Every finding on record at West Chester Rehabilitation and Healthcare Center

Based on interview, observation, and record review, it was determined that the facility failed to ensure the physician was notified and an intervention was put in place for a significant weight loss for one of 14 residents reviewed (Resident 14).Findings include:Review of facility policy Weight Assessment and Intervention, revised March 2022, revealed, Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation.Review of Resident 14's quarterly MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated May 14, 2026, revealed that Resident 14 was cognitively impaired and totally dependent on facility staff to assist them with eating. Resident 14's active diagnoses included Alzheimer's Disease (a brain disorder that affects memory and thinking skills) and non-Alzheimer's dementia (a brain disorder affecting memory and thinking that isn't caused by Alzheimer's disease) was well as Parkinson's disease (a progressive disease affecting the nervous system). Resident 14's quarterly MDS assessment revealed an unplanned weight loss of 5% or more during the last month and a mechanically altered (requiring a change in texture of food), therapeutic (addressing a specific health condition such as low salt, low carbohydrate) diet.Review of Resident 14's physician orders revealed a dietary order for a pureed, consistent carbohydrate diet with fortified foods for supplementation, dated January 14, 2026.Review of Resident 14's care plan revealed an intervention requiring total assistance with eating and drinking, dated November 11, 2025.Review of Resident 14's monthly weights revealed that on April 6, 2026, Resident 14 weighed 161.5 pounds in a wheelchair and on May 2, 2026, Resident 14 weighed 133 pounds in a mechanical lift, an approximately 18% weight loss.Review of nutrition progress note dated May 19, 2026, at 9:53 a.m. revealed: Rt (resident) showing sig wt (significant weight) loss x1mo (month). Reweigh requested to verify accuracy of weight loss. Rt receives fortified foods at meals for added nutrition support. Will add nourishments TID (three times a day) for wt support. POC (plan of care) updated. Will f/u (follow up) once reweigh is obtained.Review of nutrition progress note date May 27, 2026, at 11:34 a.m. revealed that Resident 14 was reweighed at 133 pounds and Weight loss is unplanned/undesired. Etiology of weight loss may be due to outlier weight documented in May 2026, not consistent with wt trends x 6 months and good po (by mouth) intake per documentation in EMR (electronic medical record). RP(responsible party/MD (medical doctor)/IDT (interdisciplinary team) notified of weight change.Review of Resident 14's weight on June 12, 2026 revealed that Resident 14 weighed 122.9 pounds in a wheelchair, a 7.5% weight loss. A nutrition progress note dated Jun 12, 2026, at 12:08 p.m. revealed: Rt triggering for sig wt loss x1mo. Reweigh requested to verify accuracy of weight loss. PO intakes are mainly adequate, 50-100%. Receives fortified foods at meals; will also add snacks TID for added nutrition support. Will f/u once reweigh is confirmed. POC updated.Review of progress notes failed to reveal that Resident 14 was reweighed, or that their responsible party and medical provider were notified of the weight loss. Review of physician orders revealed that the facility failed to implement the Dietitian's recommendation for snacks three times a day. Review of Resident 14's Task documentation for the month of June 2026, revealed that Resident 14 was only offered snacks at bedtime, which were accepted 100% of the time.Interview with the NHA (Nursing Home Administrator) on June 30, 2026 at approximately 3:00 p.m. confirmed these findings. All residents are offered snacks at bedtime, but Resident 14's dietary orders were not updated to reflect the additional snacks, nor was Resident 14 re-weighed, nor were Resident 14's responsible party and medical provider notified about the weight loss.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the clinical record and interview with staff, it was determined that the facility failed to obtain laboratory services timely for one of three residents reviewed (Resident 1).Findings include:Review of Resident 1's progress note of March 13, 2026, indicated that staff spoke with the nurse practitioner (NP) concerning Resident 1 who was noted with increased weakness. New orders were received to obtain an urine C&S (culture and sensitivity - diagnostic test that examines urine often used to diagnosis conditions like urinary tract infection and kidney disease). Review of physician's orders of March 13, 2026, included an order for UA C&S.Review of Resident 1's progress note of March 24, 2026, revealed that the resident's guardian was concerned with resident's health status and possible change in condition. New orders were received from the nurse practitioner for urinalyis to be completed on March 25, 2026. Review of nurse practitioner note of March 25, 2026, indicated per nursing the urine that this NP had ordered the other day was not collected yet, this NP reordered urine. Assessment and plan indicated that urinalysis was positive for gram negative rods (rod shaped bacteria) and Macrobid (antibiotic) was ordered.Interview with the Nursing Home Administrator on May 11, 2026, at 1:00 p.m. confirmed that the urinalysis was not obtained when ordered on March 13, 2026, and was not obtained until March 25, 2026.28 Pa. Code 211.12 (d)(1)(3)(5)

Based on review of the clinical record and staff interview, it was determined that the facility failed to ensure an x-ray was obtained in a timely manner for one of three residents reviewed (Resident 1).Findings include:Review of Resident 1's progress note of March 13, 2026, indicated that staff spoke with the nurse practitioner (NP) concerning Resident 1 who was noted with increased weakness. New orders were received to obtain a chest x-ray. Review of physician's orders of March 13, 2026, included an order for a chest x-ray.Review of Resident 1's progress note of March 24, 2026, revealed that the resident's guardian was concerned with resident's health status and possible change in condition. New orders were received from the nurse practitioner for chest x-ray to be completed on March 25, 2026. Interview with the Nursing Home Administrator on May 11, 2026, at 1:00 p.m. confirmed that the chest x-ray was not obtained when ordered on March 13, 2026, and was not obtained until March 25, 2026.28 Pa. Code 211.12 (d)(1)(3)(5)

Based on clinical record review staff interview, it was determined that the facility failed to include a resident or a resident's responsible party in the comprehensive care planning process for three of five sampled residents (Residents 1, 2, and 3). Findings include: Review of Resident 1's clinical record revealed that an annual MDS (Minimum Data Set - periodic assessment of resident needs) assessment was completed on January 27, 2025. Further review of the clinical record revealed no evidence that the resident and/or resident's responsible party was invited to the resident's plan of care meeting. Review of Resident 2's clinical record revealed that a quarterly MDS was completed on January 7, 2025. Further review of the clinical record revealed no evidence that the resident and/or resident's responsible party was invited to the resident's plan of care meeting. Review of Resident 3's clinical record revealed that an annual MDS assessment was completed on December 9. 2024. Further review of the clinical record revealed no evidence that the resident and/or resident's responsible party was invited to the resident's plan of care meeting. Interview with the Nursing Home Administrator on February 25, 2025, at 2:30 p.m confirmed that there was no documented evidence that the resident/responsible party was invited to participate in their plan of care meeting. 483.21 Comprehensive Resident Centered Care Plan Previously cited 10/3/24

Based on review of staff documentation, it was determined the facility failed to ensure the required 12 hours of annual training was completed by four of five staff members reviewed (Employee E3, Employee E4, Employee E5 and Employee E6). Findings include: Review of Employees E3, E4, E5 and E6's training documentation regarding 12-hour annual training failed to reveal evidence that Employees E3, E4, E5, and E6 completed the annual 12-hour training as required. Interview with the Nursing Home Administrator and Director of Nursing on October 3, 2024, at 2:30 p.m. confirmed Employees E3, E4, E5 and E6 did not complete the required 12-hour annual training. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 5/6/2024

Based on clinical records review, and resident, and staff interviews, it was determined that the facility failed to include the Interdisciplinary Team (IDT) in care plan meetings for 15 out of 15 resident care plan meetings reviewed (Residents 23, 27, 38, 66, 78, 85, 98, 101, 107, 114, 119, 121, 134, 143, 161). Findings include: Review of federal regulations revealed resident care plans should be prepared by an interdisciplinary team that includes but is not limited: (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Review of Resident 23's Care Plan Meeting Review dated September 13, 2024, revealed Interdisciplinary Team attendance of social services and therapy. The resident's health precluded attendance. Review of Resident 27's Care Plan Meeting Review dated September 10, 2024, revealed Interdisciplinary Team attendance of social services and nursing. The resident attended in person. Review of Resident 38's Care Plan Meeting Review dated September 13, 2024, revealed Interdisciplinary Team attendance of social services and therapy. The resident's health precluded attendance. Review of Resident 66's Care Plan Meeting Review dated September 20, 2024, revealed Interdisciplinary Team attendance of social services, nursing and respiratory. The resident attended in person. Review of Resident 78's Care Plan Meeting Review dated September 4, 2024, revealed Interdisciplinary Team attendance of social services, nursing and dietary. The resident's health precluded attendance. Review of Resident 85's Care Plan Meeting Review dated September 10, 2024, revealed Interdisciplinary Team attendance of social services and nursing. The resident's health precluded attendance. Review of Resident 98's Care Plan Meeting Review dated September 3, 2024, revealed Interdisciplinary Team attendance of social services and nursing. The resident attended in person. Review of Resident 101's Care Plan Meeting Review dated September 5, 2024, revealed Interdisciplinary Team attendance of social services and nursing. The resident's health precluded attendance. Review of Resident 107's Care Plan Meeting Review dated September 9, 2024, revealed Interdisciplinary Team attendance of social services, therapy and respiratory. The resident's health precluded attendance. Review of Resident 114's Care Plan Meeting Review dated September 5, 2024, revealed Interdisciplinary Team attendance of social services, dietary and nursing. The resident attended in person. Review of Resident 119's Care Plan Meeting Review dated September 6, 2024, revealed Interdisciplinary Team attendance of social services, dietary and nursing. The resident attended in person. Review of Resident 121's Care Plan Meeting Review dated September 5, 2024, revealed Interdisciplinary Team attendance of social services and nursing. The resident attended in person. Review of Resident 134's Care Plan Meeting Review dated September 13, 2024, revealed Interdisciplinary Team attendance of social services and therapy. The resident attended in person. Review of Resident 143's Care Plan Meeting Review dated September 10, 2024, revealed Interdisciplinary Team attendance of social services, therapy, and nursing. The resident attended in person. Review of Resident 161's Care Plan Meeting Review dated September 5, 2024, revealed Interdisciplinary Team attendance of social services and therapy. The resident's health precluded attendance. The above information was conveyed and confirmed with the Regional Director, the Nursing Home Administrator, and the Director of Nursing on October 1, 2024, at 12:20 p.m. 28 Pa Code 211.11(d) Resident care plan

Based on clinical records review and staff interviews, it was determined that the facility failed to notify the physician of a significant weight change for one of the 33 residents reviewed (Resident 21). Findings include: Review of Resident 21's diagnosis list includes End Stage Renal Disease (ESRD- kidney function has declined to the point that the kidneys can no longer function on their own), Heart Failure (condition in which the heart does not pump blood as well as it should), and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident 21's clinical records revealed resident is on Hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) three times a week. Review of Resident 21's weights and vitals documentation dated August 14, 2024, revealed a weight of 309 pounds and a weight of 322.7 pounds on August 21, 2024, which is a 13.7 pound weight gain in a week. Review of Resident 21's clinical records failed to reveal the physician was notified of the above weight changes. Review of Resident 21's weights and vitals documentation dated August 28, 2024, revealed a weight of 321.3 pounds and a weight of 330.6 pounds on September 11, 2024. Clinical records review revealed that Resident 21 had a total of 21.6 pounds (6.99%) weight gain, a significant weight change in less than a month. Review of Resident 21's clinical records failed to reveal the physician was notified of Resident 21's significant weight change. Interview with Licensed Employee E9 on October 3, 2024, at 10:45 a.m., confirmed that Resident 21's significant weight change was identified but the physician was not notified of these changes. The facility failed to ensure physician was notified of Resident 21's significant weight change. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of the medication manufacturer's guidelines, the facility's policy, observation, and staff interviews, it was determined the facility failed to ensure medications were properly labeled and stored on two of two medication carts observed (Medication Carts 4 and 5). Findings include: Review of the facility policy titled Medication Labeling and Storage, revised February 2023, revealed medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The same policy indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's guidelines for Basaglar Insulin Kwikpen (long-acting insulin) revealed the medication should be discarded 28 days after opening or removal from refrigeration. Observation of the medication cart 4 was conducted in the presence of Licensed nurse Employee E10 on October 1, 2024, at 9:07 a.m. The observation revealed one Lispro pen and one Basaglar pen. Both insulin pens were used and undated. Additional observation revealed 97 loose medications in different sizes and colors scattered on the medication cart drawers. Observation of the medication cart 5 was conducted in the presence of Licensed nurse Employee E11 on October 1, 2024, at 9:31 a.m. The observation revealed one Lispro pen, one Admelog pen, and one Lantus pen each placed in a clear zip-lock bag with the resident's name written in pentel pen. Additional observation revealed 50 loose medications in different sizes and colors scattered on the medication cart drawers. A Lidocaine (medication used to numb the skin) vial, used, undated with no name was observed. Interview conducted with Employee E11 on October 1, 2024, at 9:40 a.m. revealed the pharmacy sent multiple insulins for the residents, the original container was left in the medication refrigerator and the insulin currently in use was placed on a zip lock bag with the resident ' s name written in pentel pen. Employee E11 reported that the scattered medications in the drawers were when the medication was accidentally popped out from the blister medication packages. The above findings were conveyed to the Director of Nursing on October 3, 2024, at 1:00 p.m. The facility failed to ensure medications were properly labeled and stored on medication carts 4 and 5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, resident and staff interviews, it was determined the facility failed to follow the physician's order for two of the 33 residents reviewed (Resident 13 and Resident 419). Findings include: Review of Resident 13's diagnosis list includes Chronic kidney Disease (kidneys are damaged and cannot filter blood the way they should), and Hyponatremia (condition that occurs when the level of sodium in the blood is too low). Review of Resident 13's physician's order dated August 22, 2024, revealed an order for Fluid restriction of 1500ml per day. 840 cc allocated to dietary, 660 cc allocated to nursing. Nursing 6:00 a.m.-2:00 p.m. = 270 cc; 2:00 p.m.-10:00 p.m. =270 cc. Dietary: breakfast - 360 cc; lunch - 240 cc; and dinner - 240 cc. Review of Resident 13's August 2024 and September 2024, Medication Administration Records revealed the above orders were written with a box for the morning and evening shifts indicated with a check mark. Review of Resident 13's clinical records failed to reveal Resident 13's fluid intake was monitored to ensure fluid restriction of 1500 cc per day was followed. Observation conducted on October 1, 2024, at 1:20 p.m., revealed Resident 13 was eating lunch. The lunch tray included one cup of coffee and a four-ounce juice box. A 16-ounce Styrofoam cup filled with water was also observed on the resident's side table. Observation of Resident 13 on October 2, 2024, at 12:30 p.m., revealed two 16-ounce Styrofoam cups on the resident's bedside table. One cup was empty, and the other was 1/4 filled with water. Interview with Resident 13 on October 2, 2024, at 12:31 p.m., revealed that she/he drank all the water in one cup but did not want to finish the water on the other cup since it was already warm. The resident asked if she/he could have more water. Interview with Licensed nurse Employee E8 was conducted on October 2, 2024, at 12:23 p.m. Employee E8 indicated she/he was Resident 13's nurse for the day. When asked how much fluid Resident 13 can have, Employee E8 responded I'm not sure. When asked if the resident was on any fluid restriction, Employee E8 responded I don't recall. The above information was conveyed to the Director of Nursing on October 3, 2024, at 11:00 a.m. The facility failed to ensure Resident 13's physician's order for a fluid restriction was followed. Review of Resident 419's diagnosis list includes acute and Chronic Respiratory Failure with Hypercapnia (the lungs are unable to adequately excrete carbon dioxide), Chronic Obstructive Pulmonary Disease (damage to the lungs), Diabetes Mellitus Type II (in ability to regulate one's blood sugar), Parkinsonism (condition that affects movement), and Chronic Kidney Disease Stage 4 (loss of kidney function). Review of Resident 419's physician orders dated June 27, 2024, revealed an order for Morphine Sulfate Oral Solution 20MG/ML, give 0.25 ml (milliliter) by mouth every 3 hours as needed for moderate to severe pain and dyspnea (shortness of breath). Review of Resident 419's physician orders dated July 3, 2024, revealed an order for Morphine Sulfate Oral Solution 20 MG/ML give 5mg by mouth every 3 hours for pain/anxiety. Further review of Resident 419's physician order revealed an order dated July 3, 2024, for Morphine Sulfate Oral Solution 20 MG/ML give 5mg by mouth every (one) hour as needed for air hunger. Review of facility documents revealed the orders were entered by Registered Nurse, Employee E12 as Morphine Sulfate Oral Solution 20MG/5ML, give 5ml by mouth every 3 hours for pain/anxiety. Further review of facility documents revealed an additional order was entered by Registered Nurse, Employee E12 as Morphine Sulfate Oral Solution 20MG/5ML, give 20 ml by mouth every (one) hour as needed for air hunger. Review of Resident 419's July 2024, Medication Administration Record (MAR) revealed on July 3, 2024, the resident received 5 ml of Morphine Sulfate Oral Solution at 9:00 a.m., 12:00 p.m., 3:00 p.m., and 6:00 p.m. Further review of Resident 419's July 2024 MAR revealed on July 3, 2024, the resident received one PRN dosage of 20 ml of Morphine for air hunger. Review of the facility's narcotic logbook revealed Resident 419 received the following amounts on July 3, 2024: 12:00 a.m.- 0.25 ml (5mg) 3:55 a.m. - 0.25 ml (5mg) 6:00 a.m. - 0.25 ml (5mg) 10:00 a.m. - 0.25 ml (5mg) 12:00 p.m. - 0.5 ml (10mg) 1:30 p.m. - 0.5 ml (10mg) 3:00 p.m. - 0.25 ml (5mg) 6:00 p.m. - 0.25 ml (5mg) Review of facility investigative documents including Medication Incident Details dated July 5, 2024 revealed the resident was administered an incorrect dose of Morphine. Further review of the Medication Incident Detail document revealed Resident 419 was administered 20 mg/5 ml give 5 ml. The medication ordered was 20 mg/5 ml give 5 mg. Additional review of Medication Incident Detail document revealed no adverse effect (of Resident 419). Med (medication) was given per recommendation, not per order. The document further indicates the medication error was a transcription error. The above information was conveyed and confirmed with the Nursing Home Administrator and the Director of Nursing on October 3, 2024, at 1:45 p.m. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to ensure resident was free from unnecessary medication for one of 33 residents reviewed (Resident 21). Findings include: Review of Resident 21's diagnosis list includes Spinal Stenosis (narrowing of one or more spaces within the spinal canal), and chronic back pain. Review of Resident 21's physician order dated September 9, 2024, revealed an order for Oxycodone HCL (A medication used to treat severe pain) 10 mg Give one tablet by mouth every six hours as needed for moderate pain. Review of Resident 21's September 2024, Medication Administration Record (MAR) revealed that from September 9, 2024, until September 30, 2024, the Oxycodone medication was administered to Resident 21 a total of 11 times with a pain level rating of 0 (Numeric Pain Scale: 0-no pain; 1-3-mild pain; 4-6-moderate pain; 7-10-severe pain). Review of Resident 21's clinical record failed to reveal an explanation as to why the resident was administered with as needed Oxycodone for a pain level rating of 0. The above was conveyed to the Director of Nursing on October 3, 2024, at 11:00 a.m. The facility failed to ensure Resident 21 was free from unnecessary use of as-needed Oxycodone. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure the pharmacy provided necessary pain medications timely which resulted in Resident 2 experiencing significant pain, and prompting emergent medical intervention. The facility failed to ensure physician ordered medications were available from the pharmacy for two of four residents reviewed (Residents 2 and 3). Findings include: Review of Resident 2's progress note of July 27, 2024, revealed resident was admitted at approximately 1:30 p.m. Review of the clinical record included diagnoses of, but not limited to, Postlaminectomy Syndrome (pain that continues after a Laminectomy [surgery that reduces pressure on the nerves in the spinal cord] or other spinal surgery, fusion of the spine (surgery to connect two or more bones in any part of the spine), lumbar region (lower back) , and injury of Cauda Equina (bundle of spinal nerves and spinal nerve rootlets). Review of Resident 2's physician's admission orders included an order for MS Contin (morphine - medication used to treat moderate to severe pain) oral tablet extended release 100 milligrams (mg), one tablet two times a day for chronic pain, oxycodone HCl (opiod medication used to treat moderate to severe pain) oral tablet 30 mg two tablets every four hours as needed for breakthrough pain, and hydromorphone HCl (opiod medication used to treat moderate to severe pain) oral tablet 4 mg two tablets every eight hours as needed for severe pain if no relief from oxycodone. Additional order received to monitor resident for pain every shift. Resident 2 also had an order for Acetaminophen (pain reliever for mild to moderate pain) 325 mg two tablets every six hours as needed for pain. Review of the July 2024 Medication Administration Record (MAR) for Resident 2, revealed a pain level of 10 (scale of 0-10, 0 means no pain, 10 worst pain) recorded for nite. Further review of Resident 2's MAR revealed that MS Contin was not administered at 9:00 p.m. because it was on hold'. The MAR also indicated that Acetaminophen was not administered. Review of Resident 2's progress note of July 27, 2024, at 23:46 (11:46 p.m.) revealed Residents' routine and prn narcotics were not delivered on the last run. Scripts were faxed by day shift nurse at 1515 [3:15 p.m.] and refaxed at 1725 [5:25 p.m.] on 7/27/24. This RN (Registered Nurse) attempted to pull the medications from the pixus [pyxis - medication dispensing system] with no success. Resident is on high doses of multiple narcotics. Pixus does not have the right dose and enough dose to administer. Resident is in severe pain and requesting to go back to the hospital. [Attending Physician] made aware and is agreeable. ADON (Assistant Director of Nursing] made aware. Spouse is at bedside. Resident left the building at 2320 [11:20 p.m.] with all of his belongings. Resident went to [local hospital]. Review of Resident 3's clinical record revealed that the resident was admitted on [DATE], with diagnoses of, but not limited to, Nontraumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and tissue covering the brain), and fracture of lumbosacral spine and pelvis (lower back connecting to the lower part of the trunk). Review of Resident 3's admission orders included an order for Donepezil HCl (medication used to treat confusion related to Alzheimer's disease) oral tablet 10 mg one tablet once a day for psychotherapeutic, Tamsulosin HCl 0.4 mg one capsule one time a day for genitourinary agents (used to treat conditions of the urinary tract), and Levetiracetam (used to treat seizures) 500 mg one tablet twice a day for anticonvulsant. Review of Resident 3's July 2024 MAR revealed that Donepezil HCl, Tamsulosin HCl, and Levetiracetam were not adminstered on July 13, 2024. Review of progress note of July 13, 2024, indicated awaiting pharmacy delivery. Review of Resident 3's July 2024 MAR revealed that Donepezil HCI, Tamsulosin HCI, and Levetiracetam were not administered at HS (bedtime) resulting in 1 missed dose of each medication. Interview with the Assistant Director of Nursing on August 15, 2024, confirmed the above medications were not available for administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/6/24 28 Pa. Code: 211.9 (a)(1) Pharmacy services

Based on a review of established guidelines for Cardiopulmonary Resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident 288), creating a situation in which the residents were placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation. Findings include: Review of facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation with a revised date of February 2018; revealed under section titled General Guidelines and Number Six indicated If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death ( e.g., rigor mortis). Further review of facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation revealed Number Seven under General Guidelines indicating; If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Review of clinical record of Resident 288 revealed the resident was admitted to the facility on [DATE], as a short-term respite admission on hospice service with diagnoses including but not limited to Essential Hypertension, Cardiomyopathy, Heart Failure, and Aortic Stenosis (severe). Review of Resident 288's clinical record revealed Resident 288 had a physician's order for full life sustaining interventions of Cardiopulmonary Resuscitation dated [DATE]. Review of Resident 288's progress note completed by RN Supervisor, dated [DATE], at 2:08 a.m. indicated This RN was called by nurse that the resident had stopped breathing. Resident unresponsive to external stimuli, no pulmonary activity was noted. Not responding to sternal rub. Apical and Radial pulse not absent for 60 seconds. Pupils were fixed and Dilated. Resident was pronounced CTB at 2230 on [DATE]. Daughter [Name Withheld] made aware. [Name withheld] hospice and [name withheld] geriatrics made aware of death. Body released to [identified] funeral home. Interview conducted via telephone on [DATE] at 12:35 p.m. with RN Supervisor, Employee E3 revealed that due to resident's hospice status and full code status, CPR was withheld. Further interview with Employee E3 revealed, RN supervisor initiated a telephone conversation with resident's daughter who informed the RN Supervisor the family does not wish to have CPR performed on the resident. Review of Resident 288's clinical record revealed documents faxed to the facility by hospice provider on [DATE], at 10:47 a.m. including Patient Information Report indicated daughter was emergency contact only but an alternative family member was legal representative. Further review of Resident 288's hospice documents including Patient Information Report revealed Resident 288 also diagnosed with Congestive Heart Failure. Further review of hospice documents revealed a progress note dated [DATE] by attending hospice physician who indicated Resident 288 was FULL CODE. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE] revealed that they were aware that staff did not provide CPR to Resident 288 in accordance with the code status, and the facility's policy. On [DATE], at 3:30 p.m. the Nursing Home Administrator was informed that Immediate Jeopardy was identified due to Licensed staff failing to provide CPR in accordance with a resident's physician's order and the facility policy. Nursing Home Administrator was provided the Immediate Jeopardy template at approximately 3:35 p.m. The facility submitted an acceptable immediate action plan on [DATE]:35 p.m. that included the following actions: A facility wide review of all residents' life sustaining code status to ensure each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy including general guidelines, preparation and emergency procedure for all residents; to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders and further education on where to find the code status of residents. The plan also included to actively hold Code Blue drills (simulated event whereby staff respond to a resident experiencing cardiac arrest) with staff, and to complete ongoing audits. An audit of the eleven hospice residents including nine with Do Not Resuscitate (DNR) and Full life sustaining measures were reviewed. The Immediate Jeopardy was lifted on [DATE], at 10:15 a.m. when it was confirmed that the facility provided licensed nursing staff of 11 LPN's (Licensed Practical Nurses) and 4 RN's (Registered Nurses) with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Staff were able to identify resident's code status is located on the Medication Administration Record (MAR) which is accessible to all licensed staff. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that Cardio Pulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code. Findings include: Review of the job description for the NHA revealed the essential function is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations (put into affect) by government agencies to ensure proper healthcare services to residents. Review of the job description for the DON revealed the responsibility of the job position is overall accountability for providing leadership, direction and administration of day-to-day operations associated with direct patient care activities, nursing practice, clinical education and development, including continuing improvement in nursing services and to staff to meet patient/residents and their families' needs and expectations. The findings in this report identified that the facility failed to ensure that CPR was provided in accordance with the facility policy and procedures a resident was a FULL CODE. The NHA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed. Refer to F678 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's Responsibility 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.12(d)(2)(3) Nursing Services

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to follow physician's order regarding pre dialysis and post dialysis weight monitoring and to maintain ongoing communication with the dialysis center for four of four residents receiving dialysis (Residents 18, 98,161, and Resident 369). Findings include: Review of Resident 18's diagnosis list includes End Stage Renal Disease (ESRD), and dependence on Hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) Review of Resident 18's physician's order dated April 4, 2024, revealed an order for pre and post-dialysis weights, ensured recorded in the communication binder for dialysis did Review of Resident 18's dialysis binder revealed no information on the pre and post-dialysis weights on the following dates: April 10, 15, and April 17, 2024. Review of Resident 98's diagnosis list includes ESRD and dependence on Hemodialysis. Review of Resident 98's physician's order dated December 8, 2023, revealed an order for pre and post-dialysis weights, ensure recorded in the communication binder for dialysis two times a day every Monday, Wednesday, and Friday. Review of Resident 98's dialysis binder revealed no pre and post-dialysis weight on April 8, and 10, 2024, and no post-dialysis weight on April 24, 2024. Review of Resident 161's diagnosis list includes ESRD and dependence on Hemodialysis. Review of Resident 161's physician's order dated January 23, 2024, revealed an order for pre and post-dialysis weights, which was recorded in the communication binder for dialysis. Review of Resident 161's dialysis binder revealed no information on the pre and post-dialysis weights on April 5, 8, 10, and April 15, 2024. No post-dialysis weight was recorded on April 12, 2024, and no pre weight documented on April 22, and April 24, 2024. Interview with the Nursing Home Administrator conducted on April 29, 2024, at 1:30 p.m., confirmed that there were no documented pre and post-dialysis weights on the dates mentioned above for Residents 18, 98, and 161. Review of Resident 369's clinical record indicated Resident 369 was admitted to the facility on [DATE]. Review of Resident 369's Minimum Data Set (MDS - periodic assessment of care needs) dated February 18, 2024, indicated diagnoses of end-stage renal disease (ESRD - an inability of the kidneys to filter the blood), and dependence on renal dialysis. Review of Resident 369's physician's order dated March 20, 2024, indicated Resident 369 received dialysis treatment three times a week on Monday, Wednesday, and Friday. Review of Resident F369's order dated March 20, 2024, indicated a Dialysis Communication Tool was to be completed and sent to dialysis with Resident 369 every Monday, Wednesday, and Friday. Review of Resident 369's clinical record revealed an additional physician order dated March 20, 2024, indicating Record pre and post dialysis weight in communication book. Interview conducted on April 29, 2024, at 12:46 p.m. the Nursing Home Administrator (NHA) reported the facility does not have a communication book for Resident 369. NHA stated If they haven't given it to you by now, then we don't have it. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(2) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management

Based on clinical record review, it was determined that the facility failed to ensure one of 32 residents reviewed was free of unnecessary psychotropic medication (Resident 42). Findings include: Review of Resident 42's clinical record revealed a physician's order dated November 7, 2023, for trazodone (antidepressant medication) 50 milligrams (mg) 1 tablet by mouth at bedtime. Review of Resident 42's Consultant Pharmacist Report dated November 8, 2023, revealed the pharmacist questioned if the resident's trazodone was still needed, with the physician responding Defer to psych. Review of Resident 42's psychiatrist note from January 24, 2024, revealed that the resident is currently on 3 antidepressants. Trazodone previously ineffective. Recommend taper off trazodone by reducing the dose to 25mg 1 tablet by mouth at bedtime. Review of Resident 42's January, February, and March 2024 Medication Administration Records revealed the resident continued to receive Trazodone 50 mg until March 28, 2024. Review of Resident 42's progress notes revealed a nurse's note dated February 10, 2024, which stated: Resident seen sleeping more than usual during shift. Attempted more than once to awakening but he verbally expressed he was more tired than usual. Ate 20% of his breakfast and slept through lunch. Meds held due to resident being sleep. Vitals stable . Resident denied any pain but verbally expressed he felt too tired to do anything. MD notified. Review of Resident 42's next psychiatrist note dated March 27, 2024, revealed that the resident complained of low energy, daytime sleepiness at times with recommendations again to reduce the resident's trazodone dose from 50mg to 25mg. Interview with the Director of Nursing on April 29, 2024, at 11:30 a.m. confirmed that the facility did not follow Resident 42's psychiatrist recommendations from January 24, 2024, to reduce the resident's trazodone dose until March 28, 2024. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure wound treatment was consistently completed and wound recommendation from a wound consultant was followed for a surgical wound for one of 32 residents reviewed. Finding include: Review of the Nurse Practitioner's (NP) progress notes dated March 11, 2024, revealed Resident 18 was readmitted to the facility on [DATE], with a surgical wound post incision and drainage of a hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) to the left lateral leg. A wound treatment order to cleanse the wound with cleanser, apply Collagen to the base of the wound then cover with dressing daily and as needed was ordered. Review of Resident 18's April 2024, Treatment Administration Record revealed that wound treatment to Resident 18's left lateral surgical wound was not done on April 7, 14, 16, 20, and 21, 2024. Review of the wound NP's notes dated April 18, 2024, revealed Resident 18's surgical wound to the left lateral leg was evaluated, a new wound treatment recommendation was made, to cleanse the wound with cleanser, apply Medihoney (A dressing that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns), cover with dressing daily and as needed. Review of the April 2024, TAR revealed that the wound NP's surgical wound treatment recommendation made on April 18, 2024, was not placed as an order, and therefore was not implemented. Interview with the Director of Nursing was conducted on April 29, 2024, at 11:00 a.m., The Director of Nursing (DON) reported that the wound NP's recommendation was supposed to be relayed to the physician for approval. The facility was unable to provide documented evidence that the physician was notified of the wound NP's new surgical wound recommendations. The DON was unable to provide an answer as to why the wound NP's surgical wound treatment recommendation was not implemented. The DON was unable to provide an explanation of the missed surgical wound treatment on April 7, 14, 16, 20, and April 21, 2024. The facility failed to ensure Resident 18's surgical wound treatment to the left lateral leg was consistently done and wound recommendation of the wound specialist was followed. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 95) Findings include: Review of Resident 95's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), Bpolar Disorder (condition associated with episodes of mood swings ranging from depressive lows to manic highs), and Anxiety disorder. Review of Resident 95's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 22, 2024, revealed that the resident had a severe cognitive impairment. Review of the Psychiatry notes dated January 10, 2024, revealed resident was previously on another facility with history of at least four prior psychiatry hospitalization s and previous attempts of hurting self. Resident on medication management. Review of Resident 95's care plan revealed no plan of care developed for resident's behavior (previous attempt to hurt self). Interview with the Nursing Home Director conducted on April 29, 2024, at 1:30 p.m., confirmed that Resident 95's behavior of previous attempts to hurt self plan of care was not developed. The facility failed to ensure a comprehensive care plan was developed for Resident 95's behavior of previous attempts to hurt self. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for one of six residents reviewed (Residents 369). Findings include: Review of Resident 369's clinical record revealed a nursing progress note dated March 21, 2024, revealed that the resident had a new order to be sent to the hospital due to being unresponsive. Further review of Resident 369's clinical record failed to reveal documented evidence of the State Ombudsman's office notified of Resident 369's transfers from the facility to the hospital. Interview with the Nursing Home Administrator (NHA) on April 29, 2024, at 10:40 a.m. confirmed that the facility did not notify the State Ombudsman's office when Resident 369 was transferred to the Hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical records review, facility documentation review, and staff interview, it was determined that the facility failed to comprehensively investigate an injury of unknown origin for one of the 32 residents reviewed (Resident 37). Findings include: Review of Resident 37's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Cancer of the Larynx, Acute Respiratory Failure, and generalized muscle weakness. Review of the Significant Change Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated June 30, 2023, revealed that the resident had a severe cognitive impairment and required extensive with one-person assistance with bed mobility and transfers. Review of the physician notes dated July 28, 2023, revealed worsening bilateral hip pain despite conservative measures with pain medications, an X-ray was ordered. Review of the nursing progress notes dated July 29, 2023, at 4:15 a.m., revealed a call was received from the imaging company and was informed that the x-ray result of the bilateral hips with pelvis done on July 28, 2023, revealed Bilateral sub capital fractures of undetermined age involving the hips without dislocation. The physician was notified and ordered to transfer the resident to the hospital. Review of the nursing progress notes dated July 29, 2023, revealed Resident 37 was admitted to the hospital with a diagnosis of bilateral hip fracture. Review of the facility documentation dated July 29, 2023, revealed an interview with the resident who denied trauma to the area or abuse. The resident reported chronic pain in the lower back and hips but got worse over the last week. The resident denied falling and does not know how the injury occurred. A review of the same document revealed no interviews/statements from staff who could have an encounter or cared for the resident. Interview was conducted with licensed employee E3 on April 29, 2024, at 11:00 a.m. Employee E3 reported that for injury of unknown origin, an interview/statement of staff that cared for the resident for the last 48 hours should have been completed. Interview with the Nursing Home Administrator on April 29, 2023, at 2:00 p.m., confirmed that there were no staff interviews/statements completed for Resident 37's bilateral hip fracture of unknown origin. The facility failed to ensure Resident 37's bilateral hip fracture of unknown origin was comprehensively investigated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to notify the physician of the significant weight change of two of the 32 residents reviewed (Resident 18 and 161). Findings include: Review of Resident 18's diagnosis list includes End Stage Renal Disease (ESRD- Where kidney function has declined to the point that the kidneys can no longer function on their own), and dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident 18's weights and vitals dated April 2, 2024, revealed a weight of 182 pounds, and April 7, 2024, revealed a weight of 205.8, a 13.8% significant weight gain in five days. A re-weight was done on April 16, 2024, which revealed a weight of 205 pounds. Review of Resident 18's clinical record failed to reveal that the physician was notified of Resident 18's significant weight change. Review of Resident 161's diagnosis list includes ESRD and Dependence on Hemodialysis. Review of Resident 161's weights and vitals dated March 1, 2024, revealed a weight of 175.3 pounds, and March 5, 2024, revealed a weight of 227.5 pounds a 29.78 % significant weight gain in four days. Re-weight was not done until March 27, 2024, which revealed a weight of 218. 5, a 24.64% significant weight gain from the March 1, 2024, weight. Review of Resident 161's clinical record revealed the physician was not notified of Resident 161's significant weight change until April 17, 2024, six weeks after a significant weight change was identified. Interview conducted with the Director of Nursing on April 29, 2024, at 11:00 a.m., confirmed Resident 18's physician was not notified of the significant weight change, and Resident 161's physician was not notified of the resident's significant weight change timely. 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, review of the clinical record, facility documentation, and policy and procedures, as well as staff interviews, it was determined that the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent elopement (unauthorized leave from a safe area) of a resident (Resident 27) assessed to be at risk for eloping and who successfully left the building without staff knowledge. This failure placed residents at the facility in an Immediate Jeopardy situation one for nine residents who were identified as at risk for elopement. The incident has been identified as past non-compliance. Findings include: Review of the facility's policy titled Emergency Procedure-Missing Resident, undated, revealed residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Review of Resident 27's diagnosis list revealed Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life and anxiety disorder. Review of Resident 27's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 9, 2023, revealed the resident had severe cognitive impairment. The same MDS assessment revealed resident was able to ambulate on and off the unit needing one staff supervision. Review of Resident 27's elopement assessment dated [DATE], revealed resident was at risk for wandering and elopement. The assessment revealed resident had verbally expressed desire to go home, packed belongings to go home, or remained near exit doors. Review of the current care plan (initiated on January 27, 2022) revealed Resident 27 is at risk for elopement related to cognitive loss, wandering, exit seeking, packing clothes/personal items in a bag looking to leave, getting on an elevator, and believes personal car is in the parking lot. Interventions include monitoring the resident's location with visual checks and wander guard placement. Review of information dated May 11, 2023 submitted by the facility revealed, approximately 4:30 a.m., the nurse was notified by the nursing assistant (NA) that Resident 27 was not able to be located during the hydration pass. The missing resident protocol was initiated, and the police department was notified. At 6:15 a.m., the resident was observed walking adjacent to the facility along the side of the road and was returned to the facility by the police. The resident interview revealed no recollection of the incident. Review of the nursing progress notes dated May 11, 2023, at 6:45 a.m., revealed resident was found outside the facility, and was brought to the unit. The nursing assessment revealed resident did not have injuries or pain, the wandering guard was on the left wrist. The resident was placed on 1:1 supervision, MD and family were notified of the incident. Review of the facility documentation, facility investigation, and staff statements revealed the following: Review of the facility investigation, written statement from N.A, Employee E5 revealed Yes, I heard the alarm but knew nothing about it, I did not do anything because the alarm is always going off. Review of the facility investigation, written statement from N.A, Employee E6 revealed, I saw [resident] around 3:00 a.m., and [resident] was at the nurse's station, I am uncertain about the time I have seen [resident]. The same statement revealed that Employee E6 heard a normal beeping originating the front door but also revealed lack of action taken by Employee E6 upon hearing the alarm. The statement revealed Employee E6 went outside to look around 4:30-5:00 a.m. Review of the facility investigation, revealed a written statement from the licensed nurse, Employee E7 dated May 12, 2023, indicating she/he was working on the first floor. Employee E7 reported hearing an alarm and was told by another staff member that it was because someone was in the bathroom. Employee E7 reported, I looked through the bathroom on my floor and I didn't see a concern, so I disregarded the alarm. Review of the facility investigation, written statement from licensed nurse Employee E8, dated May 11, 2023, revealed Resident 27 was seen near the nursing station around 11:15 p.m., but Employee E8 was transferred to the first floor. Employee E8 further stated, A red box at the nurses' station randomly alarms when no one uses the doors, I heard it last night, but it stopped. The statement failed to reveal that Employee E8 did anything when an alarm was heard. Review of the facility investigation, written statement from N.A, Employee E9, dated May 11, 2023, revealed the employee was working on the first floor. Employee E9 stated, I heard beeping, but I thought it was a bed or chair alarm. The statement failed to reveal any action Employee E9 did upon hearing the alarm sound. Review of the facility investigation, written statement from N.A, Employee E10, dated May 11, 2023, revealed I heard an alarm that I thought was to the front door, but I know people go to Wawa and stuff. The statement revealed that Employee E10 was not assigned to the floor where Resident 27 resided. The statement failed to reveal actions taken by Employee E10 upon hearing the alarm from the front door. Review of the facility investigation, written statement from N.A, Employee E11, dated May 11, 2023, revealed Resident 27 was last seen at 3:00 a.m., and was seated by the front of the nursing station. Employee E11 stated, At around 4:45 a.m., while putting ice water in [resident's] room, I noticed that I did not see [resident] there in his/her room, I notified the RN nurse supervisor immediately. Employee E11 denied hearing any alarms sounding during the shift. Review of the facility investigation, written statement from the licensed nurse, Employee E12, revealed Resident 27 was seen around 2:00 - 3:00 a.m., walking back and forth in the hallway. Employee E12 stated, I heard an alarm, but I've been hearing the same alarm that I've heard since I started two weeks ago. No one knows how to turn it off, I looked around and didn't see anything, so I stopped looking at exits and elevator doors. Another statement completed by Employee E12 revealed Resident was seen at 3:00 a.m., wandering in the hallway. The resident asked during the night Where do I go? The statement further revealed that there was a sound going off at the nurse's station but does not know what it was. The employee went for a break around 3:00 - 3:40 a.m. Another statement completed by Employee E12 revealed that she/he came back from a break at approximately 3:45 a.m. At around 4:30 p.m., NA reported that Resident 27 had not been seen while passing water, and the missing resident protocol was initiated. Review of facility documentation and interview with the Nursing Home Administrator (NHA) were conducted on June 13, 2023, at 1:00 p.m. The NHA reported that the camera surveillance captured Resident 27 exiting the ground exit door (front building) at 2:35 a.m. At 2:38 a.m., camera #7 captured Resident 27 by the front entrance trying to reenter the facility. The resident was found by the police in the back parking lot at 6:15 a.m. At 6:23 a.m., camera #8 captured the resident brought back to the facility by the nursing supervisor. Observation conducted on June 13, 2023, at 1:00 p.m., in the presence of the NHA and maintenance director, Employee E15 revealed Resident 27 resides on the second-floor unit. An exit door with an alarm was observed on the second-floor front side of the building, including two levels of stairs to reach the ground floor exit door (where a resident was captured by the camera exiting). Additional observation revealed an alarm sounded when the ground floor exit door was opened. Observation and interview conducted with the NHA and Director of Nursing on May 14, 2023, at 8:30 a.m. revealed Resident 27 walking in the hallway, and a wander guard was observed on the resident's left wrist. When resident 27 stood by the exit door, an alarm went off. The Director of Nursing (DON) and the NHA explained that an alarm will go off if someone wearing a wander guard was near the exit door but would automatically turn off if the resident walks away. The exit door on the second-floor front side of the building was locked but will automatically open when someone leans on it for 15 seconds, an alarm will go off when the door opens and would require someone to manually enter a code to the panel to turn off the alarm. The NHA also explained that the exit door on the ground floor front side of the building will alarm when the door was opened but would automatically shut off at approximately 20 seconds. Interview with the DON on May 14, 2023, at 8:40 a.m., revealed that the facility investigation did not reveal who/how the second-floor exit door alarm stopped. The DON confirmed that based on the facility investigation, and staff statements multiple employees that worked during the time of the incident heard an alarm but did not do anything about it. Resident 27 was assessed as an elopement risk, with episodes of exit-seeking behaviors. On May 11, 2023, facility documentation review revealed that from around 2:00 a.m., until 4:30 a.m., Resident 27, who was last seen wandering in the hallway was not sufficiently monitored. An alarm/door alarm was heard by multiple staff but was disregarded resulting in an elopement of a confused resident, climbing down two flights of stairs, walking out of the building at 2:35 in the morning, and wandering on an area with a two-lane highway nearby with the potential to experience negative outcomes. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on June 14, 2023, at 2:45 p.m., and the IJ template was presented to the NHA, regarding the elopment of Resident 27 from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure the implementation of supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. The facility identified the jeopardy at the time of the incident, May 11, 2023. The facility submitted and completed an immediate action on June 14, 2023, which included: Placing Resident 27 on 1:1 monitoring upon return to the facility; Audited current residents at risk for elopement, wander guard orders, care plan reviewed for accuracy; All doors/exit doors audited for functioning; Installation of additional auditory and visual alarm system as well as additional screamer alarm placed at the nursing station placed on May 17, 2023; Review of the elopement risk evaluation for all new admission, and re-admission; Elopement drills completed and will continue to be conducted on each shift monthly; Weekly audits for four weeks to validate wander guard system is being audited by maintenance department; Random audits of ten resident records weekly to assure compliance with the implemented process; and bringing findings to the Quality Assurance and Process Improvement committee meetings monthly for review until sustained compliance is achieved. Facility staff was educated on the following: elopement prevention; search of facility and grounds during elopement; notification of appropriate parties during elopement; supervision of exit seeking residents: and timely response to alarms. The administration educated 181 facility staff, six dialysis staff and eight agency staff. On June 15, 2023, a review of audits, and documentation of conducted to verify the employee education was completed. Licensed Employee E21 and E25 and non licensed employees E16, E17, E 22, E23, E24, Activity Director Employee E19, and Housekeeping Employee E20 were interviewed regarding supervision of residents and education provided. The staff members interviewed, confirmed receiving above education and verbalized knowledge of the education provided, facility had completed the interventions developed for the action plan on May 11, 2023. The Immediate Jeopardy was lifted on June 15, 2023, at 1:20 p.m., after confirmation that the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 6/17/22, 3/3/22, 10/22/21, 5/6/21 28 Pa. Code 211.5(h)Clinical records Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 6/17/22, 5/6/21 28 Pa. Code 211.12(c) Nursing Services Previously cited 6/17/22

Based on interview, observation, and clinical record review, it was determined that the facility failed to follow physician's orders for two of 33 residents reviewed (Residents 70 and 18), causing actual harm to Resident 70, who experienced a delay in obtaining treatment and services at the hospital for a urinary tract infection and septic shock. Findings include: Review of Resident 70's clinical record revealed a significant change MDS (Minimum Data Set -periodic assessment of a resident's abilities and care needs assessment dated [DATE] where resident had a BIMS (Brief Interview of Mental Status) score of 15 of 15; indicating intact cognitive function. Review of Resident 70's clincial record revealed progress note dated May 9, 2023 indicating past medical history that included Chronic Kidney Disease, Sepsis, Urinary Incontinence and a UTI (Urinary Tract Infections). Interview with Resident 70 on June 14, 2023, at 12:45 p.m. revealed the resident had recently been hospitalized for sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and a urinary tract infection. Observation of Resident 70 at this time revealed the resident had a right nephrostomy (tube inserted through the skin into the kidney which drains urine directly from the kidney). Further interview with Resident 70 at this time revealed the resident received the nephrostomy during the recent hospitalization . Resident 70 further revealed that the resident had been complaining of generalized pain prior to being hospitalized , but the facility would not let the resident go to the hospital. Review of Resident 70's progress notes revealed a physician's progress note dated May 18, 2023 (3:58 a.m.) which stated: I saw patient at about 1.5 hours ago for pain management. At that time, she was asking to go to the ER for pain management because she has pain all over. At that time, I discussed with her that we can manage her pain in the facility and that she is likely to wait a long time in the ER for the same pain, she finally agreed to stay in the facility. She is now asking to be transferred to the ER. I offered to adjust her pain regimen but she no longer wants to be treated at the facility. She also wants to know why she is having so much pain. Further review of Resident 70's progress notes revealed a nurse's note from the Assistant Director of Nursing on May 18, 2023, at 11:02 a.m. which stated: Spoke with [licensed nurse Employee E2] regarding why there was an order given from [physician] to send resident to the ER and resident did not go. Per [Employee E2], after speaking with [physician] and getting the verbal order to send the resident he went back into resident's room and she was comfortable and sleeping. [Employee E2] did not feel that she needed to go to the ER for pain at that time. Primary nurse was made aware and advised to notify supervisor if resident woke up in pain again and they would re-evaluate the need to send her to the ER at that time. Further review of Resident 70's progress notes revealed a physician's progress note dated May 18, 2023, which stated: Patient seen for follow-up this morning as on-call report stated resident requested to go to ER due to pain overnight as she requested pain medication. Patient still in room this am. Discussed situation with [Assistant Director of Nursing] and found out that patient stayed at facility after she recieved pain medication as she was resting comfortably in early am. Upon assessment, patient resting comfortably in bed, offering no complaints in early am. Later in AM staff asked for provider to assess [Resident 70] as she was requesting to go to ER again stating she 'doesn't feel well, I want to go to hospital.' Upon evaluation, patient continues with generalized pain and now with low grade temp. [temperature]. Further review of Resident 70's progress notes revealed a nurse's note dated May 18, 2023 at 2:46 p.m. which stated: Resident [complained of] back pain, Oxycodone [(narcotic pain reliever)] 5mg (miligram) was administered for pain. [vital signs] were: Tem.100.03, BP 130/66,Spos 95%,Res 19 . [Practitioner] recommended resident send out to the hospital for further evaluations. Resident sent out to [emergency room .] MD and family notified. Review of Resident 70's hospital paperwork revealed an emergency room note which stated that the resident presented to the emergency department complaints of back pain and fevers. Apparently became acutely encephalopathic [(altered mental status/confusion)] on the ride here. Here is had persistent fevers with temperature max of 104 degrees Fahrenheit with tachycardia [(elevated heart rate)] .Meeting criteria for severe sepsis on arrival. Further review of Resident 70's hospital paperwork revealed a Significant Event note on May 20, 2023 which stated: Patient noted to become febrile with [temperature max] of 103.8, [heart rate] 129 [(normal is 60-100)]. Initially hemodynamically stable, but became hypotensive with [systolic blood pressure in the] 70s [(normal is 120)] She was given 1 liter [lactated ringers (type of IV fluids)] bolus with minimal response to BP .Given worsening sepsis .given current instability, recommend to stabilize patient and complete [percutaneous nephrostomy] by [interventional radiology.] Given persistent hypotension despite [IV fluids], will transfer to ICU to initiate pressors for septic shock. Further review of Resident 70's clinical record revealed the resident returned to the facility on [DATE], after a hospital stay of 13 days. Interview with the Nursing Home Administrator and Director of Nursing on June 16, 2023, at approximately 11:50 a.m. confirmed licensed nurse Employee E2 did not follow a verbal physician's order to send Resident 70 to the hospital, nor did Employee E2 notify the physician that they made the decision to not send Resident 70 to the hospital. Review of Resident 18's physician orders revealed an order dated October 25, 2022 for daily weights. Review of Resident 18's weights on June 16, 2023 revealed Resident 18 had only been weighed twice in the month of June 2023, three times in the month of May 2023, 13 times in the month of April 2023, 8 times in the month of March 2023, 11 times in the month of February 2023 and 7 times in the month of January 2023. Interview with the Nursing Home Administrator and the Director of Nursing on June 16, 2023 at 10: 45 a.m. confirmed Resident 18 was not being weighed daily as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on review of clinical records and facility documentation, as well as staff interviews, it was determined that the facility failed to address a suspected right femur (thigh bone) non-displaced fracture (the bone breaks but retains its proper alignment) timely as evidenced by a radiology report. This failure had resulted in harm of unnecessary discomfort, pain, and hospitalization for one of 32 residents reviewed (Resident 101). Findings include: Review of Resident 101's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 101's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated October 22, 2021, revealed that the resident had moderate cognitive impairment. Further review of the same MDS assessment revealed the resident required supervision with transferring and ambulation on and off the unit. Review of the nursing documentation notes dated January 10, 2022, at 3:12 p.m., revealed Resident 101 was very anxious about not being in her/his assigned room during quarantine with COVID-19 virus. The same note further revealed the resident was confused, oriented to person, and moderately impaired with decision making. The resident's walking was not steady but able to stabilize without staff assistance. Review of the nursing documentation notes, dated January 11, 2022, at 6:58 p.m., revealed Resident 101 had a change in ambulation status, would not ambulate, and required staff assistance with standing and transferring into the wheelchair. The NP (Nurse Practitioner) was made aware. Review of the nursing documentation notes dated January 11, 2022, at 7:03 p.m., revealed, the resident was transferred by the nurse, upon attempt, the resident would not stand, and would bear weight on both legs when standing but was unsteady due to leaning to the left (leg). A small dime-sized bruise was observed on the left knee, with no grimacing during the assessment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Radiology Result Report dated January 11, 2022 (11:43 p.m.) revealed the following: Right knee had modest [CONDITION(S)] (type of arthritis that occurs when flexible tissue at the ends of bones wears down), no acute fracture or dislocation. The right femur x-ray result report revealed a suspicious non-displaced femoral neck impaction fracture. The same report revealed, Please correlate clinically and follow-up is recommended to confirm or exclude this diagnosis. Review of the Nurse Practitioner's progress note dated January 12, 2022, revealed the resident was seen for follow-up after a recent COVID positive test result and complaint of right knee pain. The note further indicated that during the examination the resident was labile [frequently changing] at baseline. The same note revealed that the resident had right knee pain and was having difficulty standing unless with assistance. The knee was swollen but not warm to touch, the resident grimaced when the right knee was moved, and the right knee had a bruise. The note also revealed the resident reported falling three times (no dates or times indicated) while in another room. The NP's note had documentation of the right knee x-ray result of January 11, 2022, but failed to indicate documentation of the right femur x-ray result. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing documentation notes dated January 15, 2022, at 2:29 p.m., revealed Resident 101's right knee was still swollen, and resident continued to have difficulty bearing weight on the right leg. Review of the nursing documentation notes dated January 17, 2022, at 3:41 p.m., revealed resident had bilateral lower extremity (BLE) pain. On January 18, 2022, Resident 101 was seen by attending physician with documentation revealing resident had a right knee inflammation and was on Ibuprofen. The physician's notes did not mention anything regarding the resident's right femur x-ray result reported to the facility on [DATE]. Review of the NP's progress notes dated January 20, 2022, revealed Resident 101 was seen for continued right knee pain. The note revealed resident complained of the right knee and was having difficulty standing and walking unless with assistance. The right knee was swollen, and the resident was able to move bilateral knees but grimaces when the right knee was moved. An Orthopedic (Physician that specializes in musculoskeletal system) consult was ordered for non-improved pain. Review of the physician notes dated January 21, 2022, revealed [Resident 101] had been complaining of right knee pain and had been having trouble standing as per nursing. The same note revealed right knee pain, no evidence of gout, no swelling, and an x-ray unrevealing the acute cause. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As per physician note, attempts for an Ortho consult were made but were unsuccessful due to insurance, the resident will be reassessed. There was no mention/documentation of the resident right femur x-ray result. Review of the NP's notes dated January 26, 2022, revealed resident was still complaining of right knee pain. The same note indicated that as per discussion with the nursing assistant (NA), the NP was informed that the resident was able to stand with assistance but yells in pain when attempting to sit in the toilet. An X-ray of the right hip was ordered. Review of the Radiology Result Report dated January 26, 2022, at 10:42 a.m., revealed an acute, mildly displaced right femoral neck fracture (gap that forms where the bone breaks). Review of the progress notes dated January 26, 2022, at 1:49 p.m., revealed Resident was transferred to the hospital for a mild displaced right hip fracture. Hospital records review dated January 26, 2022, revealed Resident 101 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment and plan revealed, unclear when the hip fracture occurred, sometime in last two weeks. Ortho consults and pain management was ordered. Review of the NP's progress notes dated February 2, 2022, revealed resident was readmitted to the facility. The same note revealed Resident 101 had a Right Hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) on January 28, 2022. Interview with the Director of Nursing (DON) was conducted on June 17, 2022, at 11:45 a.m. The DON reported that radiology results can be accessed electronically. As per the Director of Nursing, nurses and/or supervisor checks the result and notifies the physician. The Nurse Practitioners can also view the radiology results electronically. Clinical records review failed to reveal that the physician/NP were notified of the right femur x-ray result on January 11, 2022, indicating suspicions of a non-displaced femoral neck impaction fracture. Interview with the Nurse Practitioner (NP) was conducted on June 17, 2022, at 11:45 a.m. The NP reported that on January 11, 2022, she/he only saw a right knee x-ray result, the NP stated, It might not have been there yet when I checked the result, I copied the result and pasted it to my notes The NP confirmed that she was not aware of the right femur x-ray result reported to the facility on [DATE]. When asked what she would have done if she had known the right femur x-ray result, the NP stated, I would have sent the resident to the hospital. The above information was discussed with the Nursing Home Administrator and Director of Nursing on July 17, 2022, at 1:00 p.m. The facility failed to address a right femur x-ray result that showed Resident 101 with a suspicious non-displaced femoral neck impaction fracture for 15 days which resulted in continued pain in right leg, hospitalization , and surgery. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 3/3/22, 10/22/21, 5/6/21 28 Pa. Code 211.5(h)Clinical records Previously cited 5/6/21 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 5/6/21 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 5/6/21 28 Pa. Code 211.12(c) Nursing Services

Based on a review of established guidelines for CardioPulmonary Resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident R1), creating a situation in which the residents were placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation and lack of knowledge on where to locate a resident's code status for 28 residents that had cardiopulmonary resuscitation orders. Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. The facility's policy regarding CPR, dated [DATE], states that if a resident was found unresponsive and not breathing normally, CPR would be initiated unless there was at least one obvious signs of irreversible death (lividity or pooling of blood in dependent body parts, hardening of muscles or rigidity, or injuries incompatible with life). If there are no obvious clinical signs of irreversible death, and there is no visual identification of a DNR order, CPR should be initiated. Call 911 and notify the primary physician and continue CPR until a DNR order is given by the physician, the patient is revived, or emergency medical services arrive and take over the care. Review of Resident R1's clinical record revealed the resident was admitted on [DATE] and a Physician's order for Full Code (life sustaining interventions including resuscitation) was written on [DATE]. Further review of the clinical record revealed a nursing note dated [DATE] by Licensed Employee E3 stating the resident was seen at 0530 the call light was activated. The nurse aide called for assistance to roll the resident to put her pillow back under head. While changing the resident's position, (Licensed Employee E3) noted resident had watery eyes and sudden change in breathing. The (Licensed Employee E3) called for the supervisor and went to get the oxygen. On the way back to the room the aide yelled that the resident stopped breathing. Continued review revealed a nursing note dated [DATE] by Registered Nurse Employee E4 that indicated, (I) was called to the room at 6:18 a.m. and the resident was found in bed unresponsive to verbal or external stimuli. No respirations, apical heartbeat absent x 1 minute, no radial pulse, pupils fixed and dilated. Resident pronounced dead. There was no documented evidence that the resident was provided CPR in accordance with the code status or with the facility policy that states if the resident is found in cardiopulmonary arrest (no apparent pulse, blood pressure, or respirations) CPR will be initiated until there is a DNR order, or a physician's order not to administer CPR or EMS arrive. A telephone interview conducted on [DATE] at 1:10 pm by the surveyor with the Licensed Employee E3 revealed Employee E3 was unaware of the code status of Resident R1 and indicated uncertainty of where to find the code status of any resident. Licensed Employee E3 indicated CPR was not initiated. When questioned why life sustaining interventions were not initiated, Licensed Employee 3 responded, the resident was already dead. Licensed Employee E3 reported they have not worked at the facility since the event. Review of facility documentation revealed an interview conducted with the Registered Nurse, Employee E4, on [DATE] by facility staff indicating Resident R1 was found in bed unresponsive to verbal or external stimuli. No respirations, apical heartbeat absent x 1 minute, no radial pulse, pupils fixed and dilated. Resident pronounced dead at 6:20 a.m. Surveyor did not receive a return phone call for further questioning. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE] at 11:00 a.m. revealed that they were aware that staff did not provide CPR to Resident R1 in accordance with the code status, and the facility's policy. On [DATE], at 3:42 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to the Licensed staff failing to provide CPR in accordance with a resident's physician's order and the facility policy and the lack of knowledge on how to locate the code status of residents. The facility submitted an acceptable immediate action plan on [DATE], at 6:29 p.m. that included the following actions: A facility wide sweep ensuring each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy and the signs of irreversible death; to ensure that CPR will be provided in accordance with each resident's advanced directive and physician orders and further education on where to find the code status of residents. The plan also included to actively hold Code Blue drills (simulated event whereby staff respond to a resident experiencing cardiac arrest) with staff, and to complete ongoing audits. The Immediate Jeopardy was lifted on [DATE], at 2:32 p.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and the facility's policy, location of code status and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility's policy, clinical records, facility investigation reviews; and staff interviews, it was determined that the facility failed to provide supervision for a resident in the use of a non-approved heat compress resulting in harm of a second-degree burn (injury that involves the outer layer of the skin and part of the inner layer of the skin) for one of three residents reviewed (Resident CL1). This was identified as passed non-compliance. Findings include: Review of the facility's policy titled Heat: Application Of, with a revision date of June 1, 2021, revealed that a warm compress is the recommended method of applying moist heat and may be used as a nursing intervention or as ordered by a physician/advanced practice provider. Patients may not use heating pads. Nursing may not use hydrocollator packs (type of clay packs applied externally to alleviate [CONDITION(S)] pain, joint pain, congestion, and strains) or microwavable hot packs. If a hydrocollator pack is needed, consult with rehabilitation staff. Review of Resident CL1's diagnosis list revealed Compression thoracic fracture (a bone in the spine collapses), Dorsalgia (pain in the upper back), and [CONDITION(S)] (chronic [CONDITION(S)] disorder affecting many joints, including those in the hands and feet). Review of Resident CL1's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated October 1, 2021, revealed that the resident was cognitively intact and required supervision with no setup from staff for ambulation, transferring, personal hygiene, and grooming. Review of the nursing progress note dated November 14, 2021, at 12:56 p.m., revealed the charge nurse was requested by the family. Upon entering the room, the resident was sitting on side of the bed with a heating pad laying on the mattress. The resident's mid-back was observed with a 'burn-like' area. The resident reported that the heat pad was used for her/his back pain. The resident and the family were educated on the facility's policy regarding the use of heat pads. The burn area was assessed, and the physician was notified. Review of the Wound Evaluation report completed on November 14, 2021, revealed the second-degree burn to the spine had a measurement of 9.04 x 2.8 cm (centimeters) with a total area of 20.14 cm. The wound was treated with [MEDICATION(S)] cream (an anti-microbial medication used to treat and prevent wound infection in patients with [CONDITION(S)]). Review of the physician's progress notes dated November 15, 2021, revealed that the resident was seen for chronic medical conditions and reported burn on the back. The physician progress notes indicated that Resident CL1 stated: was using a microwaveable heating pad, but it was not too hot and was wearing a polyester nightgown and the nightgown got too hot and caused a burn on my back. As per the note, the resident reported that she/he fell asleep on the heating pad, denied using a towel between the heating pad and her/his back. The resident was educated regarding the type of heating pad not permitted in the facility, resident verbalized understanding and informed the physician her/his daughter took it home. The same note revealed that the resident denied pain at the site, observed with a reddened area on the mid-back, worse over spine area, with no drainage noted. Review of the facility documentation including, Nursing Assistant (NA) Employee E3 statement completed on November 15, 2021, revealed that on November 14, 2021, Resident CL1 asked the NA to put the gel heat pad in the microwave, not more than 50 seconds, Employee E3 set the microwave for 30 seconds but had to answer a call light from another resident. On the way back to the room, licensed nurse Employee E4 informed Employee E3 that the heat pad was already given to Resident CL1. Interview with licensed nurse, Employee E4 on November 30, 2021, at 10:30 a.m., revealed that approximately 8:30 a.m., while doing medication pass, observed Resident CL1's light being answered by N.A, Employee E3. Upon entering resident CL1's room, the resident was asking for her/his heating pad that was taken by the N.A. The resident informed Employee E4 that the heating pad is the only thing that helps her/his back pain. Employee E4 informed the resident that her/his medication was ready, but the resident insisted on getting the heat pad as well. Employee E4 reported that she saw the resident's heating pad in the pantry and gave it to the resident, the nurse reported that the heating pad was not hot when she/he gave it to the resident. Employee E4 reported that the resident was alert and oriented and independent and often refused any assistance from the staff. Employee E4 confirmed that there was no physician order for the heat pack, as according to Employee E4, he/she wanted to provide a non-pharmacological intervention for the resident's back pain but was not aware that a microwavable beaded heating pad was not allowed to be used. Additionally during the interview, Employee E4 indicated, approximately lunchtime, the resident's son asked Employee E4 to assess the resident's back. Employee E4 reported that she observed a burn-like area on the resident's mid-back. The nurse reported that the area looked new. The resident's family refused to believe that the reddened area was a burn since they also use the same product and had never resulted in a burn. Employee E4 educated the family regarding the elderly's fragile skin but refused to listen and demanded to talk to the charge nurse instead. Interview on November 30, 2021 at 11:00 a.m. with the charge nurse, Employee E5 revealed on November 14, 2021, approximately 12 p.m., Resident CL1's son requested to talk to her/him. Employee E5 reported that the heating pad was observed on the bed, beside the resident. The nurse observed the resident's back and confirmed that it was a burn. Physician was made aware of burn, and a treatment was ordered. The heating pad was removed from the resident's room. Interview with Employee E3 on November 30, 2021, at 11:15 a.m., revealed that the heating gel pad was provided by the family. Employee E3 indicated that on November 14, 2021, approximately 8:30 a.m., Resident CL1 asked nurse aide to microwave the heating pad for no more than 50 seconds. According to the N.A., after reading the instructions (heat for 40 seconds), she/he set up the microwave for only 30 seconds but left to answer another resident's call bell request for assistance. On the way back to the room, Employee E4 informed her/him that Resident CL1 had been waiting for the heating pad so she/he gave to the resident. Employee E3 reported that she/he was not sure if the heating pad was on the resident's plan of care. Review of Resident CL1's active care plan for pain revealed, a heating pad was not included as an intervention for managing the resident's back pain. Review of Resident CL1's Physician Order Sheet failed to reveal an order for a heating pad for pain management. The above information was conveyed to the Nursing Home Administrator on November 30, 2021, at 2:15 p.m. Interview with Assistant Director of Nursing on November 30, 2021 revealed the facility has been conducting audits, weekly to ensure that residents do not have heating pads/microwavable pads in the rooms. Interviews conducted on November 30, 2021 with Employees E3, E4, E5, E6, E8 and E9 revealed the facility has provided education regarding the use of heating pads within the facility and appropriate type and usage for residents. Staff were able to verbalize knowledge of and understanding of process when families bring heating pads/applicators into the facility. Staff indicated awareness of policy and prohibition of microwavable heating pads. The facility failed to provide supervision regarding the use of a non-approved heating pad for Resident CL1 which resulted in actual harm of a second-degree burn to the mid back. This deficiency is cited as past non-compliance. The facility implemented a corrective action plan which included: Immediate removal of the heating pad from the resident; Microwave was removed; Initial audit in all residents' rooms to determine that no other residents had a heating pad in their room; Staff education/re-in-service regarding heating pads/application of heat policy; and Random weekly audits for three months to ensure no heating pads are being used. A review of the facility documentation and staff interviews showed that the corrective action had been fully implemented and completed by November 29, 2021. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 5/6/21, 2/8/21, 8/31/20, 6/5/20 28 Pa. Code 211.5(h)Clinical records Previously cited 5/6/21,2/8/21, 8/31/20, 6/5/20 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 5/6/21, 8/12/21, 10/4/21, 2/8/21, 8/31/20, 6/5/20, 1/29/20 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 5/6/21, 2/8/21, 8/31/20, 6/5/20 28 Pa. Code 211.12(c) Nursing Services Previously cited 1/29/20

Based on review of the facility's policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to provide wound treatment consistently, assess the wound timely, accurately, and comprehensively for one of seven residents reviewed, resulting in actual harm when the resident's sacral wound deteriorated (Resident 34). Findings include: A review of the facility's policy titled, Skin Integrity Management, with a revision date of January 31, 2021, revealed practice standards included completion of comprehensive evaluation of the patient upon admission/re-admission to the center, identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information which included performing skin inspection on admission/re-admission and weekly. Document on TAR (Treatment Administration Record) or in EMR (Electronic Medical Records). Perform wound observations and measurements and complete, Skin Integrity Report, upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. Perform daily monitoring of wound or dressings for presence of complications or declines and document. Review of Resident 34's clinical record revealed an admitted [DATE]. Resident 34's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's Admission Minimum Data Set assessment (MDS-an assessment tool used to facilitate the management of care) dated December 2, 2020, revealed that the resident's cognition was moderately impaired. The same MDS revealed that the resident required extensive assistance with two people for bed mobility. The MDS also revealed that the resident was always incontinent of bladder and bowel. A review of Resident 34's Braden Risk assessment scale (a tool used to determine risk factors for pressure sore development) completed on December 3, 2020, revealed a score of 13 which placed Resident 34 as a moderate risk for pressure ulcer development. A review of Resident 34's Admission Nursing Documentation dated November 26, 2020, at 11:03 a.m. revealed that the resident was admitted to the facility for wound care and long-term care. A review of the same record revealed that the resident had a skin injury. Location of the wound revealed, right and left ulcer. A review of Resident 34's Skin Check Record dated November 26, 2020, at 4:07 p.m. revealed skin injury type: pressure, location: bilateral buttocks. The record failed to identify the measurement, and characteristics of the resident's wounds. A review of the Discharge Summary dated November 25, 2020, from the facility where Resident 34 came from revealed pressure ulcers to buttocks healing well, now 100% granulated (healing). Skin: multiple pressure wounds to sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity)/buttocks-not visualized today, followed by wound team. Apply [MEDICATION(S)] cream (an anti-[CONDITION(S)] cream used to treat itching and other minor skin condition) 0.05% to sacrum/buttocks topically two times a day for multiple open areas. A review of Resident 34's Wound Evaluation Record dated November 27, 2020, at 3:23 p.m. revealed a pictured wound of the resident. The assessment revealed the following wounds: Right buttock Stage 3 (ulcer involving full thickness of skin loss, exposing tissue) with a measurement of 3.0 x 8.0 x 0.9 cm; and left buttock Stage 3, with a measurement of 1.2 x 2.3 x 0.7 cm, 20% yellow slough (separation of dead tissue from living tissue). Also documented was a Sacrum DTI (Deep Tissue Injury -purple or maroon localized area of discolored intact skin or blood filled blister due to damage or undermining soft tissue from pressure or shear) with a measurement of 9.7 x 6.3 x 1.9 cm which was not documented on the November 26, 2020, facility admission assessment. An interview with the wound nurse, Registered Nurse (RN), Employee E6 on May 6, 2021, at 2:49 p.m. confirmed that the resident was admitted to the facility with a wound on bilateral buttocks and sacrum. Employee E6 stated that wounds are assessed upon admission by the nurse, and a picture of the wounds through an electronic app must be completed within 24 hours from admission then weekly. When asked regarding the incomplete and inaccurate wound assessment on admitted (November 26, 2020) RN Employee E6 insisted that an assessment of the wounds was completed on admission day but was unable to provide the surveyor documentation of a complete and accurate assessment of the wounds. When asked about the [MEDICATION(S)] treatment, RN Employee E6 stated that the wound treatment was followed from the facility where the Resident 34 came from, the information was relayed to the physician and was ordered to treat the resident's wounds. RN Employee E6 stated that [MEDICATION(S)] was not the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the November 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's progress notes from the Nurse Practitioner (NP) dated November 30, 2020, at 3:35 p.m. revealed that PI (pressure injury) that were present from admission on Swift (a ready program that captures wound measurement, images and data without touching the wound) were assessed and order was made to change the treatment to [MEDICATION(S)] (a wound treatment used to prevent and treat wound infections in patients with burns). A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the November 2020 POS revealed an order to discontinue [MEDICATION(S)] treatment to the sacrum on November 30, 2020. A review of Resident 34's December MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's clinical record revealed that the weekly wound assessment for the resident's right and left buttock Stage 3 and DTI wound on the sacrum was not performed on the first and second weeks of December 2020. An interview with RN Employee E6 on May 6, 2021, at 2:50 p.m. confirmed that Resident 34's wounds were not assessed on the first and second weeks of December 2020. RN Employee E6 stated that the nurses and/or wound nurse were responsible for the weekly assessment of the wounds. RN Employee E6 was unable to provide an answer as to why the wounds for Resident 34 were not assessed on the first and second weeks of December 2020. A review of the Wound Evaluation Record dated December 16, 2020, at 8:38 a.m. revealed deteriorating wound, right buttock (previously Stage 3) joined with sacral wound (previously DTI), will now be identified as sacral unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and eschar [dry scab, tan, brown or black, in wound bed;dead tissue]). The wound had a measurement of 11.67 cm x 5.22 cm. Assessment of the wound bed was not completed but the picture of the joined right buttock and sacral wound revealed that the wound bed had a 40% black eschar, and 60% yellow slough. Left buttock Stage 3 had a measurement of 1.2 x 2.3 x 0.7 cm, 20% slough and 80% granulation (development of new tissue and blood vessels in a wound during the healing process). A review of the December 2020 Treatment Administration Record (TAR) revealed an order made on December 17, 2020, to cleanse sacral pressure injury with wound cleanser and apply skin prep to periphery and apply Therahoney (a dressing impregnated with honey) and foam every day shift. Review of the same TAR revealed an order made on December 17, 2020, to cleanse left buttock Stage 3 with wound cleanser and apply foam dressing every day shift. A review of the Wound Evaluation Record dated December 23, 2020, at 9:14 a.m. revealed that the sacral wound had deteriorated and is now a Stage 4 pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone), with measurements of 4.88 cm x 3.41 cm x 1.5 cm, 70% slough (black), 30% granulation, with light purulent exudate (a type of fluid that is released from the wound often described as being milky and can indicate sign of infection). NP was made aware, a new treatment order was made on December 23, 2020, to cleanse sacrum with wound cleanser and pack two fluffed Mesalt (supports the cleansing of moderately to heavily discharging infected wounds) dressing and cover with foam every day shift. A review of the left buttock Stage 3 revealed a measurement of 0.11 cm x 0.3 cm x 0.35 cm. A review of the Wound Evaluation Record dated December 30, 2020, at 7:21 a.m. revealed sacral wound Stage 4 had a measurement of 7.75 cm x 3.22 cm x 4.5 cm, and the left wound had resolved. A review of the NP's progress notes dated December 30, 2020, at 2:49 p.m. revealed that the sacral wound Stage 4 is much cleaner this week with 30% slough tissue and 70% granulation tissue, Mesalt wound treatment continued. A review of the Wound Evaluation Record dated January 6, 2021, at 7:45 a.m. revealed sacral wound Stage 4 had a measurement of 8.15 cm x 4.85 cm x 2.5 cm with undermining (refers to wound being open underneath the lip of the border) of 1.5 cm from six to 12 o'clock. Wound bed had 30% slough, 10% granulation and (+) bone. The wound had a heavy serosanguinous (may appear as a clear liquid swirled with red blood) drainage and had a faint odor. On May 6, 2021, at 9:30 a.m. Resident 34 refused to allow the surveyor to see his/her wounds or observe wound care. The sacral wound was assessed weekly, most current Wound Evaluation Record was completed on May 5, 2021, at 7:08 a.m. with a measurement of 5.72 cm x 4.26 cm x 1.5 cm, with undermining of 5.0 cm from seven to 12 o'clock. The wound bed had 10% slough, 90% granulation and (+) bone with heavy serosanguinous drainage. The above was conveyed with the Nursing Home Administrator and the Director of Nursing on May 7, 2021, at 10:00 a.m. The facility failed to provide a consistent wound treatment, ensure that wound assessments were done timely, comprehensively, and accurately which resulted in actual harm when Resident 34's sacral wound had advanced from a DTI to an unstageable pressure ulcer. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 2/8/21, 8/31/20, 10/25/19 28 Pa. Code 211.5(h)Clinical records Previously cited 2/8/21, 8/31/20, 10/25/19 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 2/8/21, 8/31/20, 3/4/20, 1/29/20, 10/25/19 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 2/8/21, 8/31/20, 3/4/20, 1/29/20, 10/25/19

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure a safe environment for assuring that windows in resident rooms were properly secured from fully opening resulting in actual harm to a resident who eloped through the window, sustaining a fall with a resulting [DIAGNOSES REDACTED]. Findings include: Review of Resident R1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated (MONTH) 20, 2019, revealed the resident was assessed with [REDACTED]. Further review of the quarterly MDS assessment revealed the resident was assessed as requiring supervision for transfers, and ambulation with one-person physical assist required. The resident's balance was not steady but able to stabilize self without staff assistance. Review of Resident R1's elopement evaluation dated (MONTH) 5, 2019, revealed the resident had a history wandering that placed the resident at risk of getting to potentially dangerous places. The evaluation further indicated the resident needed to follow staff or other residents and to seek companionship. Review of Resident R1's clinical record revealed a care plan goal of Resident exhibits or has potential to wander related to cognitive loss/dementia. The resident had poor impulse control. Further it was stated that the resident will turn on the water in the bathroom and walk away. Further review of Resident R1's care plan goals and interventions revealed an intervention to check bathroom faucet Q3 hours (every 3 hours) to verify water is off. Review of Resident R1's clinical record revealed an interdisciplinary progress note dated (MONTH) 22, 2019, indicating a Call placed to 911 at 03:55 (3:55 a.m.) after client noted to be outside on the ground under his second-floor window. Review of the facility's investigation revealed a written statement by licensed nursing staff, Employee E10 indicating that at 3:50 a.m. Employee E10 was notified that the resident was on the ground outside the one central lounge. I went to check, found resident on the ground lying on his right side with his right hand supporting his head. He was facing the grass and his back towards the wall of the building. Resident personal belongings were noted on the ground all around him. His back pack, brown pant, his glasses and number of tea bags in a sandwich pack are the items noted around him. Also I noticed a bottle of nuts and a black umbrella lying on the grass away from the resident. Hanging from the resident's room window is a blue hoyer lift sling with a broken telephone cord dangling on it end. Also noted on the ground under the resdient is another hoyer lilt sling. A complete neuro checks was done by this nurse. At this time resident was awake alert and verbally responsive. Resident was noted using his hand to rob hip left hip at intervals speaking in his native language. EMS (Emergency Medical Services) (911) was called and resident transferred to the ER (emergency room ). Review of Resident R1's clinical record revealed imaging of CT (a computed tomography scan- a combination of x-rays and computer to create pictures of organs, bones or other tissues) of the chest dated (MONTH) 22, 2019, indicating Impression: Minor, acute superior endplate compression fractures are noted at L1 and L3 (lumbar spine disks). Review of a nursing note dated (MONTH) 22, 2019, at 11:36 a.m. indicated that the resident returned to the facility on (MONTH) 22, 2019, at 10:00 a.m. accompanied by two attendants. The resident was placed on 1:1 supervision until further notice for safety. Review of facility provided elopement/fall documentation of a statement by non-licensed staff, Employee E4, dated (MONTH) 22, 2019, at 3:50 a.m. revealed I was passing out my water in the resident room. While still in room [ROOM NUMBER], I notice a sound outside the window side. I notice a resident on the floor out. I went to the nursing station and notified the nursing supervisor. Review of the facility documentation regarding the staff requirement to verify that the in-room bathroom sink faucet was turned off, revealed that staff verified the sink faucet was off at 10:16 p.m. on (MONTH) 21, 2019, and next documented that the bathroom sink verification occurred at 4:46 a.m. on (MONTH) 22, 2019. Continued review of fall/elopement documentation revealed a statement by licensed nursing staff, Employee E6, which indicated Client was in his room sleeping at 2:30 a. m. when I passed the door at 2:30 a.m. I had only peeked in resident's area. He was apparently sleeping eyes closed, facing the window. Interview on (MONTH) 27, 2019, at approximately 10:07 a.m. with Environmental Services staff, Employee E9, revealed that each room was given a detailed cleaning once a month which includes the cleaning of the windows and the blinds. If an issue is noted during the cleaning process Director of Environmental services is alerted. Interview on (MONTH) 27, 2019, at approximately 10:13 a.m. with the Nursing Home Administrator confirmed that the resident was able to open the window by removing the sliding glass pane; tied substitute rope together using Hoyer pads and phone cords in an attempt to reach the first floor safely. The resident was found on the first-floor grounds with supplies of clothes, umbrella, and snacks. Interview on (MONTH) 27, 2019, at approximately 10:45 a.m. with Employee E3, revealed recollections of events of (MONTH) 22, 2019, as follows: Here in the building at 5 a.m. In the room, I saw the window pane was removed and sitting against the wall. The [MEDICATION NAME] was in the window frame at the time of the elopement. I saw three (Hoyer lift pads) in the room with one tied to the Gerry chair, two tied together and a phone cord on the third one (pad). When questioned where and how the resident acquired the lift pads, Employee E3 responded, they are stored in the clean linen utility room which has a locking mechanism. I don't know how the resident got the pads. The facility failed to ensure that windows were properly restricted from opening which resulted in actual harm to Resident R1 lifting the sliding glass pane up into the window frame, moving the sliding glass pane out of the frame, eloping through the window and sustaining compression fractures of the lumbar spine. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 03/20/19 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/09/19, 09/10/18, 03/20/18, 07/10/17 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 01/09/19, 03/20/18, 07/10/17 28 Pa. Code 201.18(b)(3) Management Previously cited 01/09/19, 09/10/18, 03/20/18, 07/10/17 28 Pa. Code 201.18(e)(1) Management Previously cited 01/09/19, 09/10/18, 03/20/18 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. code 211.12(c) Nursing services Previously cited 01/09/19 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 01/09/19, 09/10/18, 03/20/18, 07/10/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 01/09/19, 09/10/18, 03/20/18, 10/13/17, 07/10/17

Based upon clinical record review, it was determined that the facility failed to ensure that physician's orders were followed for the treatment of [REDACTED]. Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on (MONTH) 4, (YEAR), with moisture associated skin damage (MASD) on the sacrum measuring 6.0 centimeters (cm) x 7.4 cm. Review of Resident R1's (MONTH) (YEAR) Treatment Administration Record revealed that beginning on (MONTH) 4, (YEAR), Resident R1 was ordered the skin protectant [MEDICATION NAME] Ointment to buttocks, groin, back and abdomen two times per day for dry skin. Review of Resident R1's (MONTH) (YEAR) Treatment Administration Record revealed that an order was obtained on (MONTH) 15, (YEAR), for the following treatment cleanse MASD to sacrum with vashe, apply Remedy cream with phytoplex. Cover with Allevyn life dressing every two days and as needed. Review of Resident R1's wound assessment dated (MONTH) 23, (YEAR), revealed that the MASD to the sacrum when measured, increased in length to 9.4 cm x 5.9 cm. Review of Resident R1's wound assessment dated (MONTH) 11, (YEAR), revealed that the MASD to the resident's sacrum noted to have worsened. Area re-classified as an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (separation of dead tissue from living tissue)) pressure wound. Further review of the wound assessment revealed that the pressure ulcer measured 12.1 cm x 11.3 cm. Review of Resident R1's Registered Nurse Practitioner progress note dated (MONTH) 12, (YEAR), revealed a treatment plan that included cleanse with wound cleanser, apply [MEDICATION NAME] and cover with Allevyn life every 2 days and PRN (as needed). Review of Resident R1's (MONTH) (YEAR) Treatment Administration Record revealed that Resident R1 received the following treatment: Cleanse MASD to sacrum with vashe, apply Remedy cream with phytoplex. Cover with Allevyn life dressing every two days and as needed on the following dates: (MONTH) 1, (YEAR); (MONTH) 3, (YEAR); (MONTH) 5, (YEAR); (MONTH) 7, (YEAR); (MONTH) 9, (YEAR); (MONTH) 13, (YEAR) and (MONTH) 15, (YEAR). Further review of Resident R1's (MONTH) (YEAR) Treatment Administration Record failed to reveal that Resident R1 was administered the pressure ulcer treatment ordered by the Nurse Practitioner on (MONTH) 12, (YEAR). Review of Resident R1's (MONTH) 15, (YEAR), nursing progress notes revealed this nurse was approached by family, wanting to see wound and stating a smell detected. I called to supervisor, who reached out to DON (Director of nursing). Medical proxy is (Resident R1's) son, but daughter and daughter's cousin wanted to see wound. Family was alleging neglect and that (Resident R1) had not been turned/changed in the past 2 hours. This nurse and aide changed pt. (patient), sacral wound was viewed by family, and family called 911 to send pt to (acute care facility - hospital). Review of Resident R1's emergency room notes dated (MONTH) 15, (YEAR), revealed Stage ,[DATE] sacral decub (pressure ulcer) with necrotic regions. Further review of Resident R1's emergency room notes dated (MONTH) 15, (YEAR), revealed progressive sacral decub with extensive tunneling. Sacral decubitus ulcer, stage IV (ulcer involving loss of skin layers, exposing muscle and bone). Further review of Resident R1's emergency room notes dated (MONTH) 15, (YEAR), revealed patient arrives via EMS (Emergency Medical Services) from (facility). EMS was activated by family during visit. Family expressed concern for elder neglect. Patient with large sacral wound. Further review of Resident R1's emergency room notes dated (MONTH) 15, (YEAR), revealed Resident R1's chief complaint to be detection of large sacral decubitus with foul odor. Review of Resident R1's hospital history and physical dated (MONTH) 16, (YEAR), revealed when family visited the patient yesterday there was an obvious foul odor in the room. They insisted on looking at patient's sacral area and a large open decubitus was seen. 911 was called and (Resident R1) was sent to our emergency room . Review of Resident R1's hospital course note dated (MONTH) 20, (YEAR), revealed General surgery recommended debridement due to the large size and (Resident R1) did well with the first debridement. (Resident R1's) second surgery involved a packing change and (Resident R1) became hypotensive and hypothermic. (Resident R1) was also encephalopathic and appears septic. Further review of Resident R1's hospital records revealed that a Palliative Care Service consult was conducted on (MONTH) 17, (YEAR). Review of the palliative care service consult revealed that Resident R1 had an infected sacral decubitus ulcer. Further review of Resident R1's hospital records revealed that on (MONTH) 21, (YEAR), Resident R1 was discharged to inpatient hospice (end of life care to support resident and family) and subsequently expired on (MONTH) 26, (YEAR). The facilty failed to administer pressure ulcer treatment as ordered by the Registered Nurse Practitioner which resulted in Resident R1 developing an unstagable sacral pressure ulcer which required hospitalization and debridement. Treatment/Services to Prevent/Heal Pressure Ulcer CRF(s): 483.25(b)(1)(i)(ii) - Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa Code 201.18(b)(1) Management Previously cited [DATE], [DATE] 28 Pa Code 201.18(b)(3) Management Previously cited [DATE], [DATE], [DATE] 28 Pa Code 201.18(e)(1) Management Previously cited [DATE], [DATE] 28 Pa Code 211.5(f) Clinical records Previously cited [DATE], [DATE], [DATE] 28 Pa Code 211.12(c) Nursing services Previously cited [DATE], [DATE] 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(2) Nursing services Previously cited [DATE] 28 Pa Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on review of facility policy, clinical record review, review of facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure residents were free of accidents during a transfer via a mechanical lift resulting in actual harm to Resident R1 sustaining fractures of the left leg distal tibia and fibula and Resident CL2 sustaining a laceration on the right foot for two of four residents reviewed (Residents R1 and CL2). Findings include: Review of facility policy Safe Resident Handling/Transfer Equipment revised (MONTH) 15, (YEAR), indicated that patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. The sit to stand lift will be used for those patients who meet the following criteria: cannot be transferred from sitting to standing comfortably and safely by other transfer techniques, have some weight bearing ability and head/trunk control, and can follow simple directions. Use of the sit to stand lift requires two staff members. Review of Resident R1's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 14, (YEAR), indicated that the resident was cognitively intact and [DIAGNOSES REDACTED]. Further review indicated that the resident required extensive assistance of two people to transfer. Review of Resident R1's care plan initiated on (MONTH) 31, (YEAR), indicated that the resident was to utilize the sit to stand lift (mechanical device use to transfer a resident from one surface to another by lifting the body during transfer) for transfers. Review of the Lift Transfer Reposition assessment dated (MONTH) 10, (YEAR), revealed that the resident was not able to transfer independently or with supervision without using a device and was not able to consistently perform a stand-pivot transfer with limited assist. The assessment also indicated that a sit-to-stand lift was required. Review of information submitted by the facility to the State agency indicated that on (MONTH) 15, (YEAR), Resident R1 was being transferred by a stand-pivot transfer by nursing staff Employee E3, the resident's foot slipped and the resident was lowered to the floor. Review of nursing note of (MONTH) 15, (YEAR), at 4:03 p.m. revealed that the certified registered nurse practioner (CRNP) ordered a stat (immediate) x-ray of the left knee, tibia, and fibula (bones in the lower leg). Nursing note of (MONTH) 16, (YEAR), at 2:18 a.m. indicated x-rays showed post surgical change without evident acute osseous (bone) abnormality of the knee. There were mildly displaced fractures of the distal tibia and fibula of indeterminate age; however, no significant callus formation (occurs when a bone is broken and repaired) and may be acute (short duration) to subacute (longer duration). Nursing note of (MONTH) 16, (YEAR), at 9:59 a.m. indicated resident had increased pain and internal rotation of the left foot with minimal movement of toes. Nursing note of (MONTH) 16, (YEAR), at 2:54 p.m. revealed Resident R1 was admitted to the hospital with [REDACTED]. Interview with Resident R1 on (MONTH) 20, (YEAR), at 2:20 p.m. revealed that nursing staff Employee E3 wanted to use the sit-to-stand lift to transfer the resident from the bed to the wheelchair, but the resident did not want Employee E3 to use the lift. Resident R1 had difficulty on the first attempt, but tried to transfer again when the resident's right foot slipped and the resident had to be lowered to the floor. The facility failed to ensure that Resident R1 was transferred via a sit and stand lift following the resident's refusal of the sit-to-stand lift. The facility failed to utilize the extensive assistance of two people as indicated in the resident's MDS, which resulted in actual harm to Resident R1 sustaining fractures of the left leg distal tibia and fibula. Review Resident CL1's quarterly MDS dated (MONTH) 13, (YEAR), indicated that the resident had short and long term memory issues and had severely impaired cognitive skills for decision making. [DIAGNOSES REDACTED]. Further review of the MDS indicated that the resident required extensive assistance of two people to transfer. Review of Resident CL1's Task sheet initiated (MONTH) 15, (YEAR), revealed that the resident was to use a sit-to-stand lift for transfers. Review of facility submitted information to the State agency revealed that on (MONTH) 7, (YEAR), at 8:30 a.m. the resident was transferred to a chair using the sit-to-stand lift by nursing staff Employee E4. Blood was noticed on the resident's sock. Review of nursing note of (MONTH) 7, (YEAR), at 9:16 a.m. revealed that resident had a laceration under the toes on the right foot. Review of wound assessment of (MONTH) 7, (YEAR), indicated a laceration measuring 0.9 centimeters by 0.9 centimeters. Review of (MONTH) (YEAR) physcian's orders revealed that the physician ordered Resident CL1 to be sent to the emergency room for evaluation. Review of nursing note dated (MONTH) 8, (YEAR), revealed that the resident received four sutures to the laceration sustained on the right foot. Review of facility submitted information to the State agency revealed that the facility's investigation confirmed that nursing staff Employee E4 used the sit-to-stand lift without assistance of another nursing staff as per facility policy. Interview with the Nursing Home Administrator on (MONTH) 20, (YEAR), at 2:30 p.m. confirmed that transfers were not completed appropriately for Residents R1 and CL1. The facility failed to ensure that Resident R1 and Resident CL1 were free of accidents while being transfer via use of a mechanical lift and failed to provide the assistance of two staff during transfer which resulted in harm to Residents R1 and CL1. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) Previously cited 08/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/10/17, 09/23/16, 08/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 07/10/17, 09/23/16, 08/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 07/10/17, 08/09/16 28 Pa. Code 201.18(e)(1) Management Previously cited 08/09/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/09/16 28 Pa. Code 211.12(c) Nursing services Previously cited 08/09/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/13/17, 7/10/17, 08/09/16

Based on review of facility policy, clinical record review, review of facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure residents were free from neglect during a transfer via a mechanical lift resulting in actual harm to Resident R1 sustaining fractures of the left leg distal tibia and fibula and Resident CL2 sustaining a laceration on the right foot for two of four residents reviewed (Residents R1 and CL2). Findings include: Review of facility policy Abuse Prohibition effective (MONTH) 1, 1996, and revised (MONTH) 1, (YEAR), revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of facility policy Safe Resident Handling/Transfer Equipment revised (MONTH) 15, (YEAR), indicated that patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. The sit-to-stand lift will be used for those patients who meet the following criteria: cannot be transferred from sitting to standing comfortably and safely by other transfer techniques, have some weight bearing ability and head/trunk control, and can follow simple directions. Use of the sit-to-stand lift requires two staff members. Review of Resident R1's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 14, (YEAR), indicated that the resident was cognitively intact and [DIAGNOSES REDACTED]. Further review indicated that the resident required extensive assistance of two people to transfer. Review of Resident R1's care plan initiated on (MONTH) 31, (YEAR), indicated that the resident was to utilize the sit-to-stand lift (mechanical device use to transfer a resident from one surface to another by lifting the body during transfer) for transfers. Review of the Lift Transfer Reposition assessment dated (MONTH) 10, (YEAR), revealed that the resident was not able to transfer independently or with supervision without using a device and was not able to consistently perform a stand-pivot transfer with limited assist. The assessment also indicated that a sit-to-stand lift was required. Review of information submitted by the facility to the State agency indicated that on (MONTH) 15, (YEAR), Resident R1 was being transferred by a stand-pivot transfer by nursing staff Employee E3, the resident's foot slipped and the resident was lowered to the floor. Review of nursing note of (MONTH) 15, (YEAR), at 4:03 p.m. revealed that the certified registered nurse practioner (CRNP) ordered a stat (immediate) x-ray of the left knee, tibia, and fibula (bones in the lower leg). Nursing note of (MONTH) 16, (YEAR), at 2:18 a.m. indicated x-rays showed post surgical change without evident acute osseous (bone) abnormality of the knee. There were mildly displaced fractures of the distal tibia and fibula of indeterminate age; however, no significant callus formation (occurs when a bone is broken and repaired) and may be acute (short duration) to subacute (longer duration). Nursing note of (MONTH) 16, (YEAR), at 9:59 a.m. indicated resident had increased pain and internal rotation of the left foot with minimal movement of toes. Nursing note of (MONTH) 16, (YEAR), at 2:54 p.m. revealed Resident R1 was admitted to the hospital with [REDACTED]. Interview with Resident R1 on (MONTH) 20, (YEAR), at 2:20 p.m. revealed that nursing staff Employee E3 wanted to use the sit-to-stand lift to transfer the resident from the bed to the wheelchair, but the resident did not want Employee E3 to use the lift. Resident R1 had difficulty on the first attempt, but tried to transfer again when the resident's right foot slipped and the resident had to be lowered to the floor. Review of facility submitted information to the State agency revealed that the facility's investigation substantiated neglect because nursing staff Employee E3 did not utilize the mechanical lift that the resident was assessed to use. The facility failed to ensure that Resident R1 was transferred via a sit and stand lift following the resident's refusal of the sit-to-stand lift. The facility failed to utilize the extensive assistance of two people as indicated in the resident's MDS, which resulted in actual harm to Resident R1 sustaining fractures of the left leg distal tibia and fibula. Review Resident CL1's quarterly MDS dated (MONTH) 13, (YEAR), indicated that the resident had short and long term memory issues and had severely impaired cognitive skills for decision making. [DIAGNOSES REDACTED]. Further review of the MDS indicated that the resident required extensive assistance of two people to transfer. Review of Resident CL1's Task sheet initiated (MONTH) 15, (YEAR), revealed that the resident was to use a sit-to-stand lift for transfers. Review of facility submitted information to the State agency revealed that on (MONTH) 7, (YEAR), at 8:30 a.m. the resident was transferred to a chair using the sit-to-stand lift by nursing staff Employee E4. Blood was noticed on the resident's sock. Review of nursing note of (MONTH) 7, (YEAR), at 9:16 a.m. revealed that resident had a laceration under the toes on the right foot. Review of wound assessment of (MONTH) 7, (YEAR), indicated a laceration measuring 0.9 centimeters by 0.9 centimeters. Review of (MONTH) (YEAR) physcian's orders revealed that the physician ordered Resident CL1 to be sent to the emergency room for evaluation. Review of nursing note dated (MONTH) 8, (YEAR), revealed that the resident received four sutures to the laceration sustained on the right foot. Review of facility submitted information to the State agency revealed that the facility's investigation substantiated neglect because nursing staff Employee E4 used the sit to stand lift without assistance of another nursing staff as per facility policy. Interview with the Nursing Home Administrator on (MONTH) 20, (YEAR), at 2:30 p.m. confirmed that transfers were not completed appropriately for Residents R1 and CL1. The facility failed to ensure that transfers using the assistance of two staff were completed resulting in harm to Residents R1 and CL1. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/10/17, 09/23/16, 08/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 07/10/17, 09/23/16, 08/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 07/10/17, 08/09/16 28 Pa. Code 201.18(e)(1) Management Previously cited 08/09/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/09/16 28 Pa. Code 211.12(c) Nursing services Previously cited 08/09/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/13/17, 7/10/17, 08/09/16

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a food serving area was adequately supervised to ensure the safety of the residents with dementia in one of two dining rooms with steam tables (One South Dining Room) placing the residents in Immediate Jeopardy. Findings include: Observation conducted on August 7, 2016, at approximately 9:00 a.m. of the One South Dining Room revealed a bar style counter top with a three compartment steam table. The steam table measured approximately three feet from the floor and the steam table wells (compartment containing water that rises to a hot temperature that heats a metal tray containing food placed on top of the well). The food trays inserted into the steam tables were placed approximately five to six inches from the edge of the table. Steam was observed escaping underneath two lids towards the ceiling. The steam table wells were easily accessible and there was no facility staff observed to be present in the One South Dining Room to attend to the steam table and to provide supervision to the residents. On August 7, 2016 at 9:00 a.m. five residents were observed in the dining area at different tables. Resident A8 was observed walking with a walker through out the dining area and stopping at each table, picking up plates and empty cups and bringing them to her face, and placing the item back down again. This type of behavior occurred for approximately three minutes until a facility staff person arrived and escorted Resident A8 down the hall and away from the dining area. Further investigation on August 7, 2016, at 9:05 a.m. revealed that the lids, on the three compartment steam table, were not sitting securely on the food allowing a four inch opening over the compartment containing the oatmeal. At the time of this same observation, Dietary Staff, Employee E4 was asked to take a temperature of the oatmeal and verified a temperature reading of 180.3 degrees Fahrenheit. During an interview with Employee E4 on August 7, 2016, at 9:05 a.m. it was confirmed that Employee E4 left the dining room to deliver a tray to a resident's room. Employee E4 indicated that the staff can leave the steam tables unattended if it was not busy in the dining room. Review of Resident A8's clinical record revealed [DIAGNOSES REDACTED]. (progressive mental deterioration of the brain.) Review of Resident A8's Minimal Data Set assessment (MDS-a periodic assessment of resident needs) dated August 3, 2016, identified the resident with a BIMS score of a 2 (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment.) which placed the resident's cognitive level as severe impairment. Review of the resident's care plan evaluation note dated August 4, 2016, stated, Completed MDS with a date of August 3, 2016, for which Resident A8 triggered for wandering daily, with four to six days of socially inappropriate behaviors of rummaging especially for food from dirty trays or any food she comes across during her travels. Interview with Licensed Staff, Employee E5, on August 7, 2016, at 8:00 a.m. revealed that Resident A8 wanders freely on the unit. She further stated that the applesauce and pudding being used for medications must be kept in the bottom drawer of the medication cart during the medication pass or this resident would stick her fingers in it and scoop it into her mouth. During an interview conducted with the Nursing Home Administrator on August 7, 2016, at approximately 9:57 a.m. it was stated that the facility did not have a policy to safe guard the steam tables during operation. Immediate Jeopardy was identified on August 7, 2016, at 11:01 a.m. for the facility failing to ensure that proper supervision was provided to residents on the One South Dining Room when steam tables were in operation, which placed the health and safety of the residents in Immediate Jeopardy. An action plan was requested on August 7, 2017, at 11:10 a.m. to immediately put systems in place to provide adequate supervision of the One South Dining Room and to ensure the safety of the residents. The action plan provided by the facility on August 7, 2016, at 12:14 p.m. included for the steam table to be unplugged when not in use, ten minutes prior to meal service a dietary staff was to go to the dining room, plug in the steam tables, turn them on and the dining services staff or designated staff was to remain in the dining room with the steam table until the food arrives to the unit. The designated facility staff was to remain with the steam table once it was plugged in and turned on at all times. At the end of the meal service, the steam table was to be turned off and unplugged. The designated facility staff was to remain in the dining room until the steam table had cooled to room temperature. Observation conducted on August 8, 2016, at 10:15 a.m. in the One South Dining Room revealed that the dining room was unattended and the three compartment steam table was noted to be hot to the touch. The pans easily lifted out to reveal water underneath which was very hot to the touch. Employee E2, the Director of Nursing and Employee E3, the Assistant Director of Nursing, were walking by the dining room and the surveyor called them in to observe the unattended steam table. Temperature of the water in the steam table wells in the company of Employee E6, Dietary Aide, who was assigned to the dining room revealed a temperature of 142.8 degrees Fahrenheit. Employee E6 stated that she had turned the steam table off at 9:55 a.m. The Nursing Home Administrator agreed during an interview on August 8, 2016, at 11:00 a.m. that the water temperature of 142.8 degrees Fahrenheit could quickly cause a burn. The facility submitted a revised action plan on August 8, 2016, at 11:30 a.m. which noted that the water in the steam table was to be drained or brought to a safe temperature using cool water or ice. Once the water had been removed or cooled, the dining room staff was to notify the Food Service Director or designated staff to complete a, Steam Table Safety Checklist. The Supervisor was to complete the, Steam Table Safety Checklist to ensure that the steam table temperature was no higher than 100 degrees Fahrenheit. If the temperature was higher than 100 degrees Fahrenheit, the staff member needed to remain in the dining room until the appropriate temperature was reached. Immediate Jeopardy was removed on August 8, 2016, at 2:40 p.m. following the implementation of an acceptable plan of action. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 07/13/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/26/16, 07/13/15, 08/25/14 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 07/13/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/25/14