Every finding on record at Westmoreland Manor

Based on review of Pennsylvania's Nursing Practice Act, facility policy, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that nursing services met professional standards of quality by failing to ensure that medications were administered by licensed medical or nursing personnel in accordance with the medical and nursing regulations of Pennsylvania which resulted in the need for transfer to the hospital. This deficiency was cited as past non-compliance.Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, Section 21.145 (a)(1)(i)(2) indicated that the Licensed Practical Nurse is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The Licensed Practical Nurse participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. A Licensed Practical Nurse shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when: The patient's care needs exceed the licensed practical nursing scope of practice. A Licensed Practical Nurse shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures. Section 21.145a (5) indicated that Licensed Practical Nurses are prohibited from administering medications via push or bolus rate (the rapid administration of a concentrated medication or fluid directly into a vein, typically via syringe, over a very short period).Review of a facility policy for Medication Administration: Rights dated February 1, 2026, indicated that to ensure accountability and six rights' (right resident, right drug, right dose, right time, right route, right dosing form), charting guidelines are set. All medications are to be administered by licensed medical or nursing personnel in accordance with the medical and nursing regulations of Pennsylvania. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 5, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnosis that included Atherosclerotic heart disease (hardening of your arteries from plaque building up gradually inside them). Review of a nurse's note for Resident 2 dated April 17, 2026, at 10:47 p.m. revealed that the resident had a right upper arm midline (flexible tube inserted into a vein in the upper arm, used for infusion of fluids and medications).Physician's orders for Resident 2 dated April 18, 2026, included for the resident to receive 5 milligrams (mg) of Apixaban (a blood thinner) by mouth two times a day for atrial- fibrillation (an irregular and often very rapid heart rhythm), 100 mg of Gabapentin (used to treat partial seizures and nerve pain) two tablets by mouth three times a day for rheumatoid arthritis (condition that causes pain, swelling and irritation in the joints), 400 mg of magnesium oxide (dietary supplement) by mouth two times a day for magnesium deficiency, and 20 MEQ of potassium chloride extended release (mineral supplement that is used to prevent or treat low levels of potassium) by mouth three times a day for potassium deficiency. Physician's orders dated April 19, 2026, included for the resident to receive 5 mg of midodrine (used to treat low blood pressure) two tablets by mouth three times a day for hypotension (low blood pressure). Review of a facility incident report dated April 23, 2026, at 9:50 p.m. revealed that the resident had an order for oral tablets to be crushed and mixed in pudding, and a right arm intravenous midline for the administration of Zosyn (an antibiotic medication). Oral medications to be administered at 6:00 p.m. that included Eliquis 5mg, Gabapentin 100 mg, Magnesium oxide 400 mg, Midodrine 5 mg and potassium 20 MEQ were administered via midline. A witness statement by Registered Nurse 1, dated April 23,2026, revealed that Licensed Practical Nurse 2 admitted to her that he had crushed Resident 2's oral medications, mixed them with warm water, and administered them into the resident's midline catheter. A witness statement by Registered Nurse 3, dated April 23, 2026, revealed that she spoke with Licensed Practical Nurse 2 at approximately 10:30 p.m. and he reported to her that he used the silent knight to crush Resident 2's medications, dissolved them in water and administered them through the resident's midline using a normal saline flush syringe to administer the medications.A respiratory therapist's note for Resident 2 dated April 23, 2026, at 11:25 pm revealed that the resident's oxygen saturation remained between 85% and 87% on 12 Liters of supplemental oxygen. The physician was notified and orders were received to send the resident to the hospital. Physician's note for Resident 2 dated April 24, 2026, at 3:06 p.m. revealed that the resident was given oral medications that were dissolved in water through her midline last evening. The midline has since been removed, and she remains vitally stable on supplemental oxygen. emergency room evaluation revealed hyponatremia (low concentration of sodium in the blood), and otherwise stable.Interview with Registered Nurse 3 on April 28, 2026, revealed that she received a phone call from Registered Nurse 1 on April 23, 2026, at 9:36 p.m. reporting that Licensed Practical Nurse 2 gave oral medications via a midline. She told staff to remove Licensed Practical Nurse 2 from the floor. At 9:59 p.m. the physician was made aware and said to monitor the resident's condition. At 10:12 p.m. she interviewed Licensed Practical Nurse 2 via telephone who admitted that he crushed the resident's medication, mixed it in warm water and administered it through her midline. At 10:59 p.m. she interviewed him again and he reportedly stated that he had made a terrible mistake and got confused with giving medications crushed in a gastric tube. Interview with Licensed Practical Nurse 4 on April 28, 2026, at 5:58 p.m. revealed that Resident 2's daughter reported to her that Licensed Practical Nurse 2 put medications in the resident's midline catheter and she questioned if it was appropriate to do. Licensed Practical Nurse 4 revealed that she asked Licensed Practical Nurse 2 if he was crushing the resident's medications and giving them orally and he replied that he was. She was aware of him giving an as needed pain medication by mouth. Licensed Practical Nurse 4 attempted to show Licensed Practical Nurse 2 how to administer antibiotics in the midline for Resident 2 and the medication would not infuse and attempts to flush the midline catheter were unsuccessful despite Licensed Practical Nurse 2 stating he just flushed the midline catheter. Licensed Practical Nurse 4 reported the allegation of improper medication administration to Registered Nurse 1 who reported it to Registered Nurse 3. Licensed Practical Nurse 2 later admitted to Licensed Practical Nurse 4 that he crushed Resident 2's 6:00 p.m. medications and put them in her midline catheter.Interview with the Director of Nursing, Nursing Home Administrator and the facility's Clinical Compliance Certified Registered Nurse Practitioner on April 29, 2026, at 3:25 p.m. confirmed that Licensed Practical Nurse 2 administered medications that were ordered to be given by mouth via a syringe into a midline catheter and should not have. Following the incident on April 23, 2026, the facility's corrective actions included:Licensed Practical Nurse 2, who was involved in the improper administration of medications to Resident 2, was removed from duty, and was reported to the nursing agency that employed him as well as the state board of nursing. A full facility audit of the residents with intravenous access devices was completed and education of staff was initiated regarding the six rights of medication administration with emphasis on the right route, the Pennsylvania Licensed Practical Nurse scope of practice an code of conduct including that Licensed Practical Nurses are not permitted to administer intravenous push medications, adherence to proper routes of administration at all times, and safe practices for IV medication administration, subcutaneous injections, and enteral feeding. The education provided also included competency evaluations. A review of the facility's corrective actions revealed that they were in compliance with F658 on April 27, 2026.Interview with the Clinical Compliance Certified Registered Nurse Practitioner on April 29, 2026, at approximately 2:00 p.m. revealed that the facility had initiated audits three times a week for proper medication administration and proper intravenous medication administration. The results of the audits were to be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of nine residents reviewed (Resident 2) that resulted in a transfer to the hospital. This deficiency was cited as past non-compliance.Findings include:Review of a facility policy for Medication Administration: Rights dated February 1, 2026, indicated that to ensure accountability and six rights' (right resident, right drug, right dose, right time, right route, right dosing form), charting guidelines are set. All medications are to be administered by licensed medical or nursing personnel in accordance with the medical and nursing regulations of Pennsylvania. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 5, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnosis that included Atherosclerotic heart disease (hardening of your arteries from plaque building up gradually inside them). Review of a nurse's note for Resident 2 dated April 17, 2026, at 10:47 p.m. revealed that the resident had a right upper arm midline (flexible tube inserted into a vein in the upper arm, used for infusion of fluids and medications).Physician's orders for Resident 2 dated April 18, 2026, included for the resident to receive 5 milligrams (mg) of Apixaban (a blood thinner) by mouth two times a day for atrial- fibrillation (an irregular and often very rapid heart rhythm), 100 mg of Gabapentin (used to treat partial seizures and nerve pain) two tablets by mouth three times a day for rheumatoid arthritis (condition that causes pain, swelling and irritation in the joints), 400 mg of magnesium oxide (dietary supplement) by mouth two times a day for magnesium deficiency, and 20 MEQ of potassium chloride extended release (mineral supplement that is used to prevent or treat low levels of potassium) by mouth three times a day for potassium deficiency. Physician's orders dated April 19, 2026, included for the resident to receive 5 mg of midodrine (used to treat low blood pressure) two tablets by mouth three times a day for hypotension (low blood pressure). Review of a facility incident report dated April 23, 2026, at 9:50 p.m. revealed that the resident had an order for oral tablets to be crushed and mixed in pudding, and a right arm intravenous midline for the administration of Zosyn (an antibiotic medication). Oral medications to be administered at 6:00 p.m. that included Eliquis 5mg, Gabapentin 100 mg, Magnesium oxide 400 mg, Midodrine 5 mg and potassium 20 MEQ were administered via midline. A witness statement by Registered Nurse 1, dated April 23,2026, revealed that Licensed Practical Nurse 2 admitted to her that he had crushed Resident 2's oral medications, mixed them with warm water, and administered them into the resident's midline catheter. A witness statement by Registered Nurse 3, dated April 23, 2026, revealed that she spoke with Licensed Practical Nurse 2 at approximately 10:30 p.m. and he reported to her that he used the silent knight to crush Resident 2's medications, dissolved them in water and administered them through the resident's midline using a normal saline flush syringe to administer the medications.A respiratory therapist's note for Resident 2 dated April 23, 2026, at 11:25 pm revealed that the resident's oxygen saturation remained between 85% and 87% on 12 Liters of supplemental oxygen. The physician was notified and orders were received to send the resident to the hospital. Physician's note for Resident 2 dated April 24, 2026, at 3:06 p.m. revealed that the resident was given oral medications that were dissolved in water through her midline last evening. The midline has since been removed, and she remains vitally stable on supplemental oxygen. emergency room evaluation revealed hyponatremia (low concentration of sodium in the blood), and otherwise stable.Interview with Registered Nurse 3 on April 28, 2026, revealed that she received a phone call from Registered Nurse 1 on April 23, 2026, at 9:36 p.m. reporting that Licensed Practical Nurse 2 gave oral medications via a midline. She told staff to remove Licensed Practical Nurse 2 from the floor. At 9:59 p.m. the physician was made aware and said to monitor the resident's condition. At 10:12 p.m. she interviewed Licensed Practical Nurse 2 via telephone who admitted that he crushed the resident's medication, mixed it in warm water and administered it through her midline. At 10:59 p.m. she interviewed him again and he reportedly stated that he had made a terrible mistake and got confused with giving medications crushed in a gastric tube. Interview with Licensed Practical Nurse 4 on April 28, 2026, at 5:58 p.m. revealed that Resident 2's daughter reported to her that Licensed Practical Nurse 2 put medications in the resident's midline catheter and she questioned if it was appropriate to do. Licensed Practical Nurse 4 revealed that she asked Licensed Practical Nurse 2 if he was crushing the resident's medications and giving them orally and he replied that he was. She was aware of him giving an as needed pain medication by mouth. Licensed Practical Nurse 4 attempted to show Licensed Practical Nurse 2 how to administer antibiotics in the midline for Resident 2 and the medication would not infuse and attempts to flush the midline catheter were unsuccessful despite Licensed Practical Nurse 2 stating he just flushed the midline catheter. Licensed Practical Nurse 4 reported the allegation of improper medication administration to Registered Nurse 1 who reported it to Registered Nurse 3. Licensed Practical Nurse 2 later admitted to Licensed Practical Nurse 4 that he crushed Resident 2's 6:00 p.m. medications and put them in her midline catheter.Interview with the Director of Nursing, Nursing Home Administrator and the facility's Clinical Compliance Certified Registered Nurse Practitioner on April 29, 2026, at 3:25 p.m. confirmed that Licensed Practical Nurse 2 administered medications that were ordered to be given by mouth via a syringe into a midline catheter and should not have. Following the incident on April 23, 2026, the facility's corrective actions included:Licensed Practical Nurse 2, who was involved in the improper administration of medications to Resident 2, was removed from duty, and was reported to the nursing agency that employed him as well as the state board of nursing. A full facility audit of the residents with intravenous access devices was completed and education of staff was initiated regarding the six rights of medication administration with emphasis on the right route, the Pennsylvania Licensed Practical Nurse scope of practice an code of conduct including that Licensed Practical Nurses are not permitted to administer intravenous push medications, adherence to proper routes of administration at all times, and safe practices for IV medication administration, subcutaneous injections, and enteral feeding. The education provided also included competency evaluations. A review of the facility's corrective actions revealed that they were in compliance with F760 on April 27, 2026.Interview with the Clinical Compliance Certified Registered Nurse Practitioner on April 29, 2026, at approximately 2:00 p.m. revealed that the facility had initiated audits three times a week for proper medication administration and proper intravenous medication administration. The results of the audits were to be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations from wound consultations for one of 55 residents reviewed (Resident 15).Findings include:The facility's wound treatment management policy, dated February 1, 2026, indicated that to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated January 13, 2026, revealed that the resident was cognitively intact, was dependent on staff for her care needs, had limited range of motion to her upper and lower extremities, and had pressure ulcers.A wound consultation for Resident 15, dated February 3, 2026, revealed that the resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure sore on her left ischial tuberosity (bone in your lower pelvis that absorbs weight when you sit) that measured 2.0 x 0.3 x 0.1 centimeters (cm) and an open area on the right gluteus (buttocks) caused from moisture associated dermatitis (MASD) that measured 0.1 x 0.1 x 0.1 cm. The plan was to apply calcium alginate with silver (absorbent wound dressing that had antimicrobial protection) to the wound beds every two days. A wound consultation for Resident 15, dated March 3, 2026, revealed that the Stage 4 pressure sore on her left ischial tuberosity that measured 0.5 x 0.5 x 0.1 cm and the open area on her right buttocks caused from moisture associated dermatitis measured 0.1 x 0.1 x 0.1 cm. The plan was to continue calcium alginate with silver to the wound beds every two days. A review of Resident 15's Treatment Administration Records (TAR's) for February and March 2026 revealed that the treatments to the left ischial tuberosity were completed daily from February 5 through March 30, 2026, and there was no documented evidence that calcium alginate with silver was applied to the resident's right gluteus every two days.Interview with Director of Nursing on April 9, 2026, at 2:11 p.m. confirmed that the treatments for Resident 15's pressure ulcer on the left ischial tuberosity and MASD on the right gluteus were not completed as recommended by the wound consultant and should have been.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 55 residents reviewed (Residents 12 and 66) who had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). Findings include: The facility's policy for tube feedings, dated February 1, 2026, indicated that all tube feedings were to have a physician's order and the physician's order for feedings was to be documented on the order recaps, electronic Medication Administration Record, and the tube feeding container.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated January 8, 2026, indicated that the resident was cognitively impaired, was dependent on staff for daily care tasks, and had a feeding tube. Physician's orders for Resident 12, dated March 13, 2026, included orders for the resident to receive a bolus feeding (method of delivering nutrition through a feeding tube in meal-sized amounts several times a day) via pump of 240 milliliters/hour of Jevity 1.2 RTH (a tube feeding formula) every five hours between the hours of 9:00 a.m. and midnight.Physician's orders for Resident 12, dated March 24 and 25, 2026, included orders for the resident to receive a house diet with pureed texture and a bolus feeding (method of delivering nutrition through a feeding tube in meal sized amounts several times a day) of Jevity 1.2 RTH (a tube feeding formula) at 9:00 a.m., 2:00 p.m., and 7:00 p.m., if the resident's meal intake was less than fifty percent. The midnight bolus feeding was to be discontinued.A nutrition note for Resident 12, dated April 6, 2026, indicated that the resident was to receive bolus feedings of 240 cubic centimeters (CC's) of Jevity 1.2 RTH scheduled for 9:00 a.m., 2:00 p.m., and 7:00 p.m., and administered if the resident's meal intake was less than fifty percent.The Medication Administration Records (MAR's) for Resident 12 for March and April 2026 revealed that staff administered the resident's tube feeding at 10:00 p.m. on March 24, 30, and 31, and April 2, 4, 5, and 7, 2026.Interview with the Clinical Compliance Certified Registered Nurse Practitioner on April 8, 2026, at 2:59 p.m. confirmed that staff were not following the current physician's order for tube feedings and the resident should not have been receiving the feeding at 10:00 p.m.An annual MDS assessment for Resident 66, dated January 7, 2026, indicated that the resident was severely cognitively impaired, was dependent on staff for daily care needs, and had a feeding tube. Physician's orders for Resident 66, dated December 1, 2025, included orders for the resident to receive Peptamen (a tube feeding formula) continuously at 35 cubic centimeters (cc's) per hour for 20 hours per day via a feeding tube pump. Physician's orders for the resident, dated December 1, 2025, indicated that the tube feeding was to be hung daily and taken down daily, and the feeding was scheduled to be hung at 12:01 a.m. and taken down at 8:00 p.m. A physician's order note for Resident 66, dated April 8, 2026, at 2:03 p.m. indicated that the physician had seen the resident and ordered to hold the resident's tube feeding for six hours and check for residual before resuming the feeding. Physician's orders for Resident 66, dated April 8, 2026, included an order to hold his tube feeding for six hours then resume, and to check for residual before resuming the feeding. Review of Resident 66's MAR for April 2026, revealed that there was no documented evidence that the tube feeding was held as ordered. Interview with the Director of Nursing on April 9, 2026, at 11:33 a.m. confirmed that there was no documented evidence that Resident 66's tube feeding was held as ordered. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of 55 residents reviewed (Resident 19). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated January 16, 2026, revealed that the resident was severely cognitively impaired, received psychotropic medications, including, antidepressant medications, antianxiety medications and antipsychotic medication, and had diagnoses including anxiety and dementia. A physician's order note for Resident 19, dated August 11, 2025, at 11:34 a.m. revealed that the Certified Registered Nurse Practitioner assessed the resident and new orders were obtained to increase her clonazepam (an antianxiety medication) to 1 milligram (mg) twice daily prior to a.m. and p.m. care. Physician's orders for Resident 19, dated August 11, 2025, included an order for the resident to receive 1 mg of Klonopin (Clonazepam) twice daily for anxiety and agitation There was no documented evidence in Resident 19's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Klonopin (Clonazepam). Interview with the Clinical Compliance Certified Registered Nurse Practitioner on April 8, 2026, at 1:34 p.m. confirmed that there was no documented evidence in Resident 19's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Klonopin (Clonazepam). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for two of 55 residents reviewed (Residents 134 and 135). Findings include: Observations of Resident 135's wheelchair during an interview with the resident on April 6, 2026, at 10:49 a.m. revealed that the left arm rest had a large piece of vinyl torn off of the armrest exposing the foam padding, and the right arm rest was taped up with duct tape. She stated at that time that her wheelchair was old, and she had asked for a new one. Interview with Licensed Practical Nurse 1 on April 7, 2026, at 1:17 p.m. confirmed that the vinyl on the left arm rest of Resident 135's wheelchair was torn with the foam exposed and the right armrest was wrapped with duct tape. She indicated that she believed maintenance repaired issues with the chairs. She contacted maintenance via the phone at that time, and they informed her to put in a work order. Observations of Resident 134's wheelchair during an interview on April 7, 2026, at 1:30 p.m., revealed that the arm rests had vinyl pieces that were peeling off in places. An interview with Maintenance Employee 2 at the time of the observation confirmed that the wheelchair armrests had vinyl pieces peeling off in places. Interview with Maintenance Employee 2 on April 7, 2026, at 1:30 p.m. indicated that normally maintenance repairs wheelchair issues. He indicated that they would receive work orders from nursing or therapy for repairs. He indicated that there were no routine wheelchair checks that he is aware of and stated maybe therapy does that. Interview with the Nursing Home Administrator on April 7, 2026, at 1:40 p.m. revealed that she was aware of the torn wheelchair arm rests for Resident 135 and indicated that maintenance was currently working on them. She was informed that it was confirmed with Maintenance Employee 2 that Resident 134 had worn wheelchair armrests with the vinyl peeled off in places. She indicated that anyone could submit a work order for issues that need repaired, and that the wheelchairs are on a routine cleaning schedule by housekeeping and they would report any issues as well. Interview with the Nursing Home Administrator on April 7, 2026, at 2:44 p.m. revealed that Resident 135 had a wheelchair cleaning done on March 18, 2026, and there was no mention of any repairs needing addressed; however, there was a work order communication submitted in January 2026 for a general wheelchair assessment, but it did not mention anything specific. There was no mention of any work order submitted for Resident 134 related to her wheelchair arm rests needing repaired. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 55 residents reviewed (Residents 98, 135, 159). Findings include: A facility policy regarding care plan development, dated February 1, 2026, indicated that the care plan will be reviewed and revised as necessary by the interdisciplinary team at least quarterly after each MDS assessment both comprehensive and quarterly, or more often as changes occur. A facility policy for care plans dated, February 1, 2026, revealed that the care plan will be reviewed and revised as necessary by the Interdisciplinary team at least quarterly after each Minimum Data Set (MDS) (a mandated assessment of a resident's abilities cand care needs) assessment both comprehensive and quarterly, or more often as changes occur. A quarterly MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 98, dated March 12, 2026, revealed that the resident was cognitively intact, was dependent on staff for care needs, and has a diagnosis of diabetes mellitus. The care plan for Resident 98 dated January 27, 2027, revealed that the resident was to have her blood sugar checked every Wednesday morning. Physician's orders for Resident 98 dated January 15, 2026, included an order to check blood glucose monitoring in the morning and evening. Interview with the Nursing Home Administrator on April 9, 2026, at 8:15 a.m. revealed that the care plan should have been updated to reflect blood glucose checks being completed twice a day. A significant change MDS assessment for Resident 135, dated January 15, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included anxiety and bipolar disorder. An interview with Resident 135 on April 6, 2026, at 3:03 p.m. revealed that she receives her shower on Tuesday evenings and would prefer to go back to showers in the morning before breakfast. An interview with Nurse Aide 3 on April 7, 2026, at 11:48 a.m. revealed that Resident 135 had her shower changed from day shift to evening shift because she wanted it changed. She stated that the resident frequently changes her mind related to shower times. Review of Resident 135's shower record for January through April 2026 revealed that she received her showers in the evenings on the evening shift. A care plan for the resident, dated June 9, 2016, indicated that the resident preferred bathing on the day shift after breakfast. Documentation of an interview that occurred between the Assistant Director of Nursing and Resident 135, on April 8, 2026, at 12:10 p.m., revealed that the resident confirmed she was an early shower, but sometimes it was hard to get up in the morning, so she asked to be showered before bed. Interview with the Director of Nursing on April 8, 2026, confirmed the Resident 135's care plan was not revised to reflect the change in her shower preference to evening shift. An annual MDS for Resident 159 dated April 4, 2026, revealed that the resident was cognitively impaired, was dependent on staff for all care needs, and was not out of bed due to medical and safety concerns. Physician's orders for Resident 159, dated March 3, 2026 included orders for the resident to be non-weight bearing, was not to utilize hoyer lifts and was not to be out of bed. However, care plans for Resident 159 dated February 26, 2026, revealed that the resident uses a wheelchair for locomotion; a care plan dated February 23, 2024, revealed that the resident utilizes bilateral assist bars to help transfer in and out of bed; and a care plan dated March 25, 2026, indicated that the resident was to be out of bed to an 18-inch specialty chair as tolerated. Interview with the Director of Nursing on April 9, 2026, at 8:27 a.m. confirmed that Resident 159's care plan was not updated to reflect her current status. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 55 residents reviewed (Residents 9, 10). Findings include:A comprehensive Minimum Data Set (MDS) assessment (mandated assessments of a resident's abilities and care needs) for Resident 9, dated January 27, 2026, indicated that the resident had impaired cognition and required help from staff for her daily care needs.Physician's orders for Resident 9, dated April 1, 2026, included an order for the resident to receive 5 milligrams (mg) of Midodrine hydrochlorothiazide (HCL) (a blood pressure medication), three times a day and to hold the medication if the resident's systolic (top number) blood pressure was less than 100.Resident 9's Medication Administration Record (MAR), dated April 2026, revealed that on April 4, 2026 at 5:00 p.m. the resident's blood pressure was 119/75 millimeters of mercury (mmHg) indicating that the Midodrine should have been held, however, it was administered. On April 5, 2026 at 2:00 p.m. the resident's blood pressure was 139/81 mmHg indicating that the Midodrine should have been held, however, it was administered.Interview with the Director of Nursing on April 8, 2026 at 1:34 p.m. revealed that the Midodrine should have been held on the dates mentioned above.An annual MDS assessment for Resident 10, dated February 13, 2025, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes.Physician's orders for Resident 10, dated November 26, 2025, included an order for the resident to have accu-checks (blood sugar check) before meals and at bedtime. If the resident's blood sugar result was over 300 milligrams/dL, staff were to re-check the resident's blood sugar in two hours, and if the blood sugar was still over 300 mg/dL after the re-check the physician was to be notified.The Medication Administration Records (MARs) for Resident 10 for January, February, and March 2026 revealed that the resident's blood sugar result on January 15 at 4:00 p.m. was 367 mg/dL, on February 13 at 4:00 p.m. was 360 mg/dL, on February 13 at 9:00 p.m. was 311 mg/dL, on February 14 at 9:00 p.m. was 369 mg/dL, and March 8, 2026 at 4:00 p.m. was 400 mg/dL. However, there was no documented evidence that staff re-checked the resident's blood sugar in two hours per the physician's order.Interview with the Director of Nursing on April 9, 2026, at 1:13 p.m. confirmed that staff did not re-check Resident 10's elevated blood sugars in two hours as ordered on the dates and times mentioned above.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who required urinary catheterization (a flexible tube inserted into the bladder to drain urine) was completed as ordered for one of 55 residents reviewed (Resident 16).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16 dated March 18, 2026, revealed that the resident was cognitively intact, required assistance for care needs, had a diagnosis of benign prostatic hyperplasia (a condition in aging men where the prostate gland enlarges causing urinary issues, and received intermittent catheterization. A care plan for Resident 16, dated December 5, 2025, indicated that the resident had benign prostatic hyperplasia, and was to be provided straight catheterization (a medical procedure used to drain urine from the bladder using a thin, flexible tube called a straight catheter) per order. Physician's orders for Resident 16, dated March 6, 2026, included an order for the resident to be straight catheterized every 12 hours after attempted to void if bladder scan shows a residual volume over 300milliliters (ml) and to record all amounts on paper flowsheet. Physician's orders for Resident 16, dated March 25, 2026, included an order for the resident to be straight catharized before bed, attempt to void prior, and to straight catharize if the residual volume is over 300ml. Review of Resident 16's March 2026, treatment administration records (TAR) and paper flowsheet revealed that the resident did not receive straight catheterization on March 17, 2026, on evening shift, March 18, 2026, morning shift, March 22, 2026, evening shift, and March 24, 2026, evening shift. Interview with the Nursing Home Administrator on April 7, 2026, 2:32 p.m. confirmed that there was no documented evidence that Resident 16's straight catheterization was completed as ordered on the dates and shifts noted above. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of six residents reviewed (Resident 3) was free from abuse perpetrated by a resident with aggressive behaviors (Resident 2), resulting in an incident in which one of six residents reviewed suffered a fractured hip (Resident 3). Findings include: The facility's abuse policy, dated February 1, 2025, revealed that the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieved the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was cognitively impaired, had no behaviors, received anti-psychotic and anti-depressant medications, and had diagnoses that included dementia and depression. A quarterly MDS assessment for Resident 3, dated March 11, 2025, revealed that the resident was cognitively impaired, had verbal behaviors directed towards others and other behaviors not directed towards others, received anti-depressant medications, and had diagnoses that included dementia and depression. The behavior care plan for Resident 2, dated December 4, 2024, and revised on May 29, 2025, revealed that he had diagnoses that included dementia, anxiety, depression, and insomnia. His behaviors included going through/entering others spaces/belongings, rummaging, anxious/restless, agitation, sleeplessness, pacing, refusing care, verbalizing persistent beliefs not true, wandering, picking at self, yelling at others, angry/hostile towards staff, paranoia, delusions, accusatory of others, threatening and inappropriate comments towards staff/others, following others closely on the unit or exit seeking, and having hallucinations of others wanting to harm/kill him. Staff were to monitor and document changes in his mood and behavior and determine if there was a specific trigger to the change, have him seen by the psychiatrist as ordered, redirect and intervene if having behaviors with others, entering others spaces/rooms, getting angry, exit seeking, etc., and provide 1:1 close observation. A behavior note for Resident 2, dated May 14, 2025, at 10:15 a.m. revealed that he pushed Resident 3 causing her to fall. A nursing note for Resident 3, dated May 14, 2025, revealed that at 10:15 a.m. Resident 3 walked down the hall and tapped Resident 2 on his left shoulder and Resident 2 turned around and used both hands to push her to the ground. Resident 3 landed on her right hip and continued to lie on the floor until staff arrived. She was exhibiting signs of severe pain to her right hip with difficulty moving it. The physician was notified and orders were received to transfer the resident to the hospital for evaluation and treatment. She was admitted to the hospital with a right hip fracture. The facility's investigation, dated May 14, 2025, revealed that video footage was reviewed and Resident 2 was standing near the nurse's station on the unit. Resident 3 was walking up the hallway in the direction of Resident 2 and was nearing Resident 2, when Resident 2 turned and began to walk in the opposite direction. When Resident 3 caught up to Resident 2, she reached forward with her left hand and began to tap Resident 2 on the left arm/shoulder area. When Resident 3 tapped Resident 2 on the shoulder, he turned around quickly and pushed Resident 3, causing her to lose her balance and fall to the ground onto her side. The facility's investigation indicated that abuse was substantiated. Interview with the Director of Nursing on May 29, 2025, at 4:24 p.m. confirmed that Resident 2 pushed Resident 3, which resulted in Resident 3 falling and fracturing her hip, substantiating abuse. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's grievance for one of six residents reviewed (Resident 5). Findings include: The facility's policy regarding grievances and concerns, dated February 1, 2025, revealed that the facility recognizes that residents have the right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Every grievance must include investigative form(s) as necessary, including but not limited to: Witness statements, investigative notes, copies of documentation evidence, summary of investigative process, and summary of investigation findings. Every grievance investigation will be summarized by the Grievance Officer, or designee and findings recorded whether the incident was confirmed or not. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 23, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly referred to as a stroke) with right side hemiplegia (paralysis on one side of the body) and diabetes (a chronic condition where the body either does not produce enough insulin or cannot effectively use the insulin it produces). Information provided by the facility revealed that Resident 5 filed a grievance via a resident/family grievance form on May 19, 2025, with concerns that last night was the last straw with Licensed Practical Nurse 1. The other nurse (a woman which the resident does not know her name) came to my room about 10:00 p.m. to give me my medication. When I saw the insulin she was going to give me, I stopped her and explained that was not the right insulin. She explained that Licensed Practical Nurse 1 prepared the insulin. I told her it's wrong and I refused to take it. The resident went on to explain that over the course of about one year Licensed Practical Nurse 1 does and says things to her and about her that he knows upsets her. For instance, he will stand outside my bedroom door and say to nobody that he is sorry for kicking her bed. Licensed Practical Nurse 1 told her once that she would be put in jail for violating HIPPA because I told my husband the floor was yellow because someone had COVID. Another time recently she was in the bathroom (unit bathroom) and Licensed Practical Nurse 1 came in and slammed cupboards and made all kind of noise. I think he was trying to scare me. The resident also presented several non-specific interactions that she believes are deliberate, passive-aggressive and attempts to gas light her. The resident also recalled that a little while ago Licensed Practical Nurse 1 told everyone that I hallucinate. I don't hallucinate. Lastly the resident added, I already requested that Licensed Practical Nurse 1 not provide care. I also don't want him preparing my meds. I don't want him to do anything with me or my care. A summary of the grievance investigation, dated May 26, 2025, revealed that a concern was received from Resident 5 listing concerns involving a staff member. The resident stated that a certain staff member does and says things deliberately to gas light her. She also stated that there was a different nurse that attempted to administer the incorrect insulin to her. Resident 5 has had ongoing concerns with the first nurse and every attempt has been made to keep him out of her sight, for instance, he only works down the opposite hall. However, going forward, the nurse has been removed from the nursing unit. Education has been provided to the second nurse regarding checking the order to ensure she has the correct insulin and to not rely on the word of other nurses. The facility's investigation revealed no documented evidence that Resident 5's concerns regarding her issues with Licensed Practical Nurse 1 doing and saying things to her and about her that he knows upsets her were investigated and/or addressed, as well as no documented evidence that a statement was obtained from Licensed Practical Nurse 1 regarding the resident's concerns. Interview with the Director of Nursing on May 29, 2025, at 4:15 p.m. confirmed that there was no documented evidence that Resident 5's concerns regarding her issues with Licensed Practical Nurse 1 doing and saying things to her and about her that he knows upsets her were investigated and/or addressed, as well as no documented evidence that a statement was obtained from Licensed Practical Nurse 1 regarding the resident's concerns. 28 Pa. Code 201.29(i) Resident Rights.

Based on a review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of 58 residents reviewed (Resident 48) resulting in a hot liquid spill with injury. This deficiency was cited as past non-compliance. Findings include: The facility policy regarding hot liquids safety, dated February 1, 2025, indicated that in order to promote safety, appropriate precautions will be implemented to maximize choice of beverages while minimizing potential for injury. Hot liquids will be severed at a temperature not greater than 140 degrees Fahrenheit (F). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated January 6, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly known as a stroke) with left-side hemiplegia (paralysis on one side of the body). A nursing note for Resident 48, dated February 23, 2025, at 9:55 p.m. revealed that an eight-ounce (oz) cup of coffee was prepared upon the resident's request. The cup was provided with a lid on and placed on the resident's bedside table. The resident prefers drinking his coffee out of an open cup and uses his right dominant hand. The resident removed the lid and proceeded to pick up the cup when it slipped out of his hand. The resident stated it was an accident. The resident is alert and oriented. The resident reported mild pain at time of incident. Light yellow blister on top of his left thigh near his groin measuring two centimeters (cm) by three cm by 0.2 cm. The surrounding tissue was intact with a light-red area measuring five cm by three cm. There was another light-yellow blister that is located to his lateral (to the side of, or away from, the middle of the body) of his left thigh measuring one cm by one cm by 0.2 cm and the surrounding tissue is light red measuring five cm by 1.3 cm. The affected area was cleansed with saline and an adaptic dressing (helps prevent dressing adherence) was applied and then covered with a dry dressing. Staff were to be educated on measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before submitting to the resident. A statement completed by Nurse Aide 1, dated February 23, 2025, revealed that at approximately 8:00 p.m. on February 23, 2025, Resident 48 requested for her to use one of his own K-Cups to brew him a fresh cup of coffee. The nurse aide used the Keurig in the A1 staff room to make it. The resident requested no lid on his coffee cup and to make it black. The nurse aide set his cup on his bedside table where he requested and asked him if he needed anything else, he stated no. Approximately five to ten minutes later the nurse aide heard him yelling out in pain. The nurse aide ran to his room where the resident stated, I dropped my coffee on my hand. The on-shift licensed practical nurse ran in behind the nurse aide, and the resident told her his hand was hurting from spilling his coffee. It was observed that his left thigh had two red areas and blisters forming on the red areas. No red areas or blisters on his hand were seen. The nurse aide was educated at the end of the shift that all drinks from the Keurig should temp at 140 degrees F and below for all residents. Interview with Resident 48 on May 6, 2025, at 12:53 p.m. revealed that he asked staff to get him a cup of coffee using one of his K-Cups that his family provides him, and that he requested that staff not put a lid on the cup and to set it on his over-bed table. He indicated that he was in bed and felt tired that night and the next thing he spilt the cup of coffee onto his left thigh. Interview with Nurse Aide 1 on May 7, 2025, at 3:15 p.m. revealed that she was providing care to Resident 48 and he stated to her not to forget his coffee and that he did not want a lid on the cup. She went to the A1 staff lounge where the Keurig was located and brewed the resident his coffee with the K-Pod he provided. After the coffee was brewed, she did not obtain a temperature on the coffee because this was how they did it in the past. She set the Styrofoam cup containing the coffee on the resident's over-bed table and left. Approximately four to five minutes went by, and she heard him scream and went to investigate. She indicated that she saw that he had spilled his coffee down onto his left thigh. Interview with the Director of Nursing on May 6, 2025, at 2:35 p.m. confirmed that there was no documented evidence that the temperature was obtained on the coffee prior to being served to Resident 48. She indicated that the hot liquid safety policy was for the kitchen staff and not for nursing staff. Following the incident on February 23, 2025, the facility's corrective actions included: Resident 48 was assessed and treatment to his left thigh was obtained. The resident was ordered Kennedy cups (a lightweight spill-proof drinking cup) to receive his hot liquids in. An audit of other residents who receive hot liquids from a Keurig or other electrical devices was completed. Nurse Aide 1 received education on measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before giving to the residents. The facility's policy regarding hot liquid safety was reviewed and revised to include the procedure for temping liquids from a Keurig or other electrical device. The facility's food temperature log was reviewed and revised to include the temperatures of liquids before being served. Facility staff as well as agency staff education on the revised hot liquid safety policy, food temperature log, as well as measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before giving to the residents was completed. Audits to identify any issues with following a resident's care plan for assistance with bed mobility/transfers were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on March 24, 2025. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 58 residents reviewed (Residents 191, 208). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 191, dated February 21, 2025, revealed that the resident was understood and could understand others. A care plan for the resident, dated September 10, 2024, revealed that the resident has an altered cardiovascular status related to congestive heart failure (CHF - a condition where the heart can not pump enough blood to meet the body's needs, leading to fluid buildup in the lungs, legs, and other parts of the body) and hypertension (high blood pressure). Staff was to administer medications as ordered by the physician. Physician's orders for Resident 191, dated February 20, 2025, and discontinued on April 30, 2025, included an order for the resident to receive one 25 milligram (mg) tablet of Hydralazine (used to treat high blood pressure) every eight hours for hypertension. Staff was to hold the medication for a systolic blood pressure (the top number of the blood pressure) reading of less than 120 millimeters of mercury (mmHg). Physician's orders for Resident 191, dated April 30, 2025, included an order for the resident to receive one 25 mg tablet of Hydralazine two times per day for hypertension. Staff was to hold the medication for a systolic blood pressure reading of less than 120 mmHg. Review of Resident 191's Medication Administration Record (MAR), dated March, April, and May 2025, revealed that the resident's systolic blood pressure was less than 120 mmHg on March 16, 2025, at 10:00 p.m.; March 31, 2025, at 10:00 p.m.; April 3, 2025, at 2:00 p.m.; April 10, 2025, at 2:00 p.m.; May 2, 2025, at 6:00 a.m.; and on May 6, 2025, at 6:00 a.m.; however, there was no documented evidence that Hydralazine was held as ordered by the physician. Interview with Clinical Compliance on May 7, 2025, at 12:50 p.m. confirmed that Resident 191's Hydralazine was not held as ordered on the above dates and times. A quarterly MDS assessment for Resident 208, dated April 19, 2025, indicated that the resident was cognitively impaired and had diagnoses that included hypertension (high blood pressure) and dementia. A care plan, dated July 2, 2024, indicated that the resident's medications were to be administered as ordered by physician. Physician's orders for Resident 208, dated February 15, 2025, included an order for the resident to receive 12.5 mg of metoprolol tartrate (treats atrial fibrillation) twice a day. The medication was to be held if the resident's systolic blood pressure (the top number of a blood pressure reading) was less then 130 millimeters of mercury (mmHg), or if the heart rate was less than 60 beats per minute. Resident 208's Medication Administration Records (MAR's) for February and March 2025 revealed that the resident's systolic blood pressure was less than 130 mmHg at 9:30 a.m. on February 12, 23, 26, and March 2, and 5 and at 6:00 p.m. on February 1, 4, 23, and March 2, 2025; however, there was no documented evidence that metoprolol tartrate was held as ordered by the physician. Interview with Clinical Compliance on May 7, 2025, at 12:50 p.m. confirmed that Resident 208's metoprolol was not held as ordered on the above dates and times. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 58 residents reviewed (Residents 84, 196, 208, 229). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge, indicated that the intent of Section J1900 was to be coded with number of falls of no injury, injury or major injury since admission/entry or reentry or prior assessment whichever is more recent. indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0415I Antiplatelet Medications (medication used to prevent blood from clotting), N0415K anticonvulsant medications was to be coded if the resident took the medication during the seven-day lookback period. A significant change MDS assessment for Resident 84, dated April 8, 2025, revealed that the resident was cognitively intact, required assistance with activities of daily living, and had medical diagnoses that included seizure disorder and cerebral palsy. Physician's orders for Resident 84, dated April 3, 2025, included an order for the resident to receive 150 milligrams (mg) of Oxcarbazepine (an anticonvulsant). A review of the resident's April 2025 Medication Administration Record (MAR) revealed that the resident received Oxcarbazepine during the seven-day look-back period. A quarterly assessment for Resident 196, dated February 18, 2025, revealed that the resident is cognitively intact, required assistance with activities of daily living, and had medical diagnoses that included coronary artery disease, history of heart attack and high blood pressure. Physician's orders for Resident 196, dated October 14, 2023, included an order for the resident to receive 75 mg of Clopidogrel Bisulfate (an antiplatelet) daily for history of heart attack. A review of the resident's February 2025 MAR revealed that the resident received Clopidogrel Bisulfate during the seven-day look-back period. An interview with the Director of Case Management on May 8, 2025. at 11:30 a.m. confirmed that the MDS assessments for Residents 84 and 196 were inaccurately coded. The RAI User's Manual, dated October 2024 revealed that if the assessment was the first assessment since the most recent admission/entry or reentry, then Section A0310E was to be coded (1) Yes. Section J1700, the resident's fall history on admission/entry or re-entry, was to be completed if Section A0310E was coded (1) Yes. If the resident had a fall any time in the month prior to admission/entry or reentry, then Section J1700A was to be coded (1) Yes. If the resident had a fracture related to a fall in the six months prior to admission/entry or re-entry, then Section J1700C was to be coded (1) Yes. A nursing note for Resident 208, dated August 15, 2024, at 7:14 p.m. revealed that the resident was observed on the floor in the dining room and complained of her left upper thigh hurt. She was transferred to the hospital and admitted with a left hip fracture. A quarterly MDS assessment for Resident 208, dated October 3, 2024, revealed that Section A0310E was incorrectly coded (0) No, indicating that this was not the resident's first MDS assessment since being readmitted (from the hospital). By coding Section A0310E as (0) No, the computerized MDS software did not allow Sections J1700A and J1700C to be completed to reflect that the resident had a fall and fracture in the past 30 days. Interview with Director of Case Management on May 7, 2025, at 3:19 p.m. confirmed that Resident 208's MDS was coded incorrectly. A nursing note for Resident 229, dated March 1, 2025, indicated that the resident was discharged to personal care home on that date. However, a discharge tracking MDS for Resident 229, dated March 1, 2025, indicated that Resident 33 was discharged to the hospital. An interview with the Director of Case Management on May 8, 2025, at 3:06 p.m. confirmed that Resident 229's discharge tracking MDS was coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 58 residents reviewed (Resident 106). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's policy regarding medication orders, transcription of substituted, dated February 1, 2025, indicated that the registered nurse or licensed practical nurse transcribing the order would be notified by the pharmacy of the substitution and would then discontinue the order for the original brand name medication in the electronic record and enter a new order with the drug substituted by the pharmacy. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 106, dated April 23, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain). Physician's orders for Resident 106, dated April 21, 2024, included an order for the resident to be administered 250 milligrams (mg) of calcium citrate twice a day for Vitamin D deficiency. Observations of medication administration on May 7, 2025, at 8:20 a.m. revealed that Resident 106 was administered 950 mg of calcium citrate that contained 200 mg of calcium. Interview with Licensed Practical Nurse 2 on May 7, 2025, at 2:23 p.m. confirmed that the physician's order was to administer 250 mg of calcium citrate, but the card dispensed from the pharmacy was for calcium citrate 950 mg with 200 mg calcium. She was not sure why the pharmacy would have provided a different medication. Interview with the Pharmacy Supervisor for Data Entry on May 8, 2025, at 10:07 a.m. confirmed that a pharmacist had changed the medication, because the previous medication was on backorder. There was no notation in the chart that the pharmacy had informed the facility, and after speaking to the pharmacist it was determined that the dose was not equivalent. The pharmacy should have called the facility to inform them of the change. There was no documented evidence in Resident 106's clinical record to indicate that the medication was clarified with the physician. Interview with the Director of Nursing on May 8, 2025, at 8:32 a.m. confirmed that pharmacy changed and sent a medication that was not an equivalent, that the current physician's order did not match the medication that was administered to Resident 106, and that nursing staff should have clarified the order with the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) was flushed as ordered by the physician for two of 58 residents reviewed (Residents 77, 207). Findings include: The facility's policy regarding flushing intravenous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated February 1, 2025, indicated that the catheter was to be flushed with 0.9 percent sodium chloride (sterile salt water solution) before and after medication administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 77, dated April 2, 2025, revealed that the resident was cognitively impaired, required assistance for daily care needs, and had diagnoses that included heart failure, high blood pressure, and extended spectrum beta lactamase in the urine (an infection in urine). Physician's orders for Resident 77, dated April 28, 2025, included an order for the resident to receive 500 milligrams of Invanz (intravenous antibiotic medication) for urinary tract infection. Review of the April and May 2025 Medication Administration Record (MAR) for Resident 77 revealed no documented evidence that the resident's PICC line was flushed after the antibiotic was administered as per facility policy. An interview with the Clinical Compliance Officer on May 8, 2025, at 9:41 a.m. confirmed that there was no documented evidence that Resident 77's PICC line was flushed after the antibiotic was administered as per facility policy. A quarterly MDS assessment for Resident 207, dated April 23, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, received antibiotics, received IV medications, and had diagnoses that included peripheral vascular disease (poor circular of the extremities), and diabetes. A nursing note, dated April 17, 2025, revealed the resident returned from the hospital following amputation of her left big toe and had a PICC line in her right arm. Physician's orders for Resident 207, dated April 18, 2025, included an order for the resident to receive 1500 mg of Vancomycin (antibiotic) intravenously (IV) daily until April 23, 2025, and the IV access site was to be flushed with 10 ml of normal saline solution before and after medication administration at bedtime. Physician's order for Resident 207, dated April 22, 2025, included an order for the resident to receive 1750 mg of Vancomycin intravenously daily until April 24, 2025. A care plan, dated April 21, 2025, indicated that IV flushes were to be provided as ordered. Resident 207's MAR's for April 2025 indicated that the resident received IV Vancomycin intravenously daily at 10:00 a.m., and not at bedtime, from April 18 through 24, 2025; however, there was no documented evidence that staff flushed the resident's IV catheter with saline solution before and after any of the IV administrations of Vancomycin. Interview with the Clinical Corporate Officer on May 7, 2025, at 12:44 p.m. confirmed that there was no documented evidence that Resident 207's PICC line was flushed with saline solution before and after every administration of antibiotics. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding medication administration: rights, dated February 1, 2024, indicated that when administering the medication, the electronic medical record should be checked against the prescription label for each resident. To ensure accountability and the six 'rights' (right resident, right drug, right dose, right time, right route, right dosing form), guidelines were set for medication administration. Observations during medication administration on August 21, 2024, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 106, dated April 23, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain). Physician's orders for Resident 106, dated April 21, 2024, included an order for the resident to be administered 250 milligrams (mg) of calcium citrate twice a day for Vitamin D deficiency. Observations of medication administration on May 7, 2025, at 8:20 a.m. revealed that Resident 106 was administered 950 mg of calcium citrate. Interview with Licensed Practical Nurse 2 on May 7, 2025, at 2:23 p.m. confirmed that the physician's order was to administer 250 mg of calcium citrate, but the card dispensed from the pharmacy was for 950 mg of calcium citrate. A quarterly MDS assessment for Resident 147, dated April 2, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included multiple sclerosis (a chronic, progressive disease of the central nervous system that can affect the brain, optic nerves, and spinal cord). Physician's orders for Resident 147, dated July 18, 2022, included an order for the resident to be administered two drops into each eye of artificial tears solution one percent (carboxymethylcellulose sodium) three times a day for dry eyes. Observations of medication administration on May 7, 2025, at 8:40 a.m. revealed that Resident 147 was administered one drop of artificial tears solution one percent (carboxymethylcellulose sodium). Interview with Licensed Practical Nurse 2 at that time confirmed that she was finished with her medication administration to Resident 147, and that she instilled one drop into each eye. At 8:44 a.m. Licensed Practical Nurse 2 confirmed that she should have administered two drops in each eye. Interview with the Director of Nursing on May 8, 2025, at 8:32 a.m. confirmed that the current physician's order did not match the medication that was administered to Resident 106, and that the correct number of eye drops were not administered to Resident 147 and should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on observations, as well as staff and resident interviews, it was determined that the facility failed to provide a safe and comfortable homelike environment in one of seven dining rooms (A1). Findings include: The facility's policy for safe and homelike environment, dated February 4, 2024, indicated that the facility, in accordance with residents' rights, will provide a safe, clean, comfortable, and homelike environment. This includes ensuring that the resident can receive care and services safely. An interview with a group of residents on May 7, 2024, at 2:00 p.m. revealed that the A1 dining room tables are peeling and are rough, and they had concerns about skin tears. Observations in the A1 dining room on May 8, 2024, at 9:06 a.m. revealed that eight of eight tables were peeling and had sharp edges. An interview with the Maintenance Director on May 8, 2024, at 9:08 a.m. confirmed that all eight tables located in the A1 dining room were peeling and had sharp edges. An interview with the Director of Nursing on May 8, 2024, at 1:18 p.m. confirmed the tables in the A1 dining room were peeling and that it was not a comfortable, safe and homelike environment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for one of 48 residents reviewed (Resident 82). Findings include: The facility's policy regarding psychotropic medication (any medication that affects brain activities associated with mental processes and behavior), dated February 4, 2024, indicated that staff are to utilize non-pharmacological interventions (individualized approaches to care not primarily based on medication) when clinically indicated to reduce the need for psychotropic medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 82, dated March 6, 2024, indicated that the resident was usually understood, had cognitive impairment, required partial to moderate assist with transfers to bed/wheelchair/toilet, had a bed alarm used daily, and had diagnoses that included dementia and anxiety. Physician's orders for Resident 82, dated December 26, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Lorazepam (a psychotropic medication to treat anxiety) every six hours as needed for anxiety. A psychiatric evaluation for Resident 82, dated February 21, 2024 recommended to continue positive psychosocial and non-pharmacological approaches to enhance the resident's wellness. Review of the Medication Administration Records (MAR) for Resident 82 for January and February 2024 revealed that the resident was administered 0.5 mg of Lorazepam on January 1, 2024, at 2:42 a.m. and 7:02 p.m.; January 2, 2024, at 5:57 p.m.; January 3, 2024, at 1:00 a.m.; January 4, 2024, at 12:42 a.m. and 9:37 p.m.; January 6, 2024, at 12:11 a.m. and 10:43 p.m.; January 7, 2024, at 7:23 p.m.; January 14, 2024, at 6:26 p.m.; January 20, 2024, at 6:14 a.m.; January 31, 2024, at 6:46 p.m.; February 8, 2024, at 4:02 a.m.; and February 11, 2024, at 5:44 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on the above-mentioned dates and times. An interview with the Director of Nursing on May 9, 2024, at 11:54 a.m. confirmed that there were no non-pharmacological behavioral interventions attempted for Resident 82 prior to the administration of Lorazepam on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 48 residents reviewed (Resident 25) and failed to label multi-dose containers of insulin with the date they were opened in one of six medication carts reviewed (A1). Findings include: The facility's policy regarding medication label changes, dated February 4, 2024, indicated that in the event that an order change was made, allowing for the administration of the same medication, but requiring a label change, staff were to place an auxiliary label stating Direction Changed over the old directions on the label. Physician's orders for Resident 25, dated March 21, 2024, included an order for the resident to receive 20 units of Lantus insulin one time a day for diabetes. Observations during medication administration on May 8, 2024, at 9:00 a.m. revealed that Resident 25 received 20 units of Lantus insulin; however, the label on the resident's box of Lantus insulin indicated that the resident was to receive 25 units of Lantus insulin at bedtime. Interview with Licensed Practical Nurse 4 on May 8, 2024, at 9:18 a.m. confirmed that the label on Resident 25's bottle of Lantus did not include the morning dose, and a Change in Direction label should have been placed on the bottle. The facility's multi-dose vial storage policy, dated February 4, 2024, indicated that the facility will date all multi-dose vials when opened, for the purpose of infection control and to ensure product stability. Manufacturer's instructions for Humalog and Lantus insulin, dated February 2024, revealed that the insulin vial was to be discarded 28 days after it was opened. Physician orders for Resident 26, dated March 25, 2021, included an order for the resident to receive 8 units of Humalog in the evening. Physician orders for Resident 26, dated March 5, 2024, included an order for the resident to receive 12 units of Lantus at bedtime. Manufacturer's instructions for Lispro insulin, dated February, 2024, revealed that the insulin vial was to be discarded 28 days after it was opened. Physician orders for Resident 74, dated January 8, 2024, included an order for the resident to receive Lispro two times a day. Manufacturer's instructions for Levemir insulin, dated February 2024, revealed that the insulin vial was to be discarded 42 days after it was opened. Physician orders for Resident 169, dated December 20, 2023, included an order for the resident to receive 6 units of Levemir one time a day. Observations of A1 medication cart on May 9, 2024, at 12:45 p.m. revealed that the Humalog, Lantus, Lispro, and Levemir vials for Residents 26, 74, and 169 were opened and not dated. Interview with Licensed Practical Nurse 5 on May 9, 2024, at 12:45 p.m. confirmed that the insulin vials for Residents 26, 74, and 169 were not dated when opened to indicate the date they expire and should have been. Interview with the Director of Nursing on May 9, 2024, at 1:00 p.m. confirmed that all insulin vials should have been labeled with the dates that they were opened and discarded in accordance with manufacturer's instructions. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of two residents reviewed (Resident 2), resulting in a fall with a fractured bone for Resident 2. Findings include: A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated (MONTH) 27, (YEAR), indicated that the resident was alert and oriented, did not ambulate (walk), and had range of motion deficits on both sides of her body. The resident's care plan and physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 18, (YEAR), at 10:23 p.m. indicated that Registered Nurse 2 was notified by Nurse Aide 1 at 9:45 p.m. that while doing range of motion (the range, measured in degrees of a circle, through which a joint can be extended and flexed) with the resident's evening care, her (right) leg got caught up with the left leg. The resident complained of mild right knee pain with extension of the right leg. A nursing note for Resident 2, dated (MONTH) 22, (YEAR), at 2:44 p.m. indicated that the resident's right knee was swollen, she complained of increased pain and yelled out in pain when moved, and the physician was notified and an X-ray was ordered. An X-ray report of Resident 2's right femur (thigh bone), dated (MONTH) 22, (YEAR), revealed that there was a comminuted fracture (a break or splinter of the bone into two or more fragments, usually caused by a high impact trauma such as a fall or accident). The resident was transferred to the hospital for evaluation and treatment. Review of the information submitted by the facility, dated (MONTH) 23, (YEAR), at 1:30 p.m. revealed that Resident 2 was asked if she could recall what occurred to cause her knee to become swollen and painful. The resident stated, The other night on 3:00 p.m.-11:00 p.m., a man came into my room and tried to get me into bed himself. He went to pick me up under my arms, and when he stood me up, I fell down and ended up sitting on my leg. A review of the facility's investigative report regarding Resident 2's fracture, dated (MONTH) 26, (YEAR), revealed that security videos were reviewed and at no time on (MONTH) 18, (YEAR), did Nurse Aide 1 take a mechanical lift into the resident's room (to be used during transfers), and no other staff members were observed going into the resident's room to assist Nurse Aide 1 with transferring the resident into bed. A written statement by Nurse Aide 1, dated (MONTH) 27, (YEAR), acknowledged that on the evening of (MONTH) 18, (YEAR), he did not use a mechanical lift to transfer Resident 2 as care planned and ordered, but he transferred the resident by himself and she slipped out of his arms and fell to the floor. Interview with the Director of Nursing on (MONTH) 23, (YEAR), at 12:10 p.m. confirmed that on (MONTH) 18, (YEAR), Resident 2 was not transferred using a Hoyer lift and the assistance of two as care planned and ordered by the physician. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/5/17, 9/16/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/23/18, 3/29/18, 12/8/17, 7/5/17, 9/16/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/8/17, 11/16/17, 8/17/17, 7/5/17, 6/5/17, 2/16/17, 12/1/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/23/18, 12/8/17, 8/17/17, 2/16/17, 12/1/16, 9/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/23/18, 3/29/18, 12/8/17, 11/16/17, 11/2/17, 8/17/17, 7/5/17, 6/5/17, 3/27/17, 2/16/17, 12/30/16, 12/1/16, 9/16/16.

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used for one of two residents reviewed (Resident 2) who required the use of a mechanical lift for transfer, resulting in a fall with a fractured bone for the resident. Findings include: A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated (MONTH) 27, (YEAR), indicated that the resident was alert and oriented, did not ambulate (walk), and had range of motion deficits on both sides of her body. The resident's care plan and physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 18, (YEAR), at 10:23 p.m. indicated that Registered Nurse 2 was notified by Nurse Aide 1 at 9:45 p.m. that while doing range of motion (the range, measured in degrees of a circle, through which a joint can be extended and flexed) with the resident's evening care, her (right) leg got caught up with the left leg. The resident complained of mild right knee pain with extension of the right leg. A nursing note for Resident 2, dated (MONTH) 22, (YEAR), at 2:44 p.m. indicated that the resident's right knee was swollen, she complained of increased pain and yelled out in pain when moved, and the physician was notified and an X-ray was ordered. An X-ray report of Resident 2's right femur (thigh bone), dated (MONTH) 22, (YEAR), revealed that there was a comminuted fracture (a break or splinter of the bone into two or more fragments, usually caused by a high impact trauma such as a fall or accident). The resident was transferred to the hospital for evaluation and treatment. Review of the information submitted by the facility, dated (MONTH) 23, (YEAR), at 1:30 p.m. revealed that Resident 2 was asked if she could recall what occurred to cause her knee to become swollen and painful. The resident stated, The other night on 3:00 p.m.-11:00 p.m., a man came into my room and tried to get me into bed himself. He went to pick me up under my arms, and when he stood me up, I fell down and ended up sitting on my leg. A review of the facility's investigative report regarding Resident 2's fracture, dated (MONTH) 26, (YEAR), revealed that security videos were reviewed and at no time on (MONTH) 18, (YEAR), did Nurse Aide 1 take a mechanical lift into the resident's room (to be used during transfers), and no other staff members were observed going into the resident's room to assist Nurse Aide 1 with transferring the resident into bed. A written statement by Nurse Aide 1, dated (MONTH) 27, (YEAR), acknowledged that on the evening of (MONTH) 18, (YEAR), he did not use a mechanical lift to transfer Resident 2 as care planned and ordered, but he transferred the resident by himself and she slipped out of his arms and fell to the floor. Interview with the Director of Nursing on (MONTH) 23, (YEAR), at 12:10 p.m. confirmed that on (MONTH) 18, (YEAR), Resident 2 was not transferred using a Hoyer lift and the assistance of two as care planned and ordered by the physician. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 4/23/18, 11/2/17, 8/17/17, 3/27/17, 2/16/17, 12/30/16, 9/16/16. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/23/18, 3/29/18, 12/8/17, 7/5/17, 9/16/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/8/17, 11/16/17, 8/17/17, 7/5/17, 6/5/17, 2/16/17, 12/1/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/23/18, 12/8/17, 8/17/17, 2/16/17, 12/1/16, 9/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/23/18, 3/29/18, 12/8/17, 11/16/17, 11/2/17, 8/17/17, 7/5/17, 6/5/17, 3/27/17, 2/16/17, 12/30/16, 12/1/16, 9/16/16.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about abnormal laboratory test results upon receipt and about a change in a resident's condition for one of six residents reviewed (Resident R3), resulting in a delay in treatment for [REDACTED]. Findings include: A hospital discharge summary for Resident R3, dated October 18, 2016, revealed that prior to his admission to the hospital on October 9, 2016, the resident's white blood cell count (WBC) was 12.9 (normal value is 3.5-10.8 and an elevated count can indicate infection) and at that time he was diagnosed with [REDACTED]. A physician's progress note for Resident R3, dated October 19, 2016, revealed that the resident was readmitted to the facility from the hospital that day and a 10 day course of [MEDICATION NAME] (an antibiotic) was completed while the resident was in the hospital. physician's orders [REDACTED]. Laboratory test results for Resident R3, dated as received on October 20, 2016, at 9:53 a.m. revealed that the resident's WBC was elevated at 14.9. There was no documented evidence that the physician was notified about the abnormal test results when they were received. A physician's progress note for Resident R3, dated October 19, 2016, and nursing notes dated October 18, 2016, through October 21, 2016, at 1:44 a.m. indicated that the resident had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine) and that his urine was clear yellow. A nursing note, dated October 21, 2016, at 4:42 a.m. revealed that at 4:10 a.m. the resident was found with an extreme amount of bleeding around his catheter site with large clots noted, and he complained of pain in his abdominal area. A nursing note, dated October 21, 2016, at 4:30 a.m. indicated that the resident was assessed for gross hematuria (a large amount of blood in his urine), his catheter was irrigated for small and medium blood clots, and a note was placed for the doctor to see the resident. There was no documented evidence that the physician was notified about Resident R3's change in condition at the time it occurred, until the following shift (started at 7:00 a.m.) on October 21, 2016, at which time the physician indicated that he reviewed the test results and the resident had leukocytosis (an elevated WBC) and gross hematuria (blood in his urine) secondary to hemorrhagic [MEDICATION NAME] and UTI. The resident was then transferred to the hospital on October 21, 2016, at 9:00 a.m., approximately four hours and fifty minutes after the change in condition was noted. A hospital discharge summary, dated October 25, 2016, indicated that the resident's WBC upon admission to the hospital on October 21, 2016, was 20.8. He was admitted to the intensive care unit (ICU) with a [DIAGNOSES REDACTED]. The resident required a cystoscopy (procedure in which a tube with a camera is inserted through the urethra into the bladder) with evacuation of blood clots, and he had a UTI [MEDICAL CONDITION] (overwhelming immune response to infection) with septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Interview with Registered Nurse 2 on November 23, 2016, at 1:00 p.m. revealed that the physician should have been notified about Resident R3's abnormal laboratory test results on the day they were received. She confirmed that there was no documented evidence that the physician was notified on the day the results were received. Interview with the Director of Nursing on November 23, 2016, at 1:20 p.m. revealed that Resident R3's physician should have been notified at the time of the initial change in condition when the resident presented with gross hematuria and abdominal pain. She confirmed that there was no documented evidence that the physician was notified until the following shift. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/16/16, 7/10/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/16/16, 7/2/16, 2/17/16, 11/5/15, 7/10/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified timely regarding a significant change in condition for one of six residents reviewed (Resident R3), which resulted in a delay in treatment for [REDACTED]. Findings include: A hospital discharge summary for Resident R3, dated October 18, 2016, revealed that the resident was diagnosed with [REDACTED]. A physician's progress note for Resident R3, dated October 19, 2016, revealed that the resident was readmitted to the facility from the hospital that day and a 10-day course of [MEDICATION NAME] (an antibiotic) was completed while the resident was in the hospital. physician's orders [REDACTED]. Laboratory test results for Resident R3, dated as received on October 20, 2016, at 9:53 a.m. revealed that the resident's white blood cell count (WBC) result was elevated at 14.9 (normal levels are 3.5-10.8 and an elevated level can indicate infection). A physician's progress note for Resident R3, dated October 19, 2016, and nursing notes, dated October 18, 2016 through October 21, 2016, at 1:44 a.m. indicated that the resident had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine) and that his urine was clear yellow. A nursing note, dated October 21, 2016, at 4:42 a.m. revealed that at 4:10 a.m. the resident was found with an extreme amount of bleeding around his catheter site with large clots noted, and he complained of pain in his abdominal area. A nursing note, dated October 21, 2016, at 4:30 a.m. indicated that the resident was assessed for gross hematuria (a large amount of blood in his urine), his catheter was irrigated for small and medium blood clots, and a note was placed for the doctor to see the resident. There was no documented evidence that the physician was notified about Resident R3's change in condition at the time it occurred, and no evidence that the resident's condition was monitored until the following shift (started at 7:00 a.m.) on October 21, 2016, at which time the physician indicated that he reviewed the test results and the resident had leukocytosis (an elevated WBC) and gross hematuria (blood in his urine) secondary to hemorrhagic [MEDICATION NAME] and UTI. The resident was then transferred to the hospital on October 21, 2016, at 9:00 a.m., approximately four hours and fifty minutes after the change in condition was noted. A hospital discharge summary for Resident R3, dated October 25, 2016, indicated that the resident's WBC upon admission to the hospital on October 21, 2016, was 20.8. He was admitted to the intensive care unit (ICU) with a [DIAGNOSES REDACTED]. The resident required a cystoscopy (procedure in which a tube with a camera is inserted through the urethra into the bladder) with evacuation of blood clots, and he had an UTI [MEDICAL CONDITION] (overwhelming immune response to infection) with septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Interview with the Director of Nursing on November 23, 2016, at 1:20 p.m. revealed that Resident R3's physician should have been notified at the time of the initial change in condition when the resident presented with gross hematuria and abdominal pain. She confirmed that there was no documented evidence that the physician was notified until the following shift. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services For Highest Well Being. Previously cited 9/16/16, 7/10/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/16/16, 7/10/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/16/16, 7/2/16, 2/17/16, 11/5/15, 7/10/15.

Based on observations and staff interviews, as well as review of clinical records, it was determined that the facility failed to ensure that elevators were equipped with functioning emergency call systems for one of five elevators used by residents (Elevator 2), thus placing the safety of residents in Immediate Jeopardy. The facility also failed to ensure that one additional elevator used by residents (Elevator 4) was equipped with effective emergency call systems; failed to ensure that the residents' environment remained free of accident hazards, from the use of side rails for one of 55 residents reviewed (Resident R6); failed to ensure that fall prevention interventions were in place, as ordered by the physician for one of 55 residents reviewed (Resident R13); and failed to maintain a hazard-free environment in three of nine shower rooms. Findings include: Observations on July 6, 2015, at 2:45 p.m., revealed that a surveyor was in Elevator 2 on the C-Wing, when the car stopped between the first and ground floors. When the surveyor pushed the emergency alarm button, it did not sound; and when the emergency phone was picked up, it did not connect with anyone. The surveyor then used a personal cell phone to call for assistance and was in the elevator car until 2:55 p.m. Testing of the air temperature in the elevator car, while the surveyor was in it, revealed that it was 86.6 degrees Fahrenheit. Observations on July 7, 2015, at 3:40 p.m., revealed that Elevator 2, which had been taken out of service following the above incident, was placed back in service. Interview with the Director of Maintenance on July 7, 2015, at 3:50 p.m., revealed that the mechanical function of Elevator 2 was checked by an elevator technician; however, Elevator 2 still did not have a working emergency alarm or phone. He indicated that the elevator technician was not responsible for checking the function of the emergency alarm and phone, only the elevator's mechanical function. He did not know how long the emergency alarm systems were inoperable for Elevator 2, when the emergency alarm and phone were last checked, or who was responsible for checking them. On July 7, 2015, at 4:20 p.m., the Nursing Home Administrator was informed that the safety of residents was in Immediate Jeopardy due to the facility's failure to ensure that Elevator 2, which was in service and used by residents, was equipped with working emergency call systems. The facility submitted and implemented a plan to ensure residents' safety by manning Elevator 2 with a staff person carrying a cell phone until the elevator's phone and/or alarm systems could be repaired. The Immediate Jeopardy was removed during an on-site visit on July 8, 2015, at 5:15 p.m., following the installation of an emergency phone in Elevator 2. Observations on July 7, 2015, at 3:10 p.m., revealed that Elevator 4 on the C-Wing had an emergency alarm that was faint and could not be heard past eight feet from the elevator, and the elevator car was not equipped with an emergency phone. Interview with the Director of Maintenance on July 7, 2015, at 3:10 p.m., confirmed that Elevator 4 was not equipped with an emergency phone and the emergency alarm was faint and was audible only within six to eight feet of the elevator. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 11, 2015, for Resident R6, indicated that the resident was confused, required extensive assistance of staff for bed mobility, and had a history of [REDACTED]. The incident report indicated that the resident had mild [DIAGNOSES REDACTED] (redness) to both thighs where her legs were resting on the quarter-length side rails. Following this incident, there was no documented evidence that the continued use of the side rails was assessed as a possible safety hazard for the resident. A side rail assessment form, dated September 23, 2014, indicated that Resident R6 could not walk, had a history of [REDACTED]. The recommendation was for the resident to have assist rails (smaller rails positioned at the head of the bed to aide in repositioning) on the bed; however there was no evidence that assist rails were placed on the bed as recommended. Also there was no documented evidence that the use of the side rails, which were positioned in the middle of the bed, were assessed to determine if they posed a safety hazard for the resident. A nursing note and incident report, dated November 9, 2014, indicated that Resident R6 was found on the floor, next to her bed, on the landing strip (fall mat). The incident report indicated that side rails were in place on the bed at the time of the incident. Following this fall out of bed, there was no documented evidence that the continued use of the side rails was assessed as a possible safety hazard for the resident. Observations on July 6, 2015, at 5:25 p.m., revealed that Resident R6 was in a bed that was equipped with side rails on both sides, which were positioned in the middle of the bed. Interview with the Director of Nursing on July 7, 2015, at 1:55 p.m., confirmed that potential safety hazards created by the use of side rails for Resident R6 were not assessed. A nursing note, dated October 9, 2014, revealed that Resident R13 fell on [DATE], September 3, and October 4, 2014; and a progress note, dated October 10, 2014, revealed that the resident was being prepared for a room change. physician's orders [REDACTED]. was to be equipped with non-skid strips on the floor, on both sides of his bed. Observations on July 7, 2015, at 10:35 a.m.; July 8, 2015, at 11:00 a.m.; and July 9, 2015, at 1:50 p.m., revealed that non-skid strips were applied to the floor between the resident's bed and his roommate's bed; however, there were no non-skid strips between the resident's bed and the window. Interview with Registered Nurse 1 on July 9, 2015, at 2:15 p.m., confirmed that the resident was ordered to have non-skid strips on the floor on both sides of the bed. He indicated that the non-skid strips were present on both sides of the bed, in the resident's previous room and they may not have been applied to the floor in the resident's new room. Interview with the Director of Nursing on July 10, 2015, at 2:15 p.m., confirmed that there was no evidence that the maintenance department was notified to place the non-skid strips on the floor in the resident's new room. Observations in the A-2 shower room on July 6, 2015, at 1:23 p.m., revealed that there was an unsecured bottle of nail polish remover, containing acetone, in the room. Interview with Registered Nurse 18 on July 6, 2015, at 1:25 p.m., confirmed that the bottle of nail polish remover should have been secured and should not have been accessible to residents. Observations in the shower room on the 4B unit on July 7, 2015, at 10:07 a.m., and July 8, 2015, at 10:03 a.m., revealed that there was an unsecured container of Clorox wipes on the counter. The label on the container of wipes included a warning stating, Don't get in eyes or on clothing. Wear protective eye gear. Interview with Nurse Aide 19 on July 8, 2015, at 10:05 a.m., confirmed that the wipes should have been put away, out of residents' reach. Interview with the Director of Nursing on July 10, 2015, at 2:20 p.m., confirmed that the Clorox bleach wipes should have been secured and should not have been accessible to residents. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/7/14. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 8/7/14. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/7/14, 9/26/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/7/14.