 minutes after the administration of the20 units of Humalog at 8:00 a.m. and at 12:00 p.m.high blood sugar reading as stated in the facility's policy to ensure that the resident's blood sugar reading were lowered from the HI range to a normal blood sugar range for this diabetic resident. Review of Resident CL2's medication administration record noted that on [DATE] at 8:00 a.m. the resident blood sugar level was again recorded as HI with no numerical value given on the glucometer. The physician was notified and an order was obtained for 20 units of Humalog subcutaneous and to monitor vital signs every shift for 48 hours. There was no documented evidence that Resident CL2's blood sugar levels were monitor every 15 minutes as stated in the facility's policy to ensure that blood sugar level returned to normal limits after the HI reading recorded at 8:00 a.m on [DATE]. In addition review of Resident CL2's [DATE] medication administration record revealed that there was no documentation of the results of the blood sugar levels taken at 12:00 p.m. and the units of insulin administered. Furthermore, there was no evidence that the resident vital signs were monitor during the ,[DATE] shift as it was ordered by the physician. At 5:00 p.m. the resident's blood sugar level was assessed at 400 and the resident was administered 16 units of Humalogv100 units/ml. Review of Resident CL2's nursing documentation dated [DATE] at 7:53 a.m. noted that at 7:19 a.m. licensed nursing staff was called to the resident's room by a nursing assistant and the resident was found unresponsive and chest compression (CPR) were started after the resident was noted without a pulse. The certified nurse practitioner arrived and the resident's blood sugar level was tested as HI. The resident was administered per order 20 units of Humalog. At 7:32a.m. the emergency services arrived at the facility and continue cardio [MEDICAL CONDITION] resuscitation and the physician was notified. The resident was pronounced dead at 7:45 a.m. Interview conducted on [DATE] at 2:15 p.m. with the Director of Nursing confirmed that nursing staff were expected to continue to monitor Resident CL2's blood sugar levels after a HI reading was obtained. The Director of Nursing confirmed that there was no documented evidence that the resident's vital signs were obtained and recorded during the ,[DATE] shift on [DATE] and that the resident's blood sugar levels were being monitor after each HI reading was recorded and physician orders [REDACTED]. The facility failed to properly monitor Resident CL2's blood sugar levels every 15 minutes after hyperglycemic events on [DATE] at 8:00 a.m. and 12:00 p.m. and on [DATE] at 8:00 a.m. to ensure that the resident returned to normal blood sugar levels for the resident resulting in actual harm to Resident CL2. Review of the resident H4's admission MDS (assessment of care and needs) dated [DATE] revealed that the resident was admitted [DATE] and was cognitively intact, needed assistance of staff for transfer and frequently incontinent of bowel. Review of the Resident H4's clinical record revealed no evidence that an assessment was completed or that a care plan was in place to help the resident restore as much bowel function as possible. Interview with licensed nurse Employee E 5 on [DATE] at 12:40 p.m. confirmed that there was no assessment, evaluation and care planning in place to help the resident restore as much bowel function as possible. Interview in the morning on [DATE] with licensed nursing Employee E8 revealed that there was no policy in place to direct staff on how to help potential residents restore as much bowel function as possible. Review of Resident J9's [DATE] physician orders [REDACTED]. Review of the [DATE] treatment administration record revealed that there was no evidence that skin checks were completed as ordered as there was no documentation that the skin checks were done on [DATE], 21 and 28, 2013. Interview with licensed nurse, Employee E11 on [DATE] at 10:15 a.m. confirmed that there was no evidence that skin checks were completed as ordered. Review of Resident M7's [DATE] physician orders [REDACTED]. Review of the [DATE] treatment administration record, revealed that only three skin checks were documented for that month and that the skin check for [DATE] was not documented as being completed. Interview with licensed nurse, Employee E11 on [DATE] at 10:15 a.m. confirmed that there was no evidence that skin checks were completed as ordered. Review of Resident S7 ' s current physician orders [REDACTED]. Resident was prescribed two medications for blood pressure and heart rate control: [MEDICATION NAME] 24 HR 240 milligrams; one capsule daily by mouth and [MEDICATION NAME] XL 25 mg; one tablet daily by mouth. Both medications are given at 9:00 a.m. with directions that read: Hold if the systolic blood pressure is less than 100 (the top number) or if the heart rate is less than 50 beats per minute. Both medications required that the blood pressure and pulse be recorded on the medication administration record at the time the they are to be given. Review of Resident S7's August, 2013 Medication Administration Record (MAR) revealed that neither the blood pressure nor pulse were recorded for 23 of 31 days. Both medications were initialed as being given 30 of 31 days. Review of the September, 2013 revealed that the pulse was not recorded 22 of 30 days and the blood pressure not recorded once. [MEDICATION NAME] was held on [DATE] for a blood pressure of ,[DATE] but the pulse rate was not recorded. On [DATE] both [MEDICATION NAME] and [MEDICATION NAME] were held and not given for a blood pressure of ,[DATE]. Review of the October, 2013 MAR revealed that the blood pressure was not recorded 6 of 31 days and the pulse not recorded for 10 of 31 days. Review of Resident S7's November, 2013 MAR reveals that the blood pressure was not recorded for 8 of 31 days and the pulse not recorded for 11 of 31 days Interview with licensed nurse Employee 3 on [DATE] between 9 and 11 am verified that Resident S7's blood pressure and pulses had not been recorded on the MAR or in the clinical record as ordered. Review of Resident C9 ' s clinical record revealed physician's orders [REDACTED]. Review on [DATE] of the resident's clinical record revealed no documented evidence that a psychiatric consult had been completed since the order of [DATE]. Interview with licensed nurse Employee E8 in the morning on [DATE] confirmed that a psychiatric consult was not completed until [DATE], after it was brought to the attention of the facility. The facility failed to timely provide a psychiatric consult to Resident C9. Review of Resident U1's physician orders [REDACTED]. Interview with the Director of Nursing confirmed that the psychiatric consult had not been completed until [DATE], 60 days after the physician had requested the consultation. 28 Pa Code: 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa Code: 201.18(b)(1) Management Previously cited [DATE] 28 Pa Code: 211.10(c) Resident care policies Previously cited [DATE] 28 PA Code 211.5(f) Clinical records Previously cited [DATE]; [DATE] 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited [DATE]; [DATE]