Every finding on record at West Park Rehabilitation and Nursing Center

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents with a feeding tube (Resident R2) and for one resident with airborne precautions. (Residents R2 and R3).Findings include: Review of the facility policy titled Enhanced Barrier Precautions, undated, revealed: To minimize the transmission of germs transferred from residents to staff hands and clothing, staff will wear a gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading multidrug-resistant organisms (MDROs). Enhanced barrier precautions will be applied to: (A) residents with an indwelling medical device, including a central venous catheter, urinary catheter, feeding tube (PEG tube), or tracheostomy/ventilator, regardless of their MDRO status; and (B) residents with a chronic wound, regardless of their MDRO status. Chronic wounds include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; they do not include shorter-lasting wounds such as skin breaks or skin tears covered with a dressing. Review of the facility policy titled Categories of Transmission-Based Precautions, undated, revealed: Standard Precautions shall be used when caring for residents at all times, regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Based on CDC definitions, four types of Transmission-Based Precautions (airborne, droplet, contact, and COVID-19) have been established. In addition to Standard Precautions, implement Airborne Precautions for anyone who is documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue [5 microns or smaller] of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over long distances). Examples of infections requiring Airborne Precautions include, but are not limited to: measles, varicella (including disseminated zoster), and tuberculosis. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of anoxic brain damage, persistent vegetative state, chronic obstructive pulmonary disease (airway inflammation and damage), encounter for attention to gastrostomy (feeding tube), dysphagia oropharyngeal phase following cerebral infarction (swallowing disorder that occurs due to brain injury). A physician's order dated January 17, 2026, for enhanced barrier precautions related to feeding tube. Observation conducted on March 30, 2026, at 10:20 a.m., revealed nursing aide, Employee E4 providing direct morning care to Resident R2 without wearing personal protective equipment (PPE) such as gown. This observation was confirmed by the unit manager, Employee E3. On March 30, 2026, at 9:00 a.m., an interview with the Assistant Director of Nursing, Employee E7, revealed that the facility had placed Resident R3 on airborne precautions after Resident R3 tested positive for tuberculosis. A review of Resident R3's clinical file revealed that the resident was admitted on [DATE]. On March 23, 2026, Resident R3 received a positive test result for tuberculosis. A review of the physician's order dated March 23, 2026, revealed: TBP: Airborne Precautions - Tuberculosis (gown, face mask, face shield, and gloves). On March 30, 2026, at 10:40 a.m., Licensed Nurse, Employee E5, was observed in contact with Resident R3 in the resident's room wearing only a mask. Unit Manager, Employee E3, confirmed the observation that Licensed Nurse, Employee E5, was not wearing a gown or face shield as required for airborne precautions. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatment to for pressure ulcer was obtained for Findings include:Review of the facility policy Pressure Ulcers/Skin Breakdown - clinical protocol, undated, revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nursing shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates and necrotic tissue, resident mobility status, current treatments, including support surface and relevant active diagnosis. Under Treatment/Management it further stated The practitioner will order pertinent wound treatments, including pressure reduction surfaces, would cleansing and debridement approaches, dressings (occlusive, absorptive, et) and application of topical agents. Review of Resident CLR1's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including Type 2 diabetes mellitus with hyperglycemia (chronic condition where the body doesn't use insulin properly, causing high blood sugar overtime), encounter for attention to gastrostomy (feeding tube), dysphagia following cerebral infarction (swallowing disorder that occurs after a stroke), gastro-esophageal reflux diseases without esophagitis (heartburn, acid regurgitation or chest discomfort), chronic kidney disease-stage 3 (kidneys are damaged and filtering blood less efficiently), atherosclerotic heart disease of native coronary artery without angina pectoris (arteries are narrowed), cerebral infarction (stroke). On January 7, 2026, CLR1 was diagnosed with pneumonitis due to inhalation of food and vomit, metabolic encephalopathy (dysfunction of the brain) Review of Resident CLR1's Minimum Data Set (MDS federally mandated resident assessment of care needs), dated December 25, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Review of Resident CLR1's clinical record revealed that the resident was transferred to the hospital on January 29, 2026 and readmitted to the facility on [DATE]. Review of Resident CLR1's comprehensive care plan, initiated February 4, 2026, indicated that the resident was at risk for altered skin integrity related to incontinence and impaired mobility. Interventions included biweekly skin audits by licensed staff, reporting any changes in skin integrity to the physician, providing diet and supplements per physician orders, encouraging and assisting the resident to consume fluids as needed, assisting with heel suspension/floatation when in bed, using a pressure-reduction mattress to protect the skin while in bed, and providing a pressure-reducing cushion when in a chair. Review of the CLR1 Skin assessment dated [DATE], did not reveal any existing skin issues. Review of wound tracking documentation dated February 4, 2026, noted an open area on the right buttock. There were no measurements or description of the right buttock open area and/or stage documented. On February 11, 2026, Resident CLR1 experienced a change in condition and was transferred to the hospital. The resident was readmitted to the facility on [DATE]. Review of wound tracking documentation dated February 19, 2026, noted an open area on the resident's right anterior thigh measuring 3 centimeters (cm) x 3 cm. There was no other description of the area and/or stage of the wound. Review of Resident CL R1's February 2026 medication administration records revealed no evidence that a treatment was obtained for the open area identified on the resident's right anterior thigh on February 19, 2026. Interview conducted on March 30, 2026, at 2:45 p.m., with the Director of Nursing, Employee E1, confirmed that no treatment had been provided for the right anterior thigh wound, which measured 3 cm x 3 cm on February 17, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain the Resident call bell system in working condition for two out of 10 residents' rooms observed for call bell functioning.Findings Include:On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:53 a.m., observations in room [ROOM NUMBER], Bed D, revealed the call bell device was non-functioning. Resident R2 of room [ROOM NUMBER], Bed D, stated that the call bell was not functioning for a few days.On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:57 a.m., observations in room [ROOM NUMBER], Bed B, revealed the call bell device was non-functioning.On January 28, 2026, at 11:57 a.m., the findings were confirmed with E 3, a Licensed Nurse.28 Pa Code 207.2(a) Administrator's responsibility

Based on staff interviews, review of clinical records, facility documentation, and review of facility policy, it was determined the facility failed to ensure Resident R1 was provided with the necessary equipment of wheelchair leg rest to ensure safety and proper positioning during transportation. This failure resulted in actual harm to Resident R1 who fell forward from the wheelchair and sustained a left frontal scalp hematoma and periorbital contusion for one of nine residents reviewed (Resident R1).Findings included: Review of facility policy titled Assistive Devices and Equipment revised May 2025, revealed devices and equipment that assist with resident mobility, safety and independence are provided to resident. These include a). wheelchairs (manual and powered) b). walkers and c). canes. Further review of facility policy revealed Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Staff will be trained and will demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia (progressive degenerative disease of the brain), difficulty walking, muscle weakness, and a history of falls. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident's needs) dated December 5, 2025, revealed the resident required assistance with mobility, used a wheelchair for locomotion, and had a Brief Interview for Mental status (BIMS) score of 8, which indicates moderate cognitive impairment. Review of Resident R1's care plan, initiated January 16, 2025, revealed a care plan was developed for the resident being at high risk for falls related to confusion and psychoactive drug use. Interventions identified included but not limited to offering resident to go to bed after dinner; out of bed to supervised area when awake and physical therapy for mobility, trunk control, and wheelchair cushion. Review of Resident R1's nursing notes dated December 25, 2025, revealed Resident R1 was taken to [his/her] room by the care nurse and resident fell on the floor face forward. Large hematoma observed on the left forehead. Ice applied immediately. On call [physician] notified with a verbal order to send resident to emergency room .911 arrived at 10:30 pm and resident was taking to [local hospital]. Review of hospital medical records dated December 25, 2025, revealed the resident was diagnosed with left frontal scalp hematoma and periorbital contusion following the fall. Review of facility documentation dated December 25, 2025, failed to reveal resident or staff statements describing the incident or identifying contributing factors at the time of the fall. Interview with the Occupational Therapist, Employee E3, and Director of Rehabilitation (Employee E4) on January 8, 2026, at 10:50 a.m. confirmed the facility practice requires wheelchair leg rests to be applied during transport by nursing staff, regardless of whether residents can propel themselves. Interview with Licensed Practical Nurse, Employee E5, on January 8, 2026, at 11:42 a.m. revealed that Employee E5 witnessed the fall on December 25, 2025, at approximately 10:00 p.m. Employee E5 stated the Nurse aide (Employee E6) was transporting Resident R1 to (his/her) room for bedtime sleep, as the resident appeared sleepy, when the resident placed (his/her) foot down and fell forward. Employee E5 further confirmed the wheelchair footrests were not present at the time of transport. Interview with Nurse Aide, Employee E6, on January 8, 2025, at 12:19 p.m. revealed while transporting Resident R1 to (his/her) room to prepare for bedtime, the resident appeared sleepy, placed (his/her) foot down and fell forward. Employee E6 confirmed the wheelchair leg rests were not applied prior to transport. The facility failed to ensure safe wheelchair transport for a resident with known cognitive impairment, impaired mobility, and risk of falling by not applying wheelchair leg rests. As a result of the facility's failure to follow safe transport practices, Resident R1's foot contacted the floor, causing a fall forward from the wheelchair. The fall resulted in actual harm to Resident R1, who sustained a left frontal scalp hematoma and periorbital contusion requiring hospital evaluation. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care policies 28 PA Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to administer pain medication in accordance with physician orders for one of three residents reviewed for pain management (Residents R84). Findings include: Review of facility policy titled Pain Assessment and Management, revised 2025, revealed pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Clinical record review revealed Resident R84 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis affecting left side (affect movement/sensation on one side of body), chronic obstructive pulmonary disease (condition that prevents airflow to the lungs, causing breathing problems), and pain. Review of Resident R84's physician's order, dated October 07, 2025, revealed an order for Percocet (opioid for moderate to severe pain) 5-325 mg (milligrams) every 6 hours as needed for severe pain 8-10. Review of Resident R84's medication administration record for December 2025 revealed Percocet 5-325 mg was administered for the following pain levels: -December 02, 2025 at 9:37 p.m. pain level of 6. -December 05, 2025 at 6:53 p.m. pain level of 6. -December 06, 2025 at 10:03 p.m. pain level of 5. -December 08, 2025 at 8:01 a.m. pain level of 0. -December 09, 2025 at 10:27 p.m. pain level of 5. Interview on December 18, 2025 at 9:45 a.m. with Director of Nursing, Employee E2, confirmed the facility staff did not administer Resident R84's pain medication according to physician's orders. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12 (d)(5) Nursing services

Based on observations of resident care and services, interviews with staff and residents, clinical record and policy and procedure reviews, it was determined that for one of eight residents reviewed for nutritional needs and support with eating, the facility failed to assist each resident with obtaining routine dental care in a timely manner. (Resident R15) Findings include:A review of the facility policy titled dental services dated August 2025 revealed that it was the responsibility of the facility to ensure routine dental services was provided for each resident to meet their oral health needs. The policy indicated that a consultant dentist service was responsible to provide each resident with professional dental care. The policy also indicated that the social services department was responsible for assisting residents with timely appointments with the dental group. The policy said that all dental services provided were to be documented in the resident's clinical record. Clinical record review revealed a dental consult and assessment dated [DATE], for Resident R15 that indicated the resident was edentulous and required full upper and lower dentures. Observations of Resident R15 at 10:00 a.m., on December 16, 2025, confirmed that this resident had no natural teeth.Clinical record review revealed an annual comprehensive assessment MDS (an assessment of care needs) for Resident R15 dated September 17, 2025. The assessment indicated this resident required supervision or touching assistance by staff for eating. The assessment also indicated that staff were to give verbal cues or contact guard during eating for resident R15. The assessment said that Resident R15 was ordered a mechanically altered (modified food textures) diet by the physician. Interview with Resident R15 at 10:30 a.m., on December 16, 2025, revealed that the resident needed routine dental services that entailed minor full denture adjustments. Resident R15 said that she wanted to use dentures for eating. The resident explained that her dentures were too big, especially the lower dentures. Resident R15 also reported that the nursing staff were aware during the month of August 2025 that her dentures were ill-fitting. Interview with the licensed practical nurse, Employee E5, at 10:45 a.m., on December 16, 2025, confirmed that Resident R15 had been asking to have her dentures adjusted and fitted to her since, August 2025. The licensed nurse, Employee E5, reported that Resident R15 had not been given the opportunity to have her dental needs addressed promptly. There was no documentation to indication that the dental consulting group had provided an examination and services (dental radiographs and denture fittings) as care planned on November 4, 2025, for Resident R15. This was confirmed with the director of nursing, Employee E2, at 9:30 a.m., on December 18, 2025. 28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 211.10(a)(c)(d) Resident care policies28 PA. Code 211.12(c)(3)(5) Nursing services

Based on observation, record review, and staff interview, the facility failed to ensure physician orderes were followed for one of six residents reviewed for nutrition (Resident 110).Findings include: Review of physician orders for Resident R110, dated July 24, 2024, revealed that the resident was ordered to receive snacks at 10:00 a.m. and 2:00 p.m. review of the clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (lack of proper nutrition) and abnormal weight loss, and had a BIMS score of 3, indicating severe cognitive impairment. Observation conducted on December 15, 2025, at 9:30 a.m. revealed the resident had a small bag of Cheez-It crackers labeled snack 2/14. Further observations conducted on December 16 and 17, 2025, at 10:00 a.m., 10:30 a.m., 2:00 p.m., and 2:15 p.m. revealed the residents did not receive snacks per physician orders. During follow-up interview conducted with Nurse Aid, Employee E11 on December 12, 2025, at 2:11 p.m. confirmed, I did not give the resident any snacks today. An interview conducted with Nurse Manager, Employee E12, and Nurse Aid Employee E11, conducted on December 17, 2025, at 2:30 p.m. confirmed that the resident did not receive his morning or afternoon snacks. The interview further revealed that providing snacks to residents was the responsibility of the Nurse Aid. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, interview with resident and staff as well as review of clinical record and review of facility policy, it was determined that facility did not ensure to provide appropriate treatment and services to increase range of motion and/or to prevent further decline for one of 28 residents reviewed (Resident R118)Review of facility policy Resident mobility and range of motion, revised on January 2025, indicates that residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion (ROM).Further review of policy indicates that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.Review of Residents R118 clinical record revealed a medical history of hemiplegia and hemiparesis (weakness and paralysis) following stroke affecting left non-dominant side, need for assistance with personal care.Review of Resident R118's physician orders revealed an active order placed on December 5, 2025, for resident requires left elbow extension splint to be donned for 6 hours daily as tolerated with nursing providing skin checks pre and post donning in order to reduce joint stiffness/contractures.Further review of physician orders revealed an active order placed on December 5, 2025, for resident requires left hand roll splint to be donned for 6 hours daily as tolerated with nursing providing skin checks pre and post donning in order to reduce joint stiffness/contractures.Review of Resident R118's care plan revealed interventions for left elbow extension splint to be donned for 6 hours daily as tolerated with nursing providing skin checks pre and post donning in order to reduce joint stiffness/contractures, and resident requires left hand roll splint to be donned for 6 hours daily as tolerated with nursing providing skin checks pre and post donning in order to reduce joint stiffness/contractures.Observations of Resident R118 on Monday, December 15, 2025, during day shift revealed left elbow and left hand contractures and splint/hand roll in a bin on R118's bedside table.Further observations on Monday, December 15, 2025 as well as on Thursday, December 18, 2025 during day shift, revealed no evidence of applied left elbow splint or left hand roll splint.Interview with Resident R118 on Thursday, December 18, 2025, at 10:30 am, revealed that he has not had sling or hand roll applied in about a week, further elaborating that left elbow splint and hand roll is helpful and he believes nursing staff do not know how to apply the equipment.Review of R118's electronic treatment administration record revealed no evidence of an order placed for left elbow sling application and left-hand roll application.Interview with facility's assistant director of nursing, employee E3, on Thursday, December 18, 2025 at 11:00 am revealed that an order for left elbow sling and left hand roll is inaccurately placed and nursing staff is not able to see the order during treatment administrations.Further interview with E3 revealed that it is not confirmed nursing staff received training on how to apply left elbow sling/hand roll.Findings confirmed with facility's director of nursing on Thursday, December 18, 2025 at 11:10 am.28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record and care plan reviews, observations of residents, policy and procedure review and interviews with staff and residents, it was determined that the facility failed to review and revise the residents care plan for three of 28 residents reviewed, in a timely manner, to ensure the greatest benefit to each resident for safety needs, hospice care, and oxygen use Residents (R4, R7, and R28) Findings include: A review of the facility policy titled care plans, comprehensive person-centered dated August 2025 revealed that it was the responsibility of the staff at the facility to develop and implement a care plan to meet the medical, psychosocial, physical and functional needs of each resident. The policy indicated that the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy also indicated that the care plan would include measurable objectives and time frames for the resident to meet their goals and attain or maintain their highest practicable physical, mental and psychosocial well-being. The policy said that the care plan would be revised as information about the resident and the resident's condition changed. Clinical record review for Resident R7 revealed a comprehensive quarterly assessment (MDS -an assessment of care needs) dated November 10, 2025, that indicated this resident was cognitively intact, required staff assistance with toilet hygiene and toilet transfer (staff lifts, holds or supports trunk or limbs). The assessment also indicated that Resident R7 required help from the sitting to the standing position (the staff helps by verbal cues and/or touching and/or contact guard). The assessment indicated that Resident R7 had a diagnosis of age-related osteoporosis, was occasionally in continent of bowel and bladder and had experienced falls since admission to the facility. Observations of Resident R7 at 11:00 a.m., on December 16, 2025, confirmed a diagnosis of osteoporosis (a bone disease making bones weak and brittle with symptoms of height loss and stooped posture). Interview with Resident R7on December 16, 2025, revealed that the resident was reporting delays in staff response time to the activation of her call bell. Clinical record review revealed an unwitnessed fall in the bathroom on November 1, 2025, for Resident R7. The nursing staff documented that Resident R7 was trying to transfer alone, from the wheelchair to the toilet. Clinical record review revealed several falls for Resident R7 from September 2025 through November 2025. Clinical record review revealed that resident R7's care plan had not been updated post fall November 1, 2025. Interview with the director of nursing at 10:00 a.m., on December 18, 2025, confirmed that care planning to prevent falls and promote safety for Resident R7 had not been revised to reflect new strategies/measures to ensure Resident R7 would be free from falls. Review of physician orders for Resident R4 revealed an order for hospice services, dated December 11, 2025. Review of Resident R4's current care plan revealed no care plan problem, goal, or intervention addressing hospice care, comfort treatment, pain management, psychosocial support, or coordination with the hospice agency. Review of Resident R28's clinical record revealed Resident R28 was admitted to the facility on [DATE] with a diagnosis that included acute respiratory failure with hypoxia (insufficient oxygen in the blood), acute pulmonary edema (excessive fluid accumulation in the tissue or air spaces in the lungs), and chronic obstructive pulmonary disease (condition that prevents airflow to the lungs, causing breathing problems). Observation on December 16, 2025 at 10:15 a.m. revealed Resident R28 was receiving 1 liter of oxygen via nasal cannula. Review of Resident R28's physicians order, dated August 31, 2025, revealed continuous oxygen 1 liter per nasal cannula. Review of Resident R28's care plan, revised August 12, 2025, revealed the resident has/at risk for respiratory impairment. Interventions included 5 liters of oxygen via nasal cannula. Interview with Employee E2, Director of Nursing, on December 17, 2025 at 2:00 p.m. confirmed Resident R28's care plan was not revised to reflect current oxygen orders. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(c)(1)(3)(5) Nursing services

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of three residents sampled for behavior. (Resident R45)Findings include: Review of Resident R45's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia (mental health condition that affects how people think, feel, and behave) and epilepsy (neurological disorder). Review of progress note for Resident R45 dated April 24, 2025, revealed that Resident R45 reported a history of sexual abuse and disclosed that the abuse occurred in the past. The note further documented that the resident was abused in the streets and around violence and reported not feeling safe in the streets. Review of Psychology note dated May 1, 2025, revealed that Resident R45 had a history of schizophrenia and post-traumatic stress disorder (PTSD). Review of Care Plan for Reside R45, initiated April 9, 2025, revealed that the resident was care planned for potential to exhibit behaviors that are a result of past trauma(s). The care plan noted a history of sexual trauma while incarcerated; however, the care plan failed to identify resident specific trauma triggers or interventions to mitigate or prevent re-traumatization. Continued review revealed that the facility failed to implement trauma-informed care by not identifying Resident R45's past traumatic experiences and potential triggers, despite documentation of sexual abuse and PTSD, and failed to develop individualized interventions to address those triggers. Interview with the Director of Nursing and Facility Administrator on December 18, 2025, at approximately 11:00 a.m., confirmed the facility failed to identify the residents past traumas experiences and possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of facility provided documentation, review of closed record and interview with staff, it was determined facility did not convey the discharge summary to the continuing care provider at the time of discharge and did not contain required components for one of two closed records reviewed (Resident R2) Findings include: Review of facility policy 'Discharge summary and plan,' revised May 2025, indicates discharge summary shall include a description of the residents reconciliation of pre- and post- medications, post discharge plan of care; and any post-discharge medical and non-medical services. Review of Resident R2's clinical record on July 1, 2025, indicated that the resident was admitted to facility on August 9, 2022 and discharged on June 4, 2025. Review of discharge summary plan, completed on June 3, 2025, by Licensed nurse, Employee E3, revealed that after discharge, resident was to receive ostomy care and peg tube care. Resident R1 was discharged with active tracheostomy (tube inserted through the neck to assist with breathing) treatment. Further review of Resident R2's clinical record revealed a nursing note, dated June 12, 2025 indicating that special care instructions were reviewed with resident's family member at a later date, after discharge. Further review of resident's discharge summary plan, completed on June 3, 2025, indicated no evidence of a list of medication reconciliation of all pre-discharge medications with the resident's post-discharge medications. Further review of discharge summary revealed that resident or responsible party was to acknowledge agreement of discharge plan by providing signature in wet ink. There was no documented evidence of signature of resident or resident's responsible party. Further review of discharge summary revealed Licensed nurse, Employee E3, signed and dated portion of discharge summary which was indicated for resident or residents' responsible party signature. Findings confirmed with Nursing Home Administrator and Director of Nursing on July 1, 2025 at 3:45 p.m 28 Pa Code 201.29(a)(c.3)(2) resident rights

Based on review of clinical record, review of facility policy and interview with staff, it was determined facility did not develop and implement a base line care plan for one of eight residents reviewed related to tracheostomy care and epilepsy. (Resident R1) Findings include: Review of facility policy 'Baseline Care Plan,' revised May 2025, indicates that the interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: physician orders. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE]. Further review of Resident R1's clinical record revealed physician order placed on May 22, 2025, for seizure precautions, tracheostomy (tube inserted through the neck to assist with breathing) site assessment, tracheal suction, tracheostomy care with inner cannula change and trach collar order. Further review of Resident R1's clinical record revealed nursing notes, dated May 21, 2025 through May 31, 2025 indicated tracheostomy care was performed as well as documentation related to seizures. Review of resident's care plan indicated no evidence of goals and interventions related to tracheostomy care or seizure precautions. Findings confirmed with facility's Director of Nursing and Administrator on July 1, 2025 at 3:45 p.m 28 Pa Code 211.10(c ) resident care policies 28 Pa Code 211.12(d)(5) nursing services

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures. Findings include: Review of facility policy titled Food Temperatures revised January 2025, indicated that the serving temperature required for hot foods is at 135 degrees Fahrenheit (F) or above. Temperatures for cold foods, including milk and juice must be less than 41 degrees F. On February 18, 2025, at 12:00 p.m. an interview was held with Resident R14 reported warm juices and milk, those items should be cold. On February 19, 2025, at 10:30 a.m., a resident council group meeting was held with seven alert and oriented residents (R12, R15, R114, R113, R128, R30, R33) who reported concerns about the quality of meals. They stated that the food was consistently cold and repetitive, with meal temperatures remaining low. Additionally, they noted that peas and green beans were often hard and served cold. Observations during a test tray conducted with the Food Service Director (FSD), Employee E4, on February 20, 2025, at 12:55 p.m. revealed that meatloaf registered 127.2 degrees F; green beans registered 126 degrees F; mashed potatoes registered 124 degrees F; iced tea registered 47.8 degrees F; and milk registered 48 degrees F. An interview with the FSD, on February 20, 2025, at 1:00 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Labeling and Dating Food Items revised August 1, 2024, revealed that a visible label will be used to indicate appropriate use by date. Review of facility provided protocol, color codes for cutting boards, undated, revealed that the green cutting board is designated for ready to eat produce that will be cooked; and the red cutting board is used for raw proteins to prevent bacteria from spreading to another. A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E4, on February 18, 2025, at 10:00 a.m. Observations in the food preparation area revealed the Cook, Employee E13, was cutting chicken on the green cutting board (designated for vegetables). Observations in the refrigerator revealed nine wracks of individually sliced corn cakes, were undated and unlabeled. Further observations revealed 12 turkey and cheese, 10 pound of sliced ham, and peanut butter sandwiches were undated and unlabeled. Interview with the FSD during the kitchen tour confirmed the above mentioned findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents reviewed for medication safety (Resident R118). Findings include: Review of the facility policy Self-Administration of Medication dated August 2024, indicates Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow ( or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Review of Resident R118's active physician order dated July 29, 2024, revealed an order for Asper-Flex External Cream 10 % (TrolamineSalicylate) Apply to affected areas topically two times a day for pain unsupervised self-administration. Observe resident to allow patient to use it at bed-side. Review of pharmacy consultant report dated January 28, 2025 revealed a recommendation self-administration of medication is noted on the orders. Ensure that there is a self-administration assessment completed. It was documented on the report as the recommendation was completed. Review of Resident R118's assessments on February 21, 2025, did not to include an assessment for medication self-administration. Interview with the Director of Nursing on February 21, 2025 confirmed that there was no medication self-administration assessment for Resident R60 and Resident R118. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.9(a)(1) Pharmacy services.

Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one of three nursing units. (4th [NAME] Nursing Units). Findings include: On February 18, 2025, at 12:14 p.m., an observation was made in room [ROOM NUMBER], where three mouse traps were noted. One of the traps contained mouse droppings, while another was covered in a significant amount of dust which looked like a dead mouse. The room's floors were observed to be dirty, with visible crumbs and spills present. Additionally, the trash can was dirty with brown substances and did not have a linen trash bag. During an interview, Resident R8 stated that housekeeping had entered to clean the room; however, the floor mats on both sides of the bed remained unclear with spills. These observations were confirmed by Licensed Nurse Employee E7. On February 18, 2025, at 12:14 p.m., additional observations with Licensed Nurse, Employee E7, confirmed that there were no linen trash bags in rooms 407, 408, 409, 410, 411, 412, and 413. Additionally, the trash cans in these rooms were noted to be dirty. On February 18, 2025, at 12:20 p.m., Maintenance Director Employee E12 entered room [ROOM NUMBER] and clarified that the mouse trap did not contain a dead mouse but had instead accumulated a large amount of dust. On February 18, 2025, at 12:40 p.m., an observation was made in room [ROOM NUMBER] of a strong urine odor. During an interview with Resident R41, it was noted that the resident's pillow was ripped and lacked a pillowcase. When asked about the missing pillowcase, Resident R41 stated that he was unsure why it was absent. Further observation revealed that the room's trash can did not contain a linen bag was dirty with brown spills. Multiple washcloths were seen drying on the bed railings, and the floor around the resident's bed was visibly dirty. Additionally, several used items, including dirty cups, condiment packets, and an apple juice container, were observed sitting on the windowsill. On February 18, 2025, at 1:07 p.m., an interview was held with Resident R46, who reported an ongoing shortage of essential supplies, including washcloths, linens, and briefs. Resident R46 further stated that on the previous day, there were no washcloths available, and she was instructed to wipe her face with a paper towel. On February 18, 2025, at 1:36 p.m., an observation was made on the 4th [NAME] Nursing Unit the rooms 412, 413 continued to have a strong urine smell and rooms remained unclear. This observation was confirmed by the Administrator, Employee E1. On February 20, 2025, at 12:20 p.m., during an interview with the housekeeping director, Employee E10 explained that the facility's procedure is to provide each resident with clean washcloths during every shift. Fresh linens, including washcloths, are delivered three times a day: from 7:00 a.m. to 8:00 a.m., from 2:30 p.m. to 3:00 p.m., and from 11:00 p.m. to 7:00 a.m. Each resident is expected to receive a clean washcloth at these intervals. However, the inventory available at the facility at the time of the interview indicated that only a one-day supply of washcloths remained. Employee E10 reported having placed an emergency order for additional washcloths on February 18, 2025, with expected delivery on February 20, 2025. 28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on clinical record review, observations, and interview with residents and staff, it was determined that the facility failed to provide bathing support and feeding assistance for two of two residents sampled for activities of daily living (Resident R39 and Resident R73). Findings Include: Observation of the Resident R73 on February 18, 2025, at 1:00 p.m. revealed that the resident had beard and disheveled hair. Interview with Resident R73 on February 18, 2025, at 1:00 p.m. stated he wanted to shave and cut his hair, but staff did not offer him any help. Resident stated staff sometimes gave him bed bath but very rarely offered shower. Review of MDS-Minimum Data Set-Assessment of resident care needs for Resident R73 dated November 26, 2024, revealed that the resident had a BIMS score of 15 which indicated that the resident's cognitive status was intact. Further review of the MDS revealed that the resident required substantial/maximal assistance for shower or bathing. Review of shower documentation for Resident R73 revealed that the resident was scheduled for shower on Wednesday and Saturday every week. Further review of the shower data from January 19, 2025 to February 19, 2025 revealed that the resident on received 2 shower and one bed bath for the entire 30 days. Clinical record review revealed Resident R39 was admitted to the facility September 27, 2023 with a diagnosis that included but not limited to aphasia (lack of ability to comprehend or communicate due to brain damage), dysphagia (difficulty swallowing), hemiplegia (total or nearly complete paralysis on one side of body), and lack of coordination. Review of Resident R39's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated February 02, 2025 revealed Resident R39 was cognitively impaired. Further review of Resident R39's MDS revealed Resident R39 required one person assistance with meals. Review of Resident R39's care plan, revised August 18, 2024, revealed Resident R39 has ADL (activities of daily living) self-care deficit related to dementia. Interventions for eating revealed Resident R39 is dependent and requires one staff to assist with meals. Observation conducted on February 18, 2025 at 1:06 p.m. revealed Resident R39 in bed and food tray on table. No staff was in the room to help assist Resident R39 with eating. Further observation on February 18, 2025 at 1:14 p.m. revealed Resident R39 still had meal on table that was untouched. Interview on February 19, 2025 at 9:53 a.m. with License Practical Nurse, Employee E14, confirmed Resident R39 requires feeding assistance at meals. Observation on February 19, 2025 at 12:07 p.m. revealed Resident R39 received food but no staff assisted Resident R39 with eating. Further observation on February 19, 2025 at 12:18 p.m. revealed Resident R39 eating bread with left hand and then holding cup with left hand to drink. Resident R39 had fork on plate and required assistance with using fork. Interview on February 19, 2025 at 12:41 p.m. with Unit Manager, Employee E15, stated Resident R39 does require staff assistance at meals, either with cues or assistance with feeding from staff. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that prescribed wound care treatments were not left at the bedside for one of 31 residents reviewed. (Resident R60) Findings include: Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated November 26, 2024, indicates the diagnosis of anemia (low iron in the blood) and dementia (loss of intellectual functioning). During an observation completed on February 18, 2025, at 1:00 p.m. Resident R60 was sitting in his bed and eating his lunch from a lunch tray. It was observed that there was open bottle of Dakin's wound care solution sitting next to the lunch tray which the resident was eating. When asked the resident what was inside the bottle, resident stated water. Surveyor immediately notified Employee E16, Licensed Practical Nurse. Further observation revealed that there was wound cleanser and wound care supplies sitting on top of resident's nightstand. Interview with Employee E16 stated that was open bottle of Dakin's solution with medication inside the bottle. Employee E16 stated these wound care supplies should not have left in resident's room. 28 Pa Code 211.10(d) Resident care policies 28 AP. Code 211.12(d)(1) Nursing services

Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's and administering oxygen as ordered by the physician for one of 31 residents reviewed. (Resident R19). Findings Include: Review of the facility policy Nebulizer Administration, dated January 2025 revealed that Rinse nebulizer, mouthpiece, and T piece with tap water and let air dry. a. Date and place supplies in a treatment bag. b. Replace and date the setup every seven days. c. Check compressor for air filters that require replacement and cleaning every 30 days. d. Follow manufacturer's instructions. e. Disinfect the outside of the compressor between use of Elders/residents/guests and as needed. Review of the facility policy Oxygen Administration, dated January 2025 revealed that Replace entire set-up every seven days. Date and store in treatment bag when not in use. If using a non-disposable humidifier, change bottle every seven days and change water every 24 hours to prevent bacterial decontamination. Review of physician order for Resident R19 dated December 14, 2024, revealed an order for change oxygen tubing on Tuesdays 11-7 shift weekly. Further review of the physician order revealed an order for continuous oxygen at 3Liters/per minute. Observation of Resident R19's on February 18, 2025, at 10:50 a.m. revealed that the oxygen tubing was lying on the floor without any bag, the oxygen concentrator was running. The date of the oxygen tube was February 1, 2025. Further observation of Resident R19's room revealed that there was a nebulizer mask inside the a bag. The date on the bag was January 28, 2025. Continued observation of Resident R19's room on February 18, 2025, at 1:04 p.m. revealed that the oxygen tubing was still lying on the floor, the oxygen concentrator was running. Staff provided lunch tray for the resident but did not remove the oxygen tubing from the floor. The above observation was confirmed by Employee E16, Licensed Practical Nurse, on February 18, 2025, at 1:04 p.m. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for two of five residents reviewed (Resident R118 and R104). Findings Include: Review of physician order for Resident R104 dated July 30, 2024 revealed an order for Nifedipine(antihypertensive medication), give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure less than100 or heart rate less than 60 Review of Resident R104's Consultant Pharmacist review report dated December 24, 2024, by consultant pharmacist, revealed a recommendation, Medication error noted. Nifedipine (antihypertensive medication) is not always held as required by the physician's hold order on 12/5, 12/6, 12/9, 12/10, 12/14, 12/15, 12/17, 12/18, 12/19 and 12/20. Heart rate was less than 60 (per MAR)(medication administration record) and the medication was still administered. Further review of the report revealed that the recommendation was completed on January 3, 2025. Review of Resident R104's Consultant Pharmacist review report dated January 23, 2025, by consultant pharmacist, revealed a recommendation, Medication error noted. Nifedipine(antihypertensive medication) is not always held as required by the physician's hold order on 1/2, 1/3, 1/12, 1/13, 1/14, 1/20, and 1/21. Heart rate was less than 60 (per MAR)(medication administration record) and the medication was still administered. The medication was not withheld as recommended by the pharmacist on above dates. Review of MAR for Resident R104 for February 2025 revealed that the staff administered Nifedipine on 2/12, 2/13, and 2/18 even with heart rate less than 60. Review of pharmacy consultant report dated January 28, 2025 revealed a recommendation self-administration of medication is noted on the orders. Ensure that there is a self-administration assessment completed. It was documented on the report as the recommendation was completed. Review of Resident R118's assessments on February 21, 2025, did not to include an assessment for medication self-administration. Interview with the Director of Nursing on February 21, 2025 confirmed that there was no medication self-administration assessment for Resident R118 . 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.12 (d)(5) Nursing Services.

Based on clinical records, incident/accident reports, staff training records, resident and staff interviews and information submitted by the facility, it was determined that the facility failed to ensure that Resident R1 was free from neglect related to not providing the assistance of two staff during a transfer from bed to chair via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a fall, a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the diagnoses of chronic obstructive pulmonary disease (a lung condition cause by damage and inflammation that limits airflow), age related physical debility, morbid (severe) obesity, osteoarthritis of knee (degeneration of joint cartilage), lack of coordination, muscle weakness and history of falling. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated August 2, 2024, revealed that the resident had a BIMS (Brief interview of Mental Status) of 13 which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident required substantial/maximal assistance with mobility and was dependent in transfers from bed to chair. Review of care plan for Resident R1 dated October 23, 2023, revealed that Resident R1 was a Hoyer lift transfer with assist of 2 staff. Review of physician order for Resident R1 dated July 30, 2024, revealed an order for transfer via Hoyer lift with 2 person per policy. Review of facility investigation dated September 12, 2024, revealed that Employee E3, Nurse Aide, transferred the resident with a Hoyer lift (mechanical lift) independently. When the resident was in the low position, Employee E3 tried to position the Hoyer pad in the wheelchair. While trying to safely place the resident in her wheelchair by guiding the Hoyer pad, the Hoyer lift tipped to the left side coming into contact with the resident's head causing a laceration and contusion to the left forehead measuring 0.3 X 0.3 cm which was closed using surgical glue. She was transported to the hospital for evaluation and treatment. Review of statement by Nurse Aide, Employee E3 dated September 12, 2024, confirmed that she was in Resident R1's room using the Hoyer lift without assistance. She stated she did not see any other aide, so she proceeded to use the mechanical lift. She stated she was at the back side of the resident pulling the Hoyer pad, when the resident got close to the chair, the resident fell and hit the side of resident's head. Review of statement by Licensed Practical Nurse, Employee E4, dated September 12, 2024, revealed that she heard Resident R1's roommate calling for help, observed resident halfway in the wheelchair with Hoyer lift on top of her. Blood noted to the left side of the forehead. Review of statement by Nurse Aide, Employee E5, dated September 12, 2024, revealed that Nurse Aide, Employee E3 did not ask for help. Review of statement by Unit Manager, Employee E6, dated September 12, 2024, revealed that Resident R1 stated Nurse Aide, Employee E3 was with her putting her into the chair with the machine. The machine came down on her and the employee and the resident could not get that off. Review of statement by Resident R1 dated September 12, 2024, revealed that the resident stated Nurse Aide, Employee E3 was with her putting her into the chair with the machine. The machine came down on her, her head and the employee and the resident could not get that off. Review of statement by Resident R2 (Resident R1's roommate), dated September 12, 2024, revealed that she heard a noise, sounds like a broken glass. She could not see because the curtain was pulled. She asked the nurse aide in the other side of the room, if she was okay. She stated she heard her roommate yell in pain. Then she yelled for help. Interview with Licensed Practical Nurse, Employee E4 on September 30, 2024, at 10:30 a.m. stated Nurse Aide, Employee E3 on September 12, 2024 did not get any help or get a second person as required to transfer Resident R1 to the wheelchair. Employee E4 stated there was 2 staff required for all Hoyer lift transfer. She stated she saw the resident right after the incident. When she entered the room, the lift was still on the resident. Employee E4 stated it appeared that the legs of the Hoyer lift were not opened enough to prevent the tilting of the lift. When she entered the room the two-metal legs were close to each other. Employee E4 stated if there were 2 staff, it could have been prevented. Employee E4 stated Resident R1 was scared after the incident but she was better now. Interview with Unit Manager, Employee E6 on September 30, 2024, at 10:20 a.m. stated, when she observed the resident, she had a gash on her head. Unit Manager, Employee E6 stated Nurse Aide, Employee E3 did not get any assistance when she used the Hoyer lift. Unit Manager, Employee E6 stated there should be always 2 staff present to do Hoyer transfer. Interview with Resident R1 on September 30, 2024, at 10:40 a.m. stated, Employee E3 used Hoyer lift by herself, and the Hoyer lift fell on top of her. The metal piece of the lift hit her head hard. She stated that caused severe pain, Resident stated the pain was 10 out of a scale of 10. Resident stated she was terrified after the incident. She stated she had some pain after the incident for few days. Review of hospital record for Resident R1 dated September 12, 2024, revealed that the resident was evaluated at the emergency room for evaluation of head injury which the resident sustained from Hoyer lift transfer by staff. Resident noted with bleeding to the left side of the scalp, resident complained of mild pain. Resident's scalp injury was treated with surgical glue closure. Interview with the Director of Nursing and Nursing Home Administrator, on September 30, 2024, at 12:00 p.m. stated Nurse Aide, Employee E3 admitted to that she did not ask of help when she used Hoyer lift to transfer Resident R1 which resulted in injury to Resident R1 when the Hoper lift fell on the resident. Nursing Home Administrator confirmed that facility policy required 2 staff for all Hoyer lift transfers. Nursing Home Administrator confirmed that the injury was sustained by Employee E3 independently transferring Resident R1 using Hoyer lift. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R1 was transferred safely via mechanical lift into a chair with the assistance of two staff, resulting in the resident falling and sustaining a head injury. On September 30, 2024, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on September 12, 2024, to address the failure of not providing adequate number of staff assistance during a resident tranfer from bed to chair via mecahnical lift, which resulted in Resident R1 falling from the lift and sustaining a head injury. Facility plan of correction included the following: The facility has terminated the employee for not following the facility protocol for Hoyer lift transfers. Facility conducted audits to ensure all resident who used Hoyer lift has care plan updated. The facility re-educated certified nursing assistants along with competencies on Hoyer lift transfers. The facility will also conduct random observation audits to ensure compliance. All audits will be reviewed during facility monthly QAPI (Quality Assurance Performance Improvement Plan) meetings to ensure compliance with mechanical lift policy. The facility alleged compliance with their plan of correction as of September 26, 2024. Facility education record and competency record verified for completion. Nursing staff was interviewed on September 30, 2024 to verify education of facility policy on mechanical lift. Random resident records reviewed to verify compliance with the facility policy on mechanical lift. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policies, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff and resident interviews, it was determined that the facility failed to ensure resident environment remained as free of accident hazards and failed to ensure that safe techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1) Findings include: Review of facility policy using a mechanical lift machine dated August 2024, revealed The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning. Review of Resident R1's clinical record revealed the diagnoses of chronic obstructive pulmonary disease (a lung condition cause by damage and inflammation that limits airflow), age related physical debility, morbid (severe) obesity, osteoarthritis of knee (degeneration of joint cartilage), lack of coordination, muscle weakness and history of falling. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated August 2, 2024, revealed that the resident had a BIMS (Brief interview of Mental Status) of 13 which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident required substantial/maximal assistance with mobility and was dependent in transfers from bed to chair. Review of care plan for Resident R1 dated October 23, 2023, revealed that Resident R1 was a Hoyer lift transfer with assist of 2 staff. Review of physician order for Resident R1 dated July 30, 2024, revealed an order for transfer via Hoyer lift with 2 person per policy. Review of facility investigation dated September 12, 2024, revealed that Employee E3, Nurse Aide, transferred the resident with a Hoyer lift (mechanical lift) independently. When the resident was in the low position, Employee E3 tried to position the Hoyer pad in the wheelchair. While trying to safely place the resident in her wheelchair by guiding the Hoyer pad, the Hoyer lift tipped to the left side coming into contact with the resident's head causing a laceration and contusion to the left forehead measuring 0.3 X 0.3 cm which was closed using surgical glue. She was transported to the hospital for evaluation and treatment. Review of statement by Nurse Aide, Employee E3 dated September 12, 2024, revealed she was in Resident R1's room using the Hoyer lift without assistance. She stated she did not see any other aide, so she proceeded to use the lift. She stated she was at the back side of the resident pulling the Hoyer pad, when the resident got close to the chair, the resident fell and hit the side of resident's head. Review of statement by Licensed Practical Nurse, Employee E4, dated September 12, 2024, revealed that she heard Resident R1's roommate calling for help, observed resident halfway in the wheelchair with Hoyer lift on top of her. Blood noted to the left side of the forehead. Review of statement by Nurse Aide, Employee E5, dated September 12, 2024, revealed that Nurse Aide, Employee E3 did not ask for help. Review of statement by Unit Manager, Employee E6, dated September 12, 2024, revealed that Resident R1 stated Nurse Aide, Employee E3 was with her putting her into the chair with the machine. The machine came down on her and the employee and the resident could not get that off. Review of statement by Resident R1 dated September 12, 2024, revealed that the resident stated Nurse Aide, Employee E3 was with her putting her into the chair with the machine. The machine came down on her, her head and the employee and the resident could not get that off. Review of statement by Resident R2 (Resident R1's roommate), dated September 12, 2024, revealed that she heard a noise, sounds like a broken glass. She could not see because the curtain was pulled. She asked the nurse aide in the other side of the room, if she was okay. She stated she heard her roommate yell in pain. Then she yelled for help. Interview with Licensed Practical Nurse, Employee E4 on September 30, 2024, at 10:30 a.m. stated Nurse Aide, Employee E3 on September 12. 2024 did not get any help or get a second person as required to transfer Resident R1 to the wheelchair. Employee E4 stated there was 2 staff required for all Hoyer lift transfer. She stated she saw the resident right after the incident. When she entered the room, the lift was still on the resident. Employee E4 stated it appeared that the legs of the Hoyer lift were not opened enough to prevent the tilting of the lift. When she entered the room the two-metal legs were close to each other. Employee E4 stated if there were 2 staff, it could have been prevented. Employee E4 stated Resident R1 was scared after the incident but she was better now. Interview with Unit Manager, Employee E6 on September 30, 2024, at 10:20 a.m. stated, when she observed the resident, she had a gash on her head. Unit Manager, Employee E6 stated Nurse Aide, Employee E3 did not get any assistance when she used the Hoyer lift. Unit Manager, Employee E6 stated there should be always 2 staff present to do Hoyer transfer. Interview with Resident R1 on September 30, 2024, at 10:40 a.m. stated, Employee E3 used Hoyer lift by herself, and the Hoyer lift fell on top of her. The metal piece of the lift hit her head hard. She stated that caused severe pain, Resident stated the pain was 10 out of a scale of 10. Resident stated she was terrified after the incident. She stated she had some pain after the incident for few days. Observation of the Hoyer lift with Licensed Practical Nurse, Employee E4 on September 30, 2024, revealed that the Hoyer lift was in proper working condition. Employee E4 identified the metal part fell and hit Resident R1's head. A measurement of the metal rod hit which hit the resident's head was measured with the employee. The metal rod measured 2 inch width x 1.25 inch depth and approximately 44 inch long. Review of hospital record for Resident R1 dated September 12, 2024, revealed that the resident was evaluated at the emergency room for evaluation of head injury which the resident sustained from Hoyer lift transfer by staff. Resident noted with bleeding to the left side of the scalp, resident complained of mild pain. Resident's scalp injury was treated with surgical glue closure. Review of psychiatric consult report dated September 19, 2024, revealed that the resident was seen with a recommendation from the facility due to recent incident involving injuries sustained during transfer. The resident had clear recollection of the alleged incident and was able to explain that she was accidentally hit in the forehead with the Hoyer lift during transfer. The resident explained having blood running down the side of her face which was traumatic initially but now confirms she has no depression or anxiety resulting from this incident and reports her pain was addressed immediately from the facility. Interview with the Director of Nursing and Nursing Home Administrator, on September 30, 2024, at 12:00 p.m. stated Nurse Aide, Employee E3 admitted to that she did not ask of help when she used Hoyer lift to transfer Resident R1 which resulted in injury to Resident R1 when the Hoper lift fell on the resident. Nursing Home Administrator confirmed that facility policy required 2 staff for all Hoyer lift transfers. Nursing Home Administrator confirmed that the injury was sustained by Employee E3 independently transferring Resident R1 using Hoyer lift. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R1 was transfer safely via mechanical lift into a chair with the assistance of two staff, resulting in the resident falling and sustaining a head injury. On September 30, 2024, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on September 12, 2024, to address the failure of not providing a safe transfer from bed to chair via mecahnical lift, which resulted in Resident R1 falling from the lift and sustaining a head injury. The facility plan of correction included the following: The facility has terminated the employee for not following the facility protocol for Hoyer lift transfers. Facility conducted audits to ensure all resident who used Hoyer lift has care plan updated. The facility re-educated certified nursing assistants along with competencies on Hoyer lift transfers. The facility will also conduct random observation audits to ensure compliance. All audits will be reviewed during facility monthly QAPI (Quality Assurance Performance Improvement Plan) meetings to ensure compliance with mechanical lift policy. The facility alleged compliance with their plan of correction as of September 26, 2024. Facility education record and competency record verified for completion. Nursing staff was interviewed on September 30, 2024 to verify education of facility policy on mechanical lift. Random resident records reviewed to verify compliance with the facility policy on mechanical lift. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility documentation, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to develop a plan of care for a cognitively impaired female resident who was seeking attention from others, especially men. This failure resulted in Resident R114 engaging in inappropriate sexual contact with a male resident placing Resident R114 and other residents in an Immediate Jeopardy situation. Findings Include: Review of facility policy Comprehensive Care Plans revised October 2015 revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the residents related to clinical diagnosis or identified concerns. Continued review of facility policy revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs. Review of Resident R114's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 5, 2023, revealed the resident was admitted to the facility on [DATE], and had moderate cognitive impairment. Further review of the MDS revealed Resident R114 had diagnoses of depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (disease that affects the brain's ability to think, remember, and function normally). Review of Resident R114's physician orders revealed an order dated February 7, 2023, that indicated Resident is NOT capable of understanding and making decisions - independently. Continued review of Resident R114's physician orders revealed an order dated May 10, 2023, for Abilify (antipsychotic medication used to treat mood disorders) daily for increase aggressive behavior. Review of Resident R114's clinical record revealed guardianship paperwork for the Estate of [Resident R114], An Alleged Incapacitated Person [when a person is no longer able to manage or maintain their own affairs or physical well-being] dated November 1, 2021. Review of guardianship paperwork dated November 1, 2021, revealed [Resident R114] suffers from cognitive limitations which totally impairs her capacity to receive or evaluate information effectively . or to meet essential requirements of her physical health and safety. Accordingly, it is herby ordered and decreed that [Resident R114] is adjudged [declared] a totally incapacitated person Further review of Resident R114's guardianship paperwork revealed an expert report (Form G-06: to establish incapacity, the petitioner must present testimony from an individual qualified by training and experience in evaluating persons with incapacities), regarding Resident R114, completed by Licensed Geriatric Psychiatrist, Employee E29, on June 13, 2021. It was noted that the Licensed Geriatric Psychiatrist, Employee E29, had previous experience with Resident R114 and treated/assessed her in August 2020, February 2021, April 2021, and May 2021. Review of the expert report revealed Resident R114 had a diagnosis of vascular dementia with behavior disturbance with symptoms/manifestations that included irrational thinking and poor memory. Further review revealed the resident had a diagnosis of borderline personality traits r/o borderline personality dis (mental illness characterized by the instability in mood, behavior, and functioning) with symptoms/manifestations that included seeks attention from others, especially men, in order to feel self-worth and in order to avoid boredom, paranoid ideation, impaired relationships with family members. The expert report indicated that Licensed Geriatric Psychiatrist, Employee E29, assessed Resident R114's ability to give informed consent as totally impaired. Based on further review of the expert report it was revealed that Licensed Geriatric Psychiatrist, Employee E29, expected Resident R114's abilities in the next 6 months to decline with the rationale that vascular dementia is a progressive degenerative brain disease. Review of facility documentation submitted to the Department of Health on June 5, 2023, revealed that on June 1, 2023, therapy staff witnessed Resident R114 having oral sex with Resident R126. Resident R126 said he was asleep and thought he was dreaming while it happened. Review of Resident R126's Comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Continued review of the MDS revealed the resident had a diagnosis of depression. Interview on June 6, 2023, at 12:30 p.m. with Licensed Nurse, Employee E4, revealed Resident R114 had a history of being interested in men. Reported that Resident R114 used to hold another resident's [Resident R64] hand. Continued interview with Licensed Nurse, Employee E4, revealed when Resident R114's guardian was called and made aware of the incident the guardian was not surprised about what happened. Review of Resident R64's quarterly MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and had severe cognitive impairment. Continued review of the MDS revealed the resident had diagnoses of aphasia (comprehension and communication disorder) and dementia. Interview on June 6, 2023, at 1:00 p.m. with nurse aide, Employee E8, revealed Resident R114 was already under supervision prior to the incident because she likes to go sit in/outside of Resident R64's room. Follow-up interview on June 6, 2023, at 2:21 p.m. with Licensed Nurse, Employee E4, revealed Resident R114's infatuation with Resident R64 began shortly after Resident R64 was transferred to the 3rd floor nursing unit, around October 2022. Licensed Nurse, Employee E4, reported that Resident R114 would call Resident R64 her boyfriend, was observed holding hands with him, and would frequently sit at his bedside and outside his room. Interview on June 7, 2023, at 11:00 a.m. with activities aide, Employee E5, revealed Resident R114 can be aggressive toward men and that staff needed to be careful with who the resident was placed next to during activities. Follow-up interview on June 7, 2023, at 11:32 a.m. with activities aide, Employee E5, to gather clarification on Resident R114's behaviors of being aggressive toward men revealed the resident would be touchy with men during activities such as grabbing their hand or arm. Interview on June 7, 2023, at 11:13 a.m. with Licensed Nurse, Employee E6, revealed this was Resident R114's assigned nurse on the 7:00 a.m. to 3:00 p.m. shift on June 1, 2023, at the time of the incident. Continued interview revealed around 11:15 a.m. on June 1, 2023, R114 was observed in Resident R126's room sitting in her wheelchair by the television having conversation with the male resident. Licensed Nurse, Employee E6, reported shortly after this the resident across the hall, Resident R105, made the nurse aware that she could no longer see Resident R114 in the male resident's room and was concerned of her whereabouts. Licensed Nurse, Employee E6, confirmed that Resident R114 was not visible from the doorway and when the employee approached Resident R126's bed [the bed closest to the window], Resident R114 was now sitting much closer, at the bedside of Resident R126 having conversation with the male resident. Continued interview with Licensed Nurse, Employee E6, revealed Resident R114 was not asked to leave the room as the employee did not think anything of it. Further interview revealed therapy came to Resident R126's room about 20 minutes later and observed the incident between Resident R114 and R126. Interview on June 7, 2023, at 12:00 p.m. with physical therapist, Employee E9, revealed on June 1, 2023, at 11:35 a.m. the therapist went to Resident R126's room for a physical therapy session. Physical therapist, Employee E9, reported Resident R126 always kept his curtain a little pulled. Physical Therapist, Employee E9, indicated she knocked on the door and proceeded to enter Resident R126's room and as she approached his bed, and peeked around the curtain, Employee E9 observed Resident R126 lying in bed with his eyes open, and Resident R114 at his bedside in her wheelchair in the act of providing oral sex. Physical therapist, Employee E9, reported Resident R126 was wearing shorts and no shirt at the time of the incident. Further interview with physical therapist, Employee E9, revealed about two days prior while in Resident R126's room for physical therapy, Resident R114 was sitting in the doorway smiling at Resident R126 and Resident R126 said to Employee E9, she [Resident R114] likes me. A review of Resident R114's entire clinical record revealed no documented evidence a comprehensive care plan was developed related to the resident's attention seeking behaviors from men prior to the incident with Resident R126 on June 1, 2023. An interview on June 7, 2023, at 1:50 p.m. with the Nursing Home Administrator and Director of Nursing, Employee E2, confirmed Resident R114 should have been care planned for her behaviors prior to the incident. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing, Employee E2 on June 8, 2023, at 11:16 a.m. for the facility's failure to ensure that a plan of care was developed for a cognitively impaired female resident who demonstrated attention seeking behaviors from men, resulting in Resident R114 engaging in inappropriate sexual contact with a male resident. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, and Director of Nursing on June 8, 2023, at 11:30 a.m. The facility submitted a written plan of action on June 8, 2023, at approximately 3:36 p.m. and implemented the plan of action which included: 1. Resident 1 (F) [Female] [R114] and Resident 2 (M) [Male] [R126] were immediately separated. 2. Resident 2 (M) was immediately moved to a different floor. 3. The facility implemented a behavior care plan for Resident R1 (F) and Resident R2 (M) on Thursday June 1, 2023, the date the incident occurred. 4. Resident 1 (F) was seen by the Psychiatric Nurse Practitioner on June 2, 2023, and new orders were obtained, and care plan updated. 5. Resident 2 (M) was seen by the Psychiatric Nurse Practitioner on June 7, 2023, and new orders were obtained. 6.Resident 1 (F) and Resident 2 (M) were both placed on Q [every] thirty (30) minute behavioral checks for two (2) weeks at that time and it will be reassessed by the interdisciplinary team. 7. A full house audit/assessment took place on June 7, 2023, to screen all residents to identify if any other residents experienced inappropriate touching and to ensure the residents feel safe. 8. A questionnaire was used for the alert and oriented residents and full body checks took place for residents unable to communicate effectively. No other incidents of inappropriate touching were identified, and all residents reported feeling safe. 9. Resident 1 (F) and 2 (M) received a STAT STD [sexually transmitted disease] panel on June 8, 2023. The results pending at this time. 10. [The Facility] is conducting a full-house review to identify other residents who may be displaying attention seeking behavior. 11. Staff education is being initiated related to identifying and reporting residents with attention seeking behaviors leading to sexual advances. Clinical staff will also receive education on care plan completion and updating. Staff will not be scheduled to work until education is completed. 12. Eighty (80) percent of the staff education will be completed by close of business on June 9, 2023. Such education will include contract and agency staff. 13. The action plan will also be converted to a working performance improvement plan which will go to QAPI [Quality Assurance and Performance Improvement] monthly as another level to ensure our residents are safe. Interviews with 32 staff members from all departments were conducted on June 9, 2023, during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. All staff members reported that they received education regarding identifying and reporting residents with attention seeking behaviors leading to sexual advances and education on care plan completion and updating. Licensed nursing staff, nursing assistants as well as ancillary staff from all departments, including maintenance, therapy, dietary, activities, receptionist, and housekeeping were interviewed. Review of facility plan of action confirmed that the facility completed audits to ensure other residents with attention seeking behaviors were identified and that comprehensive care plans were developed to address behaviors with 100% compliance. Further review of the facility plan of action confirmed all residents were screened to identify if any other residents experienced inappropriate touching and to ensure the residents feel safe. All resident's reported feeling safe and there were no abnormal findings from the skin checks. Review of clinical records for Resident 1 (F) [R114] and Resident 2 (M) [R126] confirmed care plans were implemented for behaviors, psych consults were completed, and every 30-minute behavioral checks were being completed. Further review of clinical records confirmed STAT STD panels were drawn for both residents on June 8, 2023, and still pending as of June 9, 2023. The Immediately Jeopardy was lifted on June 9, 2023, at 4:20 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.11 (d) Resident care plan

Based on observation, review of clinical records, facility documents, policy and procedures and the American Burn Association Scald Injury Prevention Education Guide, and interviews with staff, it was determined that the facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by increased temperatures of hot liquids served to residents. One of 48 residents reviewed [MEDICAL CONDITION] hot beverage spill, resulting in actual harm to that resident (Resident R159). This failure placed the residents at a high risk for injury, and resulted in an Immediate Jeopardy situation. Findings include: Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed that older adults have thinner skin therefore hot liquids cause [MEDICAL CONDITION] even brief exposure, and older adults' ability to feel heat may be decreased due to certain medical or medications so they may not realize water is too hot until the injury has occurred. The guide added that the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 degrees Fahrenheit, it takes only five seconds or less for a serious burn to occur. A temperature of 155 degrees Fahrenheit takes one second for a severe burn to occur. The guide additionally stated that coffee, tea and hot beverages are usually served at 160 to 180 degrees Fahrenheit resulting in almost instantaneous burns. Review of the facility's incident and accident report dated (MONTH) 27, (YEAR), revealed that on (MONTH) 27, (YEAR), during the breakfast meal service in the main dining room on the first floor of the facility, Resident R159 spilled a hot beverage (cup of coffee) onto the right thigh area. The nursing staff documented that Resident R159 was experiencing pain in the areas of the blistering on the right thigh. The comprehensive assessment Minimum Data Set assessment (MDS - an assessment of care needs) dated (MONTH) 28, (YEAR), indicated that this resident required supervision (oversight, encouragement or cueing) during eating (how a resident eats and drinks, regardless of skill). The occupational therapy assessment on (MONTH) 14, (YEAR), also indicated that this resident required supervision during eating due to conditions of abnormal posture, lack of coordination, and [DIAGNOSES REDACTED]. This assessment also indicated that this resident was always incontinent of bowel and bladder. The facility's person centered care plan for Resident R159 indicated that this resident required supervised feeding. The facility's investigation report of this incident indicated that the three to eleven shift supervisor was called to Resident R159's room at 5:00 p.m. on (MONTH) 27, (YEAR), to examine the blistered areas that were found by the nurse aide performing incontinence care for Resident R159. The resident reported that the coffee spill and burn happened at the breakfast meal on the seven to three nursing shift. The facility administrator reported that the resident ate breakfast in the main dining room on the first floor on (MONTH) 27, (YEAR). Based on a review of the documentation on the facility incident and accident report dated (MONTH) 27, (YEAR); the facility failed to provide adequate supervision for eating for Resident R159 during the seven to three nursing shift. The coffee spill and burn was not identified by the seven to three nursing staff. According to the documented report, the burn was not discovered until the nurse aide on the three to eleven nursing shift found the coffee soaked sweat pants and blisters on the resident's right thigh. The comprehensive assessment dated (MONTH) 23, (YEAR), indicated that this resident had a Brief Interview for Mental Status (BIMS-an assessment of a resident's cognitive level) score of 8 which indicates moderate impairment (decisions poor; cues required). According to the physician's progress note dated (MONTH) 6, (YEAR), this resident had neurological impairment having a [DIAGNOSES REDACTED]. According to the Nurse Practitioner's assessment dated (MONTH) 28, (YEAR), resident R159 had left sided paralysis (the loss of the ability to move in part or most of the body). Observations of Resident R159 at 12:00 p.m. on (MONTH) 11, (YEAR), for the luncheon meal service on the fourth floor nursing unit, revealed that this resident had left sided paralysis. The resident did not have the ability to use the left side of the body. The wound specialist, who was a Certified Registered Nurse Practitioner, evaluated Resident R159 on (MONTH) 28, (YEAR). The services of the wound specialist were requested by the nursing staff, after Resident R159 was identified as spilling hot coffee on his leg at breakfast on (MONTH) 27, (YEAR). The wound specialist documented that Resident R159 had a partial thickness (loss of dermis - skin) injury of the right proximal knee 2.0 cm (centimeter) by 3.0 cm by .1 cm. The wound base was documented as a ruptured blister. The wound specialist documented another partial thickness injury to the right thigh 3.5 cm by 3.5 cm by .1 cm. The wound base was documented as a ruptured blister. The wound specialist also documented additional partial thickness injuries of the right thigh. The wound base was described with multiple intact serous blisters (six blisters with 2 double blisters). Based on the Certified Registered Nurse Practitioner's description of Resident R159's skin condition; this resident was assessed and treated for [REDACTED]. Review of the wound documentation on (MONTH) 11, (YEAR), at approximately 1:40 p.m with Employee E9, the Wound Nurse, revealed that the wound measured 30.0 centimeters(approximately 12 inches) in length, 7.0 centimeter (approximately 3 inches) in width and had a depth of 0.1 centimeter and had dried exudate (a liquid produced by the body in response to tissue damage). Employee E9 stated at that time that the wound type was identified as other. Observation of Resident R159 on (MONTH) 11, (YEAR), at 1:45 p.m. revealed the resident in bed in his room. Observation of the right thigh revealed a partial thickness wound (injury involving the loss of the top layers of the skin) that the wound was irregular in shape, that it extended from the knee area to the top of the thigh, that small blistered areas were observed on either ends. The resident stated at that time that it was painful when treatments were being done, that it happened when the coffee cup slipped out of his hand, that it had occurred in the fourth floor dining room and that he had sweat pants on at that time. A review of the facility's dietary policies and procedures for serving hot liquids revealed that the facility was to serve these liquids at temperatures between 125 degrees Fahrenheit and 155 degrees Fahrenheit. It was determined that the facility's dietary staff were not following their established policies to ensure proper serving temperatures for the residents. The facility's temperature logs being recorded by the dietary department staff were reviewed in the presence of the Director of Dietary Services, Employee E10, at 10:00 a.m. on (MONTH) 11, (YEAR). The main dining room serving temperatures as well as the Fourth Floor Nursing Unit temperatures were reviewed for breakfast, lunch and dinner for (MONTH) 26 through (MONTH) 11, (YEAR). The temperatures recorded were not within the facility's dietary policy range. The temperatures were 160 degrees Fahrenheit to 191 degrees Fahrenheit. Interview with the Director of Dietary Services, Employee E10 and the Nursing Home Administrator, Employee E1 at 1:00 p.m. on (MONTH) 11, (YEAR), revealed that the facility has a policy to monitor temperatures and hot beverages that were served to the residents. The facility policy indicated that hot beverages were not to exceed 125 to 155 degrees Fahrenheit at the point of service to the resident(s). The facility policy indicated that the Dietary Director and dietitian would monitor the point of service temperatures of the foods and beverages by conducting periodic tests of them. A review of the test meal audits performed on (MONTH) 2, (YEAR), (MONTH) 30, (YEAR), (MONTH) 21, (YEAR), and (MONTH) 13, (YEAR), revealed that the point of service temperature well exceeded the established policies at the facility. The failure of the facility to adequately monitor hot beverage temperatures to prevent scalding/burning of the residents was confirmed with the Nursing Home Administrator, Employee E1 and the Director of Dietary Services, Employee E10, who presented the survey team with point of service temperatures(served to the residents), that were substantially above the facility's established polices. The service temperature recorded for coffee on (MONTH) 2, (YEAR) was 185 degrees Fahrenheit. The service temperature recorded for coffee on (MONTH) 30, (YEAR) was 163 degrees Fahrenheit. The service temperature recorded for coffee on (MONTH) 21, (YEAR) was 186 degrees Fahrenheit. The service temperature for coffee for (MONTH) 13, (YEAR) was 192 degrees Fahrenheit. Although these elevated temperatures were being recorded, the facility's administrative staff had taken no action to correct the problem. This was confirmed during an interview at 2:00 p.m. on (MONTH) 11, (YEAR), with the Nursing Home Administrator. On (MONTH) 11, (YEAR), at 12:45 p.m. in the 4th floor dining room, temperatures were observed to be 170 degrees for the hot water for tea and the temperature for the coffee was observed to be 165 degrees. These temperatures were above the temperature that the facility policy and procedure stated are acceptable. An Immediate Jeopardy situation was called at 3:55 p.m. on (MONTH) 11, (YEAR). The facility's corrective action plan included: 1. The coffee machine used to brew coffee for the residents' meal serve (breakfast, lunch, dinner) daily, was adjusted from boil setting to #2 setting, resulting in temperature reading of 156 degrees Fahrenheit; which according to administrative staff was down from 173 degrees Fahrenheit. 2. The adjuster knob on the coffee machine was removed, so that the coffee machine was now permanently set. 3. The dietary staff are to take temperatures of hot liquids before service and to notify the Dietary Manager if temps are out of range. 4. Inservicing started immediately to educate dietary staff about meal evaluation temps and communication. 5 Dietary Manager will monitor temps in the Main Dining Room and all satellite dining rooms prior to meal service. Following verification of the corrective action plan and review of the temperature assessment of the hot liquids served to the residents the Immediate Jeopardy was lifted at 11:15 a.m. on (MONTH) 12, (YEAR). The facility failed to ensure each resident received adequate supervision to prevent accidents, and failed to ensure the resident environment remained free of accident hazards related to hot beverages that caused actual harm to one resident, and placed other residents at risk for potential harm identifying an Immediate Jeopardy situation. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 05/18/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 05/18/17 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 05/18/17 28 Pa. Code 201.18(b)(3) Management Previously cited 05/18/17, 06/23/16 28 Pa. Code 201.18(e)(1) Management Previously cited 06/23/16 28 Pa. Code 211.10(d) Resident care polices Previously cited 05/18/17, 06/13/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 06/13/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/13/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 05/18/17, 06/13/16

Based on observations, review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to identify, monitor, and treat a pressure ulcer timely, until it was discovered at an Unstageable stage for one of 24 residents reviewed (Resident R71). Findings include: Review of Resident R71's clinical record revealed [DIAGNOSES REDACTED]. After suffering the second stroke, the resident was readmitted to the facility on [DATE]. Review of a readmissionskin risk assessment, known as a Braden scale, dated May 19, 2016, was completed which indicated that the resident scored a 12, which means a high risk for developing a pressure ulcer. Further review of the readmission skin assessment revealed that the resident had an opened area on the left buttock, measuring 0.5 centimeters (cm.) long, 1.5 cm. wide, and 0.1 cm. deep. Review of the wound consult report dated May 23, 2016, described the left buttock wound as a partial thickness ulceration. Review of an observation report dated May 19, 2016, described the left buttock wound as a Stage II (ulcer involving the loss of the top layers of the skin), measuring 2.3 cm. long and 3 cm. wide. Review of the MDS (minimum data set-assessment of resident needs) dated December 24, 2015, March 17, 2016, and June 1, 2016 revealed that Resident R71 needed total assistance for transferring (needed a mechanical lift) from bed to chair and vice versa, needed total assistance for bathing and dressing, and was incontinent of bowel and bladder. Review of nursing progress notes dated June 1, 2016, revealed that during wounds rounds with the wound consult team, a wound was noted to the sacral region, measuring 6.5 cm. long, 3 cm. wide, and 0.1 cm. deep. Review of the wound consult report dated June 1, 2016, which was on a reconsult visit for the left buttock wound, revealed the discovery of an Unstageable (full thickness tissue loss with the base of the wound not able to be visualized) pressure ulcer, described as a full thickness ulceration of the sacrum, with the wound base of 60% slough (dead yellow/an stringy tissue) and 40 % granular (healing tissue), measuring 4 cm. long, 7 cm. wide, and 0.1 cm. deep, with a moderate amount of drainage. Review of facility policy Wound Management Program dated May 11, 2011, revealed that all residents are to receive two baths each week where a skin assessment must be performed by the charge nurse. Also, the cna (certified nurse aid) must report any abnormal skin conditions to the charge nurse or supervisor immediately. Interview with Employee E3 on June 9, 2016 at 1:30 p.m. revealed that a licensed nurse performs the skin checks at shower /bath twice a week, and the cnas perform daily skin checks. Interview with Employee E2 on June 9, 2016 at 1:00 p.m. revealed that the resident was to have shower/bath on Mondays and Thursday on the 7-3 shift, on May 23, 26, and 30, 2016. On May 23 and May 30, nursing notes stated skin checks done, no new issues. On May 26, 2016, there is no mention of a skin check. During the interview with Employee E3, it was revealed that the skin checks are to be recorded on the Treatment Administration Record (TAR). Review of the TAR for May and June 2016 revealed no documentation of the skin checks. Review of the physician orders [REDACTED]. Observation of wound care on June 8, 2016 at 10:30 a.m. revealed an inner buttock (deep inner) pressure ulcer at the very top of the buttocks, at the sacral region. The buttocks had to be opened fully to observe the full presence, dimensions and depth of the pressure ulcer. The unstageable pressure ulcer still had slough at the base of the wound. Measurements completed on June 6, 2016, by the wound consult team were the same as noted on discovery on June 1, 2016. Review of a bowel movement record from May 19 to June 1, 2016 revealed multiple bowel movements, sometimes two a day, that the resident had to be cleansed afterwards. The facility failed to timely identify, monitor and treat a sacral pressure ulcer until it was discovered at an Unstageable stage. 28 Pa. Code: 211.10(a)(d) Resident care policies. Previously cited 5/22/2015. 28 Pa. Code: 211.11(d) Resident care plan. 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services. Previously cited 5/22/2015