Every finding on record at Whitestone Care Center

Based on select facility policy, observations, a review of clinical records, and staff interview, the facility failed to ensure information was communicated in a language understood by Spanish speaking residents for two out of eight residents reviewed with limited English proficiency (LEP) (Resident 5 and Resident 7).Findings include: The Centers for Medicare and Medicaid (CMS), The National Culturally and Linguistically Appropriate Services ([NAME]), Standards in Long Term Care Settings, indicated nursing homes should provide [NAME] for all residents as effective communication may improve the quality of life and health outcomes for nursing home residents. The guidelines reveal facilities should provide signs and handouts in the language used by the nursing home resident. A review of the facility policy entitled Communicating with Persons Limited English Proficiency last reviewed June 6, 2026 indicated the facility will take reasonable steps to ensure that persons with LEP (resident does not speak, read, write, or understand English well enough to fully participate in everyday conversations, work situations, or services without help) have meaningful access and an equal opportunity to participate in services, activities, programs, and other benefits. The purpose of the policy is to support meaningful communication with LEP residents and their representatives of medical conditions and treatment. A clinical record review revealed Resident 5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke in the left side of your brain, which caused paralysis or weakness on your right side). A review of Resident 5's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 26, 2026, revealed that Resident 5 experienced moderate cognitive impairment with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 means suggests the individual has some cognitive challenges, particularly with short-term memory or orientation, but still retains partial function). Additionally it was indicated on the MDS Resident 5 is [NAME] Rican, prefers Spanish, and requests an interpreter for communication with healthcare staff. A review of the resident's clinical record revealed a care plan-initiated September 7, 2024, noting Resident 5 speaks Spanish, uses a communication board for basic needs, is paired with bilingual peers for activity engagement, and receives translation support from Spanish speaking staff. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included arterial embolism and thrombosis of abdominal aorta (serious blockages in the body's main artery-the abdominal aorta-which carries blood from the heart to the stomach, organs, and legs). A review of Resident 7's quarterly MDS dated [DATE], revealed Resident 7 experiences severe cognitive impairment with a BIMS score of 7 (a score of 0-7 means severe difficulties with memory, orientation, and short-term recall and has substantial challenges remembering basic information such as the current date, recent words, and other everyday details) Further review of the MDS indicated the resident is Hispanic/[NAME] and prefers Spanish. A review of the resident's clinical record revealed a communication care plan initiated September 10, 2024, noting the resident speaks Spanish. The resident was noted to have an activities care plan, initiated April 18, 2024, which indicted she enjoys Spanish language TV and interacting with her family and Spanish speaking peers. The care plan also noted she was to be provided with a Spanish communication board to assist with identifying simple commands and needs. On September 2, 2026, at 9:00 AM and again at 1:58 PM, observations during a facility tour showed that the resident rights signage in the rooms of Residents 5 and 7 was posted only in English. No Spanish versions or instructions on how to obtain language assistance were available. Resident 7's room also displayed a fall prevention sign in English reminding Resident 7 to call for help. During an interview with Employee 1 Nurse Aide (NA) on September 2, 2026 at 9:04 AM, it was confirmed Resident 7's understanding of English is limited. During an interview on September 2, 2026, at 1:58 PM with Resident 5's daughter, it was confirmed Resident 5 does not understand written or spoken English language. During an interview on September 2, 2026, at 2:10 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to provide residents information in one's preferred language. 28 Pa Code 201.29 (a) Resident Rights. 28 Pa Code 210.11 (c) Resident Care Policies.

Based on the facility's abuse prohibition policy, select investigative reports, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not utilizing proper level of staff assistance when providing care as planned to ensure safety and prevent feeding tube dislodgement, for one resident, (Resident 3), out of 18 sampled residents.Findings included: Review of the facility's policy entitled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation Prevention last reviewed by the facility June 5, 2026, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included hypoxic encephalopathy (brain dysfunction caused by insufficient oxygen supply to the brain, often leading to injury that can range from mild impairment to severe, permanent damage),dysphagia (difficulty swallowing), aphagia (loss of the ability to swallow) after cerebrovascular disease (includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation and the arteries supplying oxygen and nutrients to the brain are often damaged or deformed in these disorders), and Alzheimer's disease (is a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia). Resident 3 required a PEG tube (Percutaneous Endoscopic Gastrostomy tube is a feeding tube inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medications when oral intake is insufficient or unsafe) due to inability to safely tolerate foods/fluids by mouth related to dysphagia and severe cognitive impairment. All of the resident's medications, fluids, and enteral feedings were required to be administered via PEG tube to maintain status. A review of the resident's quarterly Minimum Data Set (MDS is a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 16, 2026, revealed the resident had severe cognitive impairment. Resident 3's care plan initiated on April 15, 2024, indicated the resident had ADL (activities of daily living) deficits due to comorbidities such as stroke, encephalopathy, and impair ROM (range of motion) upper right and left extremities with a goal to reach maximum potential with ADLs. Planned approaches to achieve goals included to provide assistance with two staff members for bathing, dressing/grooming, toileting, and bed mobility. The plan of care also indicated Resident 3 required a feeding tube related to NPO (nothing by mouth) and at risk for aspiration with a goal to exhibit no signs of complications or enteral feeding solution. A review of an investigative report provided by the facility completed by Employee 8, a Registered Nurse (RN), dated June 15, 2026, at 5:45 AM indicated staff was called to the resident's room about PEG tube dislodgement (means that an object, device, or part of the body has been moved or removed from its original fixed position). The physician and RR (resident representative) were notified, and the resident was sent to hospital for peg tube reinsertion. A review of a witness statement completed by Employee 4, a Licensed Practical Nurse (LPN), dated June 15, 2026, indicated the employee was informed by Employee 9, an agency Nurse Aide (NA), that Resident 3's PEG tube came out. A review of a witness statement completed by Employee 9, agency NA, dated June 15, 2026, revealed the employee checked in on Resident 3 at 5:45 AM and noticed the PEG tube was out of the resident's stomach. Further review of investigative reports revealed on June 16, 2026, the Director of Nursing (DON) conducted a telephone interview with Employee 9 due to the unknown origin of Resident 3's PEG tube dislodgement. Employee 9 reported at that time the she independently provided care to Resident 3 during the 11P-7A shift despite the resident requiring two assist with all ADL care. Employee 9 reported, I understand about following the plan of care for a resident however I felt like I had to do it by myself, the nurse was busy assisting other people. The facility's abuse/neglect investigation was completed by the Director of Nursing on June 16, 2026, at 9:00 AM. It concluded that Employee 9, an agency NA, did not provide the required assistance of two staff members while caring for Resident 3, as specified in the care plan. This oversight led to the dislodgment of the PEG tube, necessitating a hospital transfer for reinsertion. Employee 9's employment at the facility was terminated due to non-compliance with the resident's care plan. The facility failed to ensure staff provided the necessary assistance of two staff members while caring for Resident 3, as outlined in the care plan. This oversight resulted in the dislodgment of the PEG tube, leading to a hospital transfer for reinsertion. On September 2, 2026, at 1:39 PM, an interview was conducted with the Nursing Home Administrator (NHA) to review the findings. It was acknowledged that Employee 9 did not ensure the presence of two staff members when providing care to Resident 3. This deficiency is cited as past non-compliance. Immediately after the incident, Resident 3 (affected resident) was assessed and sent to the hospital due to PEG tube dislodgement and to have the tube reinserted. The resident returned from the hospital on June 15, 2026, at 6:58 PM. Upon further investigation, it was noted that the NA did not follow the resident's plan of care resulting in neglect/abuse allegation. Skin sweeps/assessments were completed on all residents with a Brief Interview for Mental Status (BIMS is a tool used to evaluate cognitive impairment and assist with dementia diagnosis and the score ranges from 0 to 15, with higher scores indicating better cognitive function: 13-15 is normal, 8-12 indicates moderate impairment, and 0-7 indicates severe cognitive impairment) score of 12 or lower with no negative findings identified. Additionally, care concern questionnaires were completed with all cognitively intact residents with no negative outcomes/findings identified. To prevent occurrence or recurrence, the facility provided re-education to all direct care workers regarding the facility's abuse and neglect policy, with a specific focus on the importance of adhering to residents' plans of care to avoid neglect. To ensure continuous compliance, the Director of Nursing or a designated representative will choose five staff members to respond to questions about the facility's abuse and neglect policy. They will also conduct skin assessments on five cognitively impaired residents and complete five care questionnaires with cognitively intact residents on a weekly basis for four weeks and monthly for two months. The NHA or designee will examine incidents to confirm that the facility's abuse policy is being adhered to. The QAA committee will assess all investigations of abuse or neglect to decide if further follow-up is necessary. The facility's immediate corrective action plan was completed June 16, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 211.10 (a)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Service.

Based on select facility policy, clinical record review, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and competencies for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for one of 18 residents reviewed (Resident 5).Findings include: A review of Pennsylvania Code Title 49, Professional and Vocational Standards, Department of State, State Board of Nursing, S21.145 Functions of the Licensed Practical Nurse (LPN) indicate the LPN functions as a member of the health care team and administers medications and therapeutic treatments in accordance with established standards of safe nursing practice. Section 21.145(b) IV therapy curriculum requirements indicate an LPN may perform IV therapy functions only when the LPN has completed the required education and training and possesses the knowledge, skill, and ability to perform the procedure safely, and only under appropriate direction and supervision of a licensed professional nurse or other authorized health care provider. Permitted IV therapy functions include administration of IV medications and fluids, monitoring of the IV site, maintenance of IV access devices, and recognition and reporting of adverse reactions. Review of the facility policy entitled Administration of an Intermittent Infusion last reviewed June 6, 2026, indicated intermittent infusion of medications will be performed by licensed nurses according to state law and facility improvement. The policy further revealed the nurse are responsible and accountable for obtaining and maintaining competence with infusion therapy within one's scope of practice and competency validation is documented. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke in the left side of your brain, which caused paralysis or weakness on your right side). A review of physician orders revealed an order dated June 9, 2026, for Ampicillin Sodium (an antibiotic medication used to treat serious bacterial infections) 2 gram (gm) intravenously every eight hours via PICC line (a thin, flexible tube put into a vein in your arm and guided to a large vein near your heart) for treatment of an infection related to a medical device. Review of the June 2026 Medication Administration Record revealed the Ampicillin Sodium IV was administered by Employee 2 (LPN) on June 11, 12, 13, 20, 21, 22, 25, and 26, 2026 The IV was administered by Employee 3 (LPN) on June 15, 2026. The IV was adminitsterd by Employee 4 (LPN) on June 28, 2026. Review of the July 2026 Medication Administration Record revealed the Ampicillin Sodium IV was administered by by Employee 3 on July 11, and July 15, 2026. The IV was administered by Employee 4 on July 2, 3, 7, 8, and 13, 2026. The facility failed to produce evidence that Employees 2, 3, and 4 completed IV therapy education and training consistent with the requirements of Pennsylvania Code Title 49 S21.145(b). The facility was unable to provide documentation of competency validation (process used to confirm staff have demonstrated the ability to safely perform a clinical skill), supervision documentation, or evidence of training specific to administration of IV medications through a PICC line. During an interview conducted on September 2, 2026, at 11:09 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of the above findings of the facility's failure to provide documentation demonstrating the above LPNs completed the required IV therapy education or competency validation necessary to administer IV medications through a PICC line. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for one resident of 18 residents reviewed (Residents 5). Findings include: According to the Infusion Nurses Society (INS) (2024), Infusion Therapy Standards of Practice, the baseline circumference of an extremity with an intravenous catheter is measured upon insertion, noting location for future measurements to ensure consistent measurement. Facilities should assess circumference when edema or signs and symptoms of deep vein thrombosis (DVT) present, noting the location and characteristics of edema. A review of the facility policy entitled General Dose Preparation and Medication Administration, last reviewed on June 6, 2026, revealed medications are administered in a safe, timely manner, and documentation of administration occurs after medication administration in the medication administration record (MAR). A clinical record review revealed Resident 5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke in the left side of your brain, which caused paralysis or weakness on your right side). A review of Resident 5's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 26, 2026, revealed that Resident 5 experienced moderate cognitive impairment with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 means suggests the individual has some cognitive challenges, particularly with short-term memory or orientation, but still retains partial function). A review of hospital documentation revealed written communication dated June 8, 2026, to the facility confirmed Resident 5 had a single lumen, 4 Fr, 40-centimeter (cm) catheter placed into the left cephalic vein (small, flexible tube was put into the left arm so medicines/ fluids can be given, stays in the arm for a longer time than a regular intravenous insertion site). The left arm circumference was 31 cm. A physician's order dated June 9, 2026, indicated staff were to measure the exposed length of catheter and the left arm circumference weekly with the dressing change. A physician's order dated June 16, 2026, revealed Resident 5's was to receive Ampicillin Sodium 2 gram (gm) intravenously (commonly used penicillin-type antibiotic given through a vein to treat serious bacterial infections) every eight hours. A review of Resident 5's June 2026 MAR indicated that on the following dates there was no documented evidence Ampicillin Sodium IV was administered: June 19, 2026 at 12:00 MNJune 19, 2026 at 08:00 AMJune 24, 2026 at 08:00 AM Further review of the June 2026 MAR revealed no documentation the facility staff completed catheter measurements or arm circumference measurements on June 16, 2026. A review of Resident 5's July 2026 MAR indicated that on the following dates there was no documented evidence Ampicillin Sodium IV was administered: July 3, 2026 at 08:00 AM, July 5, 2026 at 08:00 AM,July 6, 2026 at 08:00 AM,July 12, 2026 at 08:00 AM, July 15, 2026 at 08:00 AM. Further review of the July 2026 MAR revealed no documentation the facility staff completed catheter measurements or arm circumference measurements on July 7, 2026, and July 14, 2026. Failure to measure the catheter length and arm circumference as ordered limited the facility's ability to identify potential catheter displacement (movement out of proper position) in a timely manner, placing residents at risk for complications. During an interview on September 3, 2026, at 2:30 PM, Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged the facility failed to provide IV therapy in accordance with physician orders and professional standards of practice 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on select facility policy, a review of controlled drug shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records one of three medication carts observed.Findings include: A review of facility policy entitled Inventory Control of Controlled Substances last reviewed June 5, 2026, revealed the facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with risk of abuse or diversions at the change of each shift at the change of each shift. A review of the facility Shift Verification of a Controlled Substance Book from the First-Floor nursing unit Rooms 101-113 Medication cart on September 2,2026, at 9:01 AM revealed the following:July 14, 2026, the evening shift off going nurse failed to sign that the narcotic count was completed and correct.August 22,2026, the dayshift off going nurse failed to sign that the narcotic count was completed and correct.September 1, 2026, the night shift oncoming and off going nurse failed to sign that the narcotic count was complete and correct.September 1, 2026, the night shift off going nurse failed to sign that the narcotic count was completed and correctSeptember 2,2026, the dayshift oncoming nurse failed to sign that the narcotic count was completed and correct. An interview with Employee 7 LPN (Licensed Practical Nurse) on September 2, 2026, at 9:05 AM confirmed the Shift Verification of a Controlled Substance Book for First-Floor nursing unit Rooms 101-113 Medication cart was not signed by the incoming nurse on the identified date. An interview was conducted on September 2, 2026, at 11:30 AM with Director of Nursing (DON) and the Nursing Home Administrator (NHA) to review the above findings related to the facility's failure to demonstrate consistent implementation of procedures for promoting accurate controlled drug records. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa Code 211.9 (c)(k) Pharmacy services. 28 Pa Code 211.5(f)(x) Clinical records. 28 Pa. Code 211.10(a) Resident Care Policies.

Based on a review of clinical records and staff interview, it was determined that the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one resident out of 18 residents reviewed (Resident 59). Findings include: A review of the clinical record revealed Resident 59 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and Alzheimer's dementia (a generally progressive disorder that is a type of brain disorder that causes problems with memory, thinking and behavior). A review of physician's orders dated July 1, 2026, revealed an order for Vraylar (an atypical antipsychotic medication used to treat bipolar disorder, major depressive disorder, as an add-on therapy, and schizophrenia but not approved for use in patients with dementia-related psychosis, including Alzheimer's disease, due to a significantly increased risk of death) capsule 1.5 milligrams (mg), give one oral for diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. A review of a consultation report completed by the facility's consultant pharmacist (PharmD) on July 2, 2026, revealed Resident 59 received an antipsychotics medication, Vryalar, without documentation of diagnosis and adequate indication for use in the medical record. If the antipsychotic medication was to continue, the PharmD's recommended to include the specific diagnosis/indication requiring treatment that is based upon an assessment of the resident's condition and therapeutic goals. The physician's response (no date and time indicate) to the above recommendation was defer to psych. At the time of survey beginning September 1, 2026, and ending September 3, 2026, the facility could not provide documented evidence of the facility's contracted psychiatric services performing an evaluation. The facility failed to ensure that Resident 59's attending physician provided clinical justification for the ongoing use of the antipsychotic, Vryalar, for a resident diagnosed with Alzheimer's. Additionally, the facility failed to ensure that contracted psychiatric services conducted an evaluation or review of the resident as noted by the attending physician. On September 3, 2026, at 12:15 PM, during an interview with the Director of Nursing (DON), the findings were reviewed. It was confirmed that the facility's contracted psychiatric consultant did not conduct an evaluation and that the physician did not offer a satisfactory clinical rationale for the continued use of the antipsychotic, Vrylar. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director.

Based on review of select facility policy, observations, and staff interview it was determined the facility failed to ensure that biologicals were stored within the expiration date in one of two medication storage areas.Findings include:Review of the facility policy entitled Storage and Expiration Dating of Medications and Biologicals last reviewed [DATE], stated the facility will store medications and biologicals that have an expired date on the label and have not been retained longer than recommended by manufacturer or supplier guidelines. An observation of the medication storage room located on the second floor nursing unit on [DATE], at 11:24 AM in the presence of Employee 1 LPN (license practical nurse) revealed one sterile dressing change kit which expired on [DATE] and four sterile dressing kits which expired on [DATE].An interview with the Nursing Home Administrator on [DATE], at 2:00 PM acknowledged the above findings that the biologicals were not maintained within the expiration dates. 28 Pa Code 211.12(d)(1) Nursing services.28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) for two of 30 residents sampled (Resident 4 and Resident 11).Findings include:The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the MDS dated [DATE], requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.A clinical records review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses including Hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (death of brain tissue caused by a lack of blood flow) affecting right dominant side. A quarterly MDS dated [DATE], revealed section GG-0115 (section related to functional abilities, the ability to perform tasks and activities necessary for daily living) indicated Resident 4 experienced no impairment in range of motion (ROM) (referring to the full movement of a joint or series of joints, measured in degrees) for upper and lower extremities. An observation of Resident 4 on December 4, 2025, at 8:50 AM revealed Resident 4's right upper extremity (including arm, wrist, and fingers) to be in a flexed (bent) position, close to Resident 4's upper body. Further observation of Resident 4 reveled the resident did not move her right upper extremity and used only her left upper extremity for all aspects of daily living, including moving her wheelchair.An interview with the Registered Nurse Assessment Coordinator (RNAC) on December 4, 2025, at 1:12 PM revealed the RNAC acknowledged the quarterly MDS did not accurately reflect the limited range of motion of the right upper extremity for Resident 4. A review of Resident 11's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (a break in the bone) of third lumbar vertebra (bone in the lower spine), subsequent encounter for fracture with routine healing.A review of the resident's progress notes indicate Resident 11 was admitted from the acute care facility, after a fall at home with L3 Burst Fracture (a severe spinal injury where the third lumbar vertebra shatters from extreme force) The admission MDS dated [DATE], revealed section J (section addressing fall history), question J1700 Fall History on Admission/ Entry or Reentry indicated Resident 11 did not have any fracture related to a fall in the six months prior to admission/ entry or reentry despite the resident having a fall at home resulting in a fracture. An interview with the RNAC on December 4, 2025, at 2:00 PM, revealed the RNAC acknowledged the admission MDS did not accurately reflect the fall with fracture prior to admission. 28 Pa. Code 211.5(f)(iii) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policy, controlled drug shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records on one of two medication carts observed.Findings include: A review of a facility policy entitled Inventory Control of Controlled Substances last reviewed April 24, 2025, revealed the facility should ensure the incoming and outgoing nurses count all Schedule II controlled substances (medications with a high potential for abuse, but it has a currently accepted medical use in the U.S. or a currently accepted medical use with severe restrictions) and any medications with potential for abuse or diversion at the change of each shift. A review of the facility Shift verification of Controlled Substance Count form for the first-floor A hall Nursing Unit medication cart revealed the following:July 28, 2025, the evening shift outgoing nurse failed to sign that the narcotic count was completed and correct.August 9, 2025, the day shift outgoing nurse failed to sign that the narcotic count was completed and correct.September 17, 2025, the day shift outgoing nurse failed to sign that the narcotic count was completed and correct.September 23, 2025, the day shift outgoing nurse failed to sign that the narcotic count was completed and correct.September 24,2025 the evening shift outgoing nurse failed to sign that the narcotic count was completed and correct.November 11,2025 the day shift outgoing nurse failed to sign that the narcotic count was completed and correct. An interview with Employee 2 RN (Registered Nurse) on December 4, 2025, at 9:00 AM confirmed the narcotic sheet for the first-floor A hall nursing unit medication cart was not signed off by the outgoing nurses on the above dates identified. An interview was conducted on December 4, 2025, at 11:00 AM, with the Nursing Home Administrator (NHA) to review the above findings related to the facility's failure to demonstrate consistent implementation of procedures for promoting accurate controlled drug records. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service 28 Pa Code 211.9 (c)(k) Pharmacy services 28 Pa Code 211.5(f)(x) Clinical records 28 Pa. Code 211.10(a) Resident Care Policies

Based on observation, clinical record review, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address skin integrity needs for one out of 20 residents sampled (Resident 69).Findings include: A clinical record review revealed Resident 69 was admitted to the facility on [DATE], with diagnoses which included Depression (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time.) and anxiety (a feeling of fear, dread, and uneasiness). A review of a Psychiatry progress note dated April 30, 2025, revealed the resident had a diagnosis of excoriation (skin picking disorder). The resident was experiencing increased skin picking related to anxiety. Further it was revealed the resident was embarrassed about the condition and covered her scars and open areas on her forehead with a mask or Band-Aid. The progress note recommended for staff to utilize non-pharmacologic interventions, supportive care, and redirection as needed. A review of the progress notes from April 2025 to December 2025, revealed the resident continued to have episodes of skin picking throughout the stay. A review of the resident's clinical record revealed no documented evidence the facility developed and implemented a person centered care plan to reflect Resident 69's skin integrity related to her skin picking disorder. The care plan failed to identify tools/nonpharmacological interventions for staff to attempt to prevent further occurrence of skin picking. During an interview on December 4, 2025, at 11:00 AM, the Director of Nursing and the Surveyor reviewed the above findings of skin integrity related to her anxiety disorder and confirmed Resident 69's comprehensive person-centered care plan did not reflect the resident's skin integrity needs. 28 Pa Code 211.12 (d)(1)(3) Nursing services.

Based on a review of clinical records, the facility's abuse prohibition policy, select investigative reports and staff interview, it was determined the facility failed to ensure the provision of care and services necessary to avoid physical harm and maintain the physical health of one resident out of two sampled (Resident 18) resulting in a serious injury, a fractured femur (thigh bone). This deficiency is cited as past non-compliance. Findings include: A review of the facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect and Exploitation last reviewed by the facility on April 24, 2025, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), history of falling, and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2025, revealed that Resident 18 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment), required total staff assistance for activities of daily living (ADLs), bed mobility and transfers. A review of the resident's Point of Care information dated August 18, 2024, (POC- a nursing information system used to obtain specific care information for each resident) revealed the resident required assistance of two staff members for bed mobility and bathing, and that the bed should be kept in the lowest position for safety. A review of Resident 18's care plan dated August 19, 2024, revealed a problem area in the category of ADLs with a goal to maintain maximum potential with ADLs. Interventions included the use of a left enabler bar (small siderail attached to the bed) to aide with repositioning, two staff for all bed mobility and bathing and toileting, and Hoyer lift (mechanical device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) transfers with two staff. Continued review of the care plan revealed a problem area in the category of falls with a goal for the resident to remain free from injury. Fall prevention interventions included bed in lowest position, bilateral bolsters, clutter-free environment, call light within reach, encourage resident to spend time in common area, and ensure accessible frequently used items. A nurse's progress note dated April 10, 2025, at 8:51 PM indicated that the resident was found lying on her left side on the floor. The floor was dry, the room was well lit, and the resident was unable to state what occurred. No visible injury was noted at the time. The physician and responsible party were notified. An IDT (Interdisciplinary Team) note dated April 11, 2025, at 11:10 AM, but recorded as a late entry on April 15, 2025, at 6:31 PM documented the resident had an unwitnessed fall out of bed. Employee 1, a nurse aide stated she was preparing to perform care on resident and left the bedside to retrieve a washcloth from the bathroom while the resident's bed was in an elevated position. Upon returning, the aide found the resident on the floor. The resident fell off the left side of the bed between bed and wall. She was found with her left side against the bed holding onto the enabler bar and sitting on her knees with legs bent under her. She was facing the back wall with her right side towards the window. She was leaning into the bed. The nurse called code apple (code called when there is a fall). This registered nurse (RN) was in hall and came into room to assess the resident. The resident showed no signs or symptoms of pain or discomfort. Neurological assessment was within normal limits and no noted injury. She was assisted to floor by two staff to position her onto Hoyer pad. RN supervisor came in at this time and assessed resident before she was lifted via Hoyer back into bed. RN supervisor did not note any injury either. Nurse aide was educated to follow plan of care and never to leave a resident unattended in an elevated bed. Resident was provided PM care by 2 staff after being put back into bed. Neuro checks were continued as per protocol. A nurse note dated April 13, 2025, at 6:23 PM revealed the resident had swelling of the right knee. No complaints or signs/symptoms of pain were documented. The physician was notified, and an x-ray was ordered. A physician note dated April 14, 2025, at 10:58 AM documented that the resident's x-ray confirmed a right femur fracture, and the physician ordered transfer to the emergency room for further evaluation. A review of the hospital CT scan report dated April 14, 2025, at 7:40 PM revealed a displaced and overlapping comminuted distal fracture of the right femur (a severe break where the bone shatters into multiple pieces and the fragments are misaligned; commonly resulting from high-impact trauma). A witness statement dated April 10, 2025, by Employee 1, nurse aide confirmed the resident's bed was raised, and while waiting for another staff member to assist her, she went into the bathroom to get a washcloth. The resident was found on the floor when the aide returned. She immediately notified the nurse. A review of a witness statement dated April 10, 2025, (no time indicated) provided by the Director of Nursing (DON), revealed that upon entering Resident 18's room she observed the resident on the floor sitting on her knees with her legs folded underneath her. She was facing the wall with her right side to the window and holding onto the enabler bar on the side of the bed. The bed was in a high position and Employee 1 stated she walked away for a second to get a washcloth in the bathroom and came back to the resident on the floor. The resident was placed on her left side with a pillow under her head while the RN assessed her, and vital signs were taken. No signs or symptoms of injury or pain noted. The resident was lifted off the floor via a Hoyer lift and placed back in bed. PM care provided by two nurse aides. Employee 1 was educated never walk away from a resident when the bed is not in the lowest position, and Employee 1 voiced understanding. Review of the facility submitted PB-22 report (report form for the investigation of alleged abuse, neglect, misappropriation of property) dated April 15, 2025, documented that Employee 1 failed to follow the resident's plan of care and left the bedside with the bed in an elevated position, resulting in the fall. The facility substantiated neglect of Resident 18. Employee 1 was terminated. During an interview on April 29, 2025, at 11:00 AM, the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that Resident 18 received the services necessary to prevent a fall and avoid physical harm. The NHA confirmed that Employee 1 failed to follow the plan of care and left the resident unattended with the bed elevated, which directly resulted in the fall and subsequent femur fracture. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. On April 10, 2025, at 8:15 PM, resident had an unwitnessed fall. On April 13, 2025, during routine post fall follow-up, the resident was noted to have a red and swollen right knee. The MD and RP were notified, and an x-ray was ordered. On April 14, 2025, an x-ray was performed, and the resident was noted to have a broken femur. The MD and RP were notified with a new order to send to the ER for evaluation. 2. To identify like residents that have potential to be affected the licensed nurses completed skin check on all incapable residents with a BIMS of 11-0 to ensure there are no s/s injuries of unknown origin which could represent abuse. To identify like residents that have the potential to be affected, the IDT/designee completed interviews with capable residents with a BIMS of 12-15. Interviews related to anyone providing care and elevating their bed and walking away. Has anyone ever left your bed elevated, and you felt unsafe? Do the residents feel safe? 3. To prevent this from happening again the IDT/designee will educate their employees on the abuse/neglect policy and following the plan of care. 4. To monitor and maintain ongoing compliance, the DON/designee will complete body audits on 5 random residents that are incapable with a BIMS of 11-0 weekly x 4, then monthly to ensure there are no s/s of injuries of unknown origin which could represent abuse. To monitor and maintain ongoing compliance, the IDT/designee will interview 5 capable residents with a BIMS of 12-15 weekly x 4, then monthly x 2 to ensure an interview is completed related to anyone hurting them, fallen and anyone pick you up without a nurse assessment, and do they feel safe? The facility's compliance date was April 15, 2025, and completion of corrective action plan noted above was confirmed during the survey ending April 29, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 20 sampled (Resident 74). Findings included: A review of Resident 74's clinical record revealed the resident was admitted to the facility on [DATE], and discharged from the facility on November 15, 2024. A review of Resident 74's Discharge MDS assessment dated [DATE], revealed in Section A 2105 Discharge Status that Resident 74 was discharged to a short-term general hospital. A review of a discharge nurses note dated November 15, 2024, at 5:38 PM revealed the resident was discharged home on November 15, 2024, with her son. An interview with the director of nursing on January 30, 2025, at approximately 9:30 AM confirmed the resident's MDS Assessment was inaccurate. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, the facility failed to promptly provide laboratory results to the ordering practitioner for one out of the 20 residents sampled (Resident 1). Findings include: A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A review of a significant change in status Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2025, revealed that Resident 1 is moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition moderately impaired). A physician progress note dated January 8, 2025, at 11:37 AM documented Resident 1 was seen for increased diarrhea. which had worsened over the past 7-10 days. The resident also indicated she had been slightly nauseated and has had some pressure in her lower abdominal area. The note indicated facility nursing staff confirmed Resident 1's complaints of diarrhea. A progress note from the same day at 7:38 PM indicated a new order for Lomotil 5 mg every six hours for three days and a laboratory panel, including a complete blood count (CBC-complete blood count, CMP-comprehensive metabolic panel, MAG-magnesium blood test). A physician's order for Resident 1 to have CBC, CMP, and MAG twice a day (3:00 PM to 11:00 PM; 11:00 PM to 7:00 AM) was initiated on January 8, 2025, at 7:34 PM. A clinical laboratory report indicated Resident 1's sample for CBC, CMP, and MAG was collected on January 9, 2025, at 6:43 AM and reported back to the facility the same day at 1:45 PM. However, further record review revealed no documented evidence that the physician received, reviewed, or acted upon the results for approximately 24 hours On January 13, 2025, at 12:03 PM, the physician documented that Resident 1's laboratory results from January 9, 2025, indicated significant dehydration, with a blood urea nitrogen (BUN- a blood test that measures the amount of urea nitrogen in the blood) of 59, creatinine (a waste product produced by muscle breakdown) 1.46, potassium slightly decreased at 3.4 (amount of potassium in the blood), and glomerular filtration rate (GFR-measures how well the kidneys are filtering waste products from the blood) 18. Despite these findings, a physician's order for a midline catheter (a type of intravenous catheter allowing for the administration of medications or fluids directly into the bloodstream) insertion was not initiated until January 10, 2025, at 8:38 PM, approximately 30 hours after the laboratory results were reported A physician's order for Resident 1 to receive supplemental fluids with directions to administer 240 ml four times a day was initiated on January 10, 2025. This order was revised from a previous ongoing order from 240 ml three times a day to 240 ml four times a day, initiated in November 2024. A physician's order for Resident 1 to be administered continuous infusion normal saline solution (NSS) 0.9% at 50 ml/hr for one liter was initiated on January 10, 2025, at 11:36 PM. A progress note dated January 10, 2025, at 10:25 PM revealed midline to left upper arm placed for Resident 1. The physician's progress note dated January 13, 2025, at 12:03 PM indicated that Resident 1's furosemide, a diuretic medication, had been held. The resident had received one liter of normal saline solution, which had been well tolerated. Laboratory tests had been redrawn on January 11, 2025, with results showing potassium at 4.5, BUN at 60, creatinine at 2.25, and GFR at 20. Furosemide had remained on hold pending further lab results. Additional laboratory tests had been scheduled for January 14, 2025. The resident had also been scheduled to receive an additional liter of normal saline prior to the next lab draw. The resident had been in no acute distress and had stated that she felt better than the previous week. She had also reported that her diarrhea had slowed down slightly. A review of Resident 1's Medication Administration Record for January 2025 revealed Resident 1 received furosemide (a diuretic medication) 20 mg tablet on January 10, 2025, at 9:00 AM. after the facility had laboratory results indicating dehydration. Subsequent doses were held per physician orders. A review of Resident 1's Medication Administration Record for January 2025 indicated that Resident 1 had received 240 ml of additional fluids on January 10, 2025, at 1:00 PM and during each subsequent shift as ordered until January 15, 2025. However, the revision of the additional fluid treatment had been implemented 23 hours after the laboratory report date, which had indicated that Resident 1 exhibited markers of dehydration. Additionally, the review of Resident 1's Medication Administration Record for January 2025 showed that Resident 1 had received continuous intravenous (IV) NSS 0.9% at 50 ml/hr beginning on the day shift of January 11, 2025, and during each subsequent shift as ordered until January 14, 2025. However, the continuous IV treatment had been initiated more than 40 hours after the laboratory report date, which had indicated that Resident 1 exhibited markers of dehydration. During an interview on January 30, 2025, at approximately 12:00 PM, the Director of Nursing (DON) explained that on January 10, 2025, Resident 1 dislodged her IV line, causing an additional delay in treatment. During an interview on January 30, 2025, at approximately 12:00 PM, the Director of Nursing (DON) confirmed the physician documented that Resident 1's laboratory result indicated significant dehydration. The DON was unable to explain why there was a delay in implementing interventions and treatment to address Resident 1's dehydration. The DON confirmed it is the facility's responsibility to ensure the physician is promptly provided with laboratory results. 28 Pa Code 211.2 (d)(3) Medical director. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(3) Nursing services.

Based on clinical record review and staff interviews, the facility failed to ensure the timely provision and/or procurement of radiology/diagnostic services to meet the needs of one of 20 residents sampled (Resident 64). Findings include: Review of Resident 64's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses to include unspecified deep vein thrombosis (condition where a blood clot forms in a deep vein, typically in the lower legs), gout (form of inflammatory arthritis), anxiety and was cognitively intact. Review of Resident 64's clinical record revealed a progress note dated January 18, 2025, indicating the resident had a fall and subsequently complained of right shoulder pain. The physician ordered an x-ray of the right shoulder to rule out a fracture. A review of the resident's clinical record conducted during the survey on January 29, 2025, confirmed that the ordered x-ray had not been completed. On January 29, 2025, a STAT x-ray of the right shoulder was ordered; however, as of 8:30 PM, the mobile x-ray company had not completed the imaging. At approximately 9:00 PM, Resident 64 was sent to the emergency room for the x-ray. According to the clinical record, upon arrival at the emergency room , Resident 64 refused the right shoulder x-ray and instead requested imaging of the left shoulder. The left shoulder x-ray was completed and was negative for acute fracture. During an interview on January 30, 2025, at approximately 10:30 AM, the Director of Nursing confirmed that the x-ray was not completed as originally ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records and interviews with staff, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that is not possible, for one out of 20 residents sampled (Resident 1). Findings include: A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A review of a significant change in status Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2025, revealed Resident 1 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status- a tool within the cognitive section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition moderately impaired). Resident 1's care plan, initiated on April 22, 2024, identified increased nutrition and hydration risk related to chronic kidney disease, overweight body mass index, and variable intake at times. The goal was to ensure the resident remained free from unplanned significant weight changes, with interventions including: Respecting the resident's dietary choices, Offering alternate foods if less than 50% of a meal was consumed, and Monitoring for increased nutritional intervention needs. A clinical record review revealed Resident 1 weighed 151 pounds on July 3, 2024, and weighed 136 pounds on August 6, 2024, which is a -9.9% (15-pound) loss of weight in 34 days. The facility conducted a re-weight on August 7, 2024, and determined Resident 1 weighed 132.2 pounds, which is a -12.25% (18.5-pound) weight loss in 35 days. A progress note dated August 9, 2024, at 8:42 AM indicated Resident 1's weight was previously stable over five months at 147-151 pounds. The resident was identified for a 10% weight loss over 30 days and 9% over 90 days. Her body mass index (BMI-a measure of body fat based on weight and height) is 24.87 (the normal range for BMI is 18.5 to 24.9). The resident's diet had been provided as ordered; her meal intake was noted to be variable, ranging from 25 to 100%. Recommending her NAS (no added salt) diet restriction was discontinued, provide 8 oz boost four times a day, and monitor weight weekly. Notify the physician and resident representative of significant weight changes. Follow up with the interdisciplinary team. A progress note dated August 13, 2024, at 11:43 AM indicated the resident had a 10% decrease in weight. The resident's NAS diet restriction was discontinued, an 8 oz boost supplemental drink was added, and weekly weight monitoring was implemented. A clinical record review revealed Resident 1 continued to lose weight from August 6, 2024, through December 3, 2024: 136.0 pounds on August 6, 2024 131.6 pounds on September 2, 2024 130.0 pounds on October 2, 2024 129.0 pounds on November 6, 2024 128.8 pounds on December 3, 2024 A progress note dated December 17, 2024, at 3:44 AM indicated Resident 1 experienced loose, watery stools twice, and the Registered Nurse (RN) Supervisor was notified. The note revealed an order to collect a stool sample was to be entered into the clinical record. However, further record review revealed no documented evidence that a physician's order for a stool sample was entered or that the resident's loose stool was addressed. The clinical record also lacked documentation clarifying whether a stool sample was deemed unnecessary. During an interview on January 30, 2025, at approximately 12:00 PM, the Director of Nursing (DON) indicated the resident no longer had loose stool, so the order was not initiated, and the stool sample never occurred. The DON was not able to provide thorough documented evidence of Resident 1's stool consistency from December 17, 2024, through January 8, 2025. A review of the facility's vitals report from November 8, 2024, through January 8, 2025, indicated Resident 1 had 133 recorded bowel movements (formed, soft, loose, etc.); however, the facility documented stool consistency in only 22 instances, making it impossible to determine the onset, frequency, and severity of diarrhea The facility failed to record the necessary clinical documentation to determine the onset, frequency, and pervasiveness of Resident 1's diarrhea/loose stools. A physician progress note dated January 8, 2025, at 11:37 AM, indicated Resident 1 reported loose stools for two months, which worsened over the last 7-10 days. The note indicated facility nursing staff confirmed Resident 1's complaints of diarrhea. A progress note dated January 10, 2025, at 11:14 AM indicated Resident 1 has stable weight over five months; however, had experienced a 14% weight loss over 180 days, despite receiving a regular diet, nutritional supplements, and fluids. She was receiving 8 oz of food caloric supplement twice a day and 8 oz of fluids three times a day with medication pass. The resident accepted supplementation and fluids; 75-100% are consumed on most days. Documented fluid intake averaged [PHONE NUMBER] ml daily and due to worsening loose stools, the physician recommended: Increasing fluids, 8 oz four times a day Discontinuing the current caloric supplement, and Providing an alternative nutritional supplement twice a day and Weekly weights for close monitoring. A physician's progress note dated January 13, 2025, at 12:03 PM indicated Resident 1 was seen for a follow-up on diarrhea and dehydration. The note indicated Resident 1 had a history of chronic kidney disease. The note indicated lab results from January 10, 2025, showed the resident was dehydrated. The resident reported feeling slightly improved but still experiencing diarrhea. A progress note dated January 17, 2025, at 4:00 PM indicated Resident 1 was reweighed and determined to be 115.5 pounds, confirming a 10% weight loss within 30 days and a 23% weight loss in 180 days, despite nutritional interventions. Further clinical record review revealed Resident 1 weighed 128.8 pounds on December 3, 2024, and weighed 115.5 pounds on January 15, 2025, which is a 10.33% (13.3 pounds) loss in 43 days and 23.5% (35.5 pounds) in 195 days. During an interview on January 30, 2025, at approximately 12:00 PM, the Director of Nursing (DON) confirmed the facility staff did not consistently document Resident 1's bowel movements, and Resident 1's clinical record lacked the documented evidence to determine or evaluate how long Resident 1 was experiencing loose stool or diarrhea. The DON was unable to provide evidence that Resident 1's diarrhea and loose stool (December 17, 2024) were addressed timely. The DON was unable to provide documented evidence that Resident 1's loss of weight or dehydration was unavoidable. The DON confirmed it is the facility's responsibility to ensure residents maintain acceptable parameters of nutritional status, such as body weight and electrolyte balance 28 Pa Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement care and services, consistent with professional standards of practice, to prevent pressure ulcer development for one resident out of two sampled. (Resident 1). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses that included Fournier gangrene (a rare, life-threatening, and rapidly progressive infection that affects the soft tissue and skin of the genital area and perineum), Type 2 diabetes (body has trouble controlling blood sugar and using it for energy) with diabetic chronic kidney disease (loss of kidney function), and cerebral infarction (stroke). Review of Resident 1's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 28, 2024, revealed the resident was severely cognitively impaired, required substantial/maximal assistance for rolling in bed, required total staff assistance for activities of daily living, required total staff assistance for transfers, and was at-risk for the development of pressure ulcers and injuries. A review of the facility admission skin assessment titled Weekly Observation dated September 26, 2024, revealed the resident had new skin issues that included right arm bruising 15 cm x 7 cm, left arm bruising 5 cm x 12 cm, left hand bruise 5 cm x 5 cm, left leg redness 3 cm x 0.5 cm, left big toe scab 1 cm x 1 cm, 2nd toe scab 0.5 cm x 0.5 cm, right buttock Stage II pressure ulcer (partial-thickness skin loss, with loss of epidermis with or without true ulceration) 1 cm x 1 cm x 0.1 cm, and a sacral pressure ulcer Stage II 0.5 cm x 3 cm. Additional site description added the resident had a scrotal opening (previous wound vaccuum site) 8 cm x 1.5 cm x 1.7 cm, and a scrotal incision with sutures 1 cm x 4 cm. A review of Resident 1's plan of care initiated September 6, 2024, revealed the resident was identified with skin impairments related to decreased mobility, and infection. Planned interventions were to provide a pressure reducing mattress and wheelchair cushion, provide incontinence care after each incontinence episode, keep resident clean and dry as possible, minimize skin exposure to moisture, maintain the head of the bed at the lowest degree of elevation possible, and keep linens clean, dry and wrinkle-free. A revision was made on October 9, 2024, to include the addition of an air mattress, and to turn and reposition the resident every two hours. The goal was the resident's pressure ulcer would heal without complications. A review of a facility skin assessment titled Weekly Observation dated November 10, 2024, revealed the resident had existing skin issues that included an abrasion to the scrotal area. No areas of pressure injury were noted on the weekly skin assessment. A review of an outside consultant wound report dated November 12, 2024, two days after the facility performed the weekly skin assessment, the wound consultant reported that Resident 1 had a new area of an unstageable pressure wound (a wound is unstageable when the assessor cannot see the base of the wound to determine the severity or stage of the wound) of the left heel. The wound was described at 100% black eschar tissue (necrotic [dead] tissue often seen in pressure ulcers) with the peri-wound soft (surrounding area of the wound edge). Orders were to Xray the left heel to rule out osteomyelitis (infection in the bone), apply Betadine to left heel with a foam dressing, and to apply heel protectors to both heels at all times. Review of a nurses noted dated November 14, 2024, at 12:04 AM, two days after the facility received the wound consultation report, the nurses note stated the following: after reviewing consult from wound care, documentation revealed a new unstageable pressure area to left heel. Upon observation, a 4 cm x 3 cm unstageable area was visualized. The MD (physician) was notified. New treatment ordered. Prevalon boots (boot with a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure that stays in place for continuous pressure relief) added to care. Will continue to monitor. Review of the facility documentation titled Skin Integrity Events dated November 14, 2024, at 12:04 AM revealed a newly identified area of the left heel measuring 4 cm x 3 cm pressure ulcer classified as unstageable as the area was covered with eschar. The area was characterized as necrotic eschar. Prior to the pressure wound development on Resident 1's left heel, there was no documented evidence the facility had developed measures to prevent the development of a pressure sore of the resident's heel. The resident's care plan included no additional measures to prevent the development of pressure sores, such as pressure relief for the resident's heels, for a resident who was identified as at-risk for pressure sore development. The facility was unable to provide documented evidence the resident was turned and repositioned every 2 hours as indicated in the plan of care. There was no evidence that staff were elevating the resident's heels off the bed prior to the wound development. The facility failed to provide documented evidence the facility developed, implemented and provided preventative measures to prevent the development of a pressure ulcer on the resident's left heel. Interview with the Nursing Home Administrator (NHA) on December 19, 2024, at 2:00 PM confirmed the facility was unable to provide documented evidence that preventative measures were timely and consistently implemented to prevent the development of an unstageable pressure injury to the left heel for Resident 1. 28 Pa. Code 211.5 (f)(ii) Medical records 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records, facility investigative reports select facility policies, and American Heart Association guidelines and staff interviews it was determined the facility failed to provide prompt cardio pulmonary resuscitation intervention consistent with a resident's advanced directives for one resident (Resident CR1) out of five residents sampled. This failure placed 33 facility residents of 86 residents residing in the facility, desiring cardiopulmonary resuscitation (CPR), in immediate jeopardy to their health and safety with the potential for death because of a similar occurrence. ( Resident's CR1 ,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32, 33 and 34. Findings include: Review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR is an emergency treatment that's done when someone's breathing or heartbeat has stopped) last reviewed by the facility [DATE], revealed, licensed nurses, respiratory therapists and van drivers will hold active CPR certificates for healthcare providers by an American Heart Association (AHA) approved provider, wherein course content requires an in-person skills verification. Courses completed in on-line only format are not acceptable. CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: -A valid Advanced directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) or POLST (Provider Orders for Life-Sustaining Treatment a type of advance directive that communicates your wishes for emergency medical treatment when you can't speak for yourself requesting withholding or providing CPR) -Documented verbal wishes by the resident /surrogate decision maker indicating the desire to be DNR (do not resuscitate means the resident does not want to be resuscitated if they suddenly go into cardiac arrest or stop breathing) but Physician order is pending -Dependent Lividity, rigor mortis (sign of death characterized by stiffening of the limbs), decapitation (separation of the head from the body) or transection, (cutting across or through a structure). Resuscitative efforts which have been initiated may be withdrawn if any of the documents listed above are discovered and efforts to that point have been unsuccessful. In the event the resident does not meet any of the above criteria, resuscitative efforts shall be initiated according to American Heart Association guidelines. 1. Activate the emergency response team: -the resident should not be left alone -if you alone with the victim, call out for help -if someone is nearby, instruct them to dial 911 (emergency services) immediately -in the event that help is not available, call 911 and retrieve emergency cart prior to starting CPR, return as soon as possible. 2. Use an AED, Automated External Defibrillator, is a portable device that can help save someone's life during sudden cardiac arrest. It delivers an electric shock to the heart to restore its normal rhythm) as soon as possible if one is available. If no AED is available, continue the cycle of compressions. 3. Continue CPR efforts until pulse is restored, EMS arrives, an onsite physician or nurse practitioner instructs otherwise, or until the team can no longer continue due to exhaustion. According to American Heart Association guidelines presumptive Signs of Death are as follows: The patient is unresponsive. The patient has no respirations. The patient has no pulse. The patient's pupils are fixed and dilated. The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature. The patient has generalized cyanosis (bluish skin color due to decreased amounts of oxygen). AHA guidelines for Conclusive (irreversible) Signs of Death are as follows: There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body). decomposition (decay or putrefaction of the body); rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop). Clinical record review for Residents 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34 and CR1 had current Physicians orders regarding code status to receive CPR in the event of cardiac arrest. Interview conducted on [DATE], at 11:00 AM with Employee 1 nurse aide revealed on [DATE], at 6:30 PM she picked up Resident CR1's dinner tray from (his/her) room. The resident was grey and not responding. Employee 1 went to the door and yelled for the nurse. Employee 2 RN responded to the room, then left the room and returned with a chart. Employee 2 informed nurse aide, Employee 1, that Resident CR1 was a DNR. RN Employee 2, and Employee 1 nurse aide left resident's room. After 7:00 PM, Employee 3 RN arrived on the nursing unit/t, checked Resident CR1's electronic medical record and told Employee 1 nurse aide to get the emergency cart and bring it to Resident CR1's room. Employee 1 nurse aide and Employee 3 RN and Employee 2 RN initiated CPR and continued until paramedics arrived at 7:10 P.M. and took over CPR. Review of Resident CR1's clinical record revealed admission to the facility on [DATE], with diagnoses including esophageal cancer, hypertension, and Atrial fibrillation (an abnormal heart rhythm, characterized by rapid and irregular beating of the heart). Review of Resident CR1's clinical record failed to reveal an MDS assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) available for review at the time of the survey. Review of Resident CR1's clinical record revealed a physician order dated [DATE], identifying the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating as immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest. This physician's order for CPR was confirmed by the RN (registered nurse) Supervisor, Employee 2 on [DATE]. Review of the facility's investigation documentation dated [DATE], at approximately 6:35 P.M., revealed Employee 1, nurse aide, was picking up the resident's dinner tray and found Resident CR1 unresponsive in (his/her) bed. She called for staff help. Employee 2 the RN 7:00 AM to 7:00 PM Supervisor responded to the room and found Resident CR1 pulseless and without spontaneous respirations. Employee 2, RN Supervisor went to the nursing station and picked up a physical chart (binder containing resident information) from the chart rack, noting the resident had a code state of do not resuscitate, (DNR). The physical resident's chart/binder was identified only by room number. CPR was not initiated by nursing staff for Resident CR1 at that time. Further review of the facility's investigation revealed Employee 2, (7:00 AM to 7:00 PM) RN Supervisor left the room, went back to the nurse's station, and called the oncoming (7:00 PM to 7:00 AM) RN Supervisor, Employee 3 to ask for advice concerning calling the deceased resident's family. At that time, he identified Resident 2 as the deceased resident, not Resident CR1. He then called Resident 2's family informing them of their family member's death. Employee 2, RN 7:00 AM to 7:00 PM Supervisor, incorrectly notified Resident 2's family of (his/her) death after failing to accurately identify resident CR1's code status. According to the facility's investigation at approximately 7:00 PM, Employee 3, RN Supervisor entered the building and observed Resident 2 ambulating in (his/her) wheelchair in the hallway. Employee 3 RN then checked the medical record and discovered that Resident CR1 was noted as full code status. CPR was initiated by Employee 3 RN and Employee 1 nurse aide at 7:05 PM, 30 minutes after Resident CR1 was found to be unresponsive. Emergency Medical Services, (EMS 911) was called. Review of nursing documentation dated [DATE], at 9:11 P.M. revealed, at 7:10 PM the paramedics arrived and took over CPR. At 7:50 PM the paramedics contacted the hospital emergency room and obtained an order to stop CPR. Resident CR1 was pronounced dead at 7:50 PM. Review of Employee 3, RN Supervisor's statement dated [DATE] (no time indicated) indicated, I received a phone call at 6:42 PM ([DATE]) as I was driving into work from Employee 2 RN Supervisor, asking my advice on what to say to the family (of the resident that he identified as deceased , Resident 2). When I arrived to work at 7:00 PM and observed Resident 2 very much alive and well, sitting in the activity room. Employee 2, RN Supervisor was at the nurse's station and informed me that he identified Resident CR1's code status incorrectly and it was Resident CR1 that had passed, not Resident 2. Employee 2, RN Supervisor, informed me that Resident CR1 was a full code (initiate CPR if no pulse or respirations). I directed Employee 2, RN Supervisor, and Employee 1, nurse aide to bring the emergency cart to the room and begin CPR. I called 911 at 7:08 PM. EMS arrived at 7:17 PM. EMS continued CPR until the local medical center was contacted and received an order to stop CPR at 7:50 P.M. Review of a witness statement by Employee 2, RN Supervisor, dated [DATE] (no time indicated) revealed, I was called to Resident CR1's room at 6:40 P.M by Employee 1 nurse aide. I assessed Resident CR1 and noted no pulse or respirations. The resident was cold to touch and pale. I then walked back to the nurse's station and inadvertently grabbed the wrong chart. The resident (Resident 2) in this chart was noted as a DNR. I then called Resident 2's family to inform them that Resident 2 had died . I also called the resident's Physician to inform him of the incident. At 7:00 PM. I realized that I had grabbed the wrong chart. I then went into the electronic medical record and confirmed that Resident CR1's code status was a full code. At 7:01 PM Employee 3 (7 PM to 7 AM RN Supervisor) arrived on the floor, I told her what happened. I grabbed the emergency cart, ran to the resident's room and with Employee 1 nurse aide initiated, Cardiopulmonary Resuscitation to Resident CR1. The facility failed to provide emergency care in accordance with the established code status of a resident who was identified as full code. Facility staff failed to obtain Resident C1's correct code status, resulting in a 30-minute delay in initiating cardiopulmonary resuscitation (CPR) for the resident during a medical emergency. According to interview with the Nursing Home Administer (NHA), Employee 3 RN Supervisor, and documentation in the clinical record, the RN did not to initiate CPR because the facility's licensed and professional nursing staff did not verify the resident's identity and correct code status to make the determination to initiate CPR. Interview with the facility NHA on [DATE], at P.M., confirmed that Employee 2 RN Supervisor did not identify Resident CR1 or resident's code status prior to his decision not to initiate CPR in an effort to revive resident. Further, she could not state why Employee 2 RN was unaware of the procedure for identification of residents and their code status at the time of the incident. The Nursing Home Administrator indicated that Employee 2 was terminated as a result of the failure to correctly identify the resident's code status and perform life sustaining measures. This delay by facility staff to perform life sustaining measures of CPR may have contributed to Resident CR1's subsequent death. The failure to follow proper emergency response protocols and accurately verify the resident's code status placed the resident in immediate jeopardy and represents a systemic failure to ensure the health and safety of residents requiring emergency care. Immediate Jeopardy was identified and called on [DATE], at 12:00 PM for the facility's failure to identify Resident CR1's proper code status and timely administration of CPR to a resident beginning on [DATE], at 6:30 PM placing residents' health and safety at serious risk. This deficiency is cited as past non-compliance. The IJ template was provided to the facility at 12:00 PM and an immediate plan of correction was requested and received on [DATE]. The plan included: -Education was completed [DATE], and is being the facility completed reeducation to staff on [DATE], after the incident, but the root cause was not identified as to why the RN went to the paper chart instead of the electronic medical record for identification and code status information. The paper chart did not contain this information so after immediate jeopardy was identified, education on where to find the identifying information needed to be conducted by the end of the day [DATE]. -Immediate training for licensed staff on the importance of verifying code status and providing CPR as indicted in the electronic medical record. The education provided included locating Physicians orders for code status in the electronic medical record. Staff demonstrated the proper location of Physicians orders for code status. Per CMS guidelines, the facility will honor code status documented in the resident's electronic medical record. -Staff CPR certifications were verified to be current on [DATE]. -Reviewed all resident's charts to ensure all residents have a Physician's order in the electronic medical record for code status by [DATE], at 8:00PM. -A code blue drill will be conducted every shift for 24 hours completed by [DATE]. -Licensed staff will be educated regarding, CPR policies and procedures to include, 2 licensed nurses to verify the right resident and right code status in the electronic medical record prior to initiating CPR by [DATE]. -The physical residents' paper charts will be removed from the nursing station by [DATE]. The action plan was completed prior to the start of the 11:00 PM to 7:00 AM shift on [DATE], ensuring that staff received the necessary training before beginning their duties. The results of audits and drills were anticipated to be reviewed at QAPI (Quality Assurance Performance Improvement) meeting on [DATE], for monitoring of facility CPR policy and procedure. The Immediate Jeopardy was lifted on [DATE], at 5:00 PM upon receipt of the facility's immediate action plan and evidence of its implementation was verified. The facility's compliance date was [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to provide timely cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to a resident's advanced directive for one out of five sampled residents (Resident CR1). Findings included: Review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR is an emergency treatment that's done when someone's breathing or heartbeat has stopped) last reviewed by the facility [DATE], revealed, licensed nurses, respiratory therapists and van drivers will hold active CPR certificates for healthcare providers by an American Heart Association (AHA) approved provider, wherein course content requires an in-person skills verification. Courses completed in on-line only format are not acceptable. CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: -A valid Advanced directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) or POLST (Provider Orders for Life-Sustaining Treatment a type of advance directive that communicates your wishes for emergency medical treatment when you can't speak for yourself requesting withholding or providing CPR) -Documented verbal wishes by the resident /surrogate decision maker indicating the desire to be DNR (do not resuscitate means the resident does not want to be resuscitated if they suddenly go into cardiac arrest or stop breathing) but Physician order is pending -Dependent Lividity, rigor mortis (sign of death characterized by stiffening of the limbs), decapitation (separation of the head from the body) or transection, (cutting across or through a structure). Resuscitative efforts which have been initiated may be withdrawn if any of the documents listed above are discovered and efforts to that point have been unsuccessful. In the event the resident does not meet any of the above criteria, resuscitative efforts shall be initiated according to American Heart Association guidelines. 1. Activate the emergency response team: -the resident should not be left alone -if you alone with the victim, call out for help -if someone is nearby, instruct them to dial 911 (emergency services) immediately -in the event that help is not available, call 911 and retrieve emergency cart prior to starting CPR, return as soon as possible. 2. Use an AED, Automated External Defibrillator, is a portable device that can help save someone's life during sudden cardiac arrest. It delivers an electric shock to the heart to restore its normal rhythm) as soon as possible if one is available. If no AED is available, continue the cycle of compressions. 3. Continue CPR efforts until pulse is restored, EMS arrives, an onsite physician or nurse practitioner instructs otherwise, or until the team can no longer continue due to exhaustion. According to American Heart Association guidelines presumptive Signs of Death are as follows: The patient is unresponsive. The patient has no respirations. The patient has no pulse. The patient's pupils are fixed and dilated. The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature. The patient has generalized cyanosis (bluish skin color due to decreased amounts of oxygen). AHA guidelines for Conclusive (irreversible) Signs of Death are as follows: There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body). decomposition (decay or putrefaction of the body); rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop). Interview conducted on [DATE], at 11:00 AM with Employee 1 nurse aide revealed on [DATE], at 6:30 PM she picked up Resident CR1's dinner tray from (his/her) room. The resident was grey and not responding. Employee 1 went to the door and yelled for the nurse. Employee 2 RN responded to the room, then left the room and returned with a chart. Employee 2 informed nurse aide, Employee 1, that Resident CR1 was a DNR. RN Employee 2, and Employee 1 nurse aide left resident's room. After 7:00 PM, Employee 3 RN arrived on the nursing unit/t, checked Resident CR1's electronic medical record and told Employee 1 nurse aide to get the emergency cart and bring it to Resident CR1's room. Employee 1 nurse aide and Employee 3 RN and Employee 2 RN initiated CPR and continued until paramedics arrived at 7:10 P.M. and took over CPR. Review of Resident CR1's clinical record revealed admission to the facility on [DATE], with diagnoses including esophageal cancer, hypertension, and Atrial fibrillation (an abnormal heart rhythm, characterized by rapid and irregular beating of the heart). Review of Resident CR1's clinical record failed to reveal an MDS assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) available for review at the time of the survey. Review of Resident CR1's clinical record revealed a physician order dated [DATE], identifying the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating as immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest. This physician's order for CPR was confirmed by the RN (registered nurse) Supervisor, Employee 2 on [DATE]. Review of the facility's investigation documentation dated [DATE], at approximately 6:35 P.M., revealed Employee 1, nurse aide, was picking up the resident's dinner tray and found Resident CR1 unresponsive in (his/her) bed. She called for staff help. Employee 2 the RN 7:00 AM to 7:00 PM Supervisor responded to the room and found Resident CR1 pulseless and without spontaneous respirations. Employee 2, RN Supervisor went to the nursing station and picked up a physical chart (binder containing resident information) from the chart rack, noting the resident had a code state of do not resuscitate, (DNR). The physical resident's chart/binder was identified only by room number. CPR was not initiated by nursing staff for Resident CR1 at that time. Further review of the facility's investigation revealed Employee 2, (7:00 AM to 7:00 PM) RN Supervisor left the room, went back to the nurse's station, and called the oncoming (7:00 PM to 7:00 AM) RN Supervisor, Employee 3 to ask for advice concerning calling the deceased resident's family. At that time, he identified Resident 2 as the deceased resident, not Resident CR1. He then called Resident 2's family informing them of their family member's death. Employee 2, RN 7:00 AM to 7:00 PM Supervisor, incorrectly notified Resident 2's family of (his/her) death after failing to accurately identify resident CR1's code status. According to the facility's investigation at approximately 7:00 PM, Employee 3, RN Supervisor entered the building and observed Resident 2 ambulating in (his/her) wheelchair in the hallway. Employee 3 RN then checked the medical record and discovered that Resident CR1 was noted as full code status. CPR was initiated by Employee 3 RN and Employee 1 nurse aide at 7:05 PM, 30 minutes after Resident CR1 was found to be unresponsive. Emergency Medical Services, (EMS 911) was called. Review of nursing documentation dated [DATE], at 9:11 P.M. revealed, at 7:10 PM the paramedics arrived and took over CPR. At 7:50 PM the paramedics contacted the hospital emergency room and obtained an order to stop CPR. Resident CR1 was pronounced dead at 7:50 PM. Review of Employee 3, RN Supervisor's statement dated [DATE] (no time indicated) indicated, I received a phone call at 6:42 PM ([DATE]) as I was driving into work from Employee 2 RN Supervisor, asking my advice on what to say to the family (of the resident that he identified as deceased , Resident 2). When I arrived to work at 7:00 PM and observed Resident 2 very much alive and well, sitting in the activity room. Employee 2, RN Supervisor was at the nurse's station and informed me that he identified Resident CR1's code status incorrectly and it was Resident CR1 that had passed, not Resident 2. Employee 2, RN Supervisor, informed me that Resident CR1 was a full code (initiate CPR if no pulse or respirations). I directed Employee 2, RN Supervisor, and Employee 1, nurse aide to bring the emergency cart to the room and begin CPR. I called 911 at 7:08 PM. EMS arrived at 7:17 PM. EMS continued CPR until the local medical center was contacted and received an order to stop CPR at 7:50 P.M. Review of a witness statement by Employee 2, RN Supervisor, dated [DATE] (no time indicated) revealed, I was called to Resident CR1's room at 6:40 P.M by Employee 1 nurse aide. I assessed Resident CR1 and noted no pulse or respirations. The resident was cold to touch and pale. I then walked back to the nurse's station and inadvertently grabbed the wrong chart. The resident (Resident 2) in this chart was noted as a DNR. I then called Resident 2's family to inform them that Resident 2 had died . I also called the resident's Physician to inform him of the incident. At 7:00 PM. I realized that I had grabbed the wrong chart. I then went into the electronic medical record and confirmed that Resident CR1's code status was a full code. At 7:01 PM Employee 3 (7 PM to 7 AM RN Supervisor) arrived on the floor, I told her what happened. I grabbed the emergency cart, ran to the resident's room and with Employee 1 nurse aide initiated, Cardiopulmonary Resuscitation to Resident CR1. The facility failed to provide emergency care in accordance with the established code status of a resident who was identified as full code. Facility staff failed to obtain Resident C1's correct code status, resulting in a 30-minute delay in initiating cardiopulmonary resuscitation (CPR) for the resident during a medical emergency. According to interview with the Nursing Home Administer (NHA), Employee 3 RN Supervisor, and documentation in the clinical record, the RN did not to initiate CPR because the facility's licensed and professional nursing staff did not verify the resident's identity and correct code status to make the determination to initiate CPR. Interview with the facility NHA on [DATE], at P.M., confirmed that Employee 2 RN Supervisor did not identify Resident CR1 or resident's code status prior to his decision not to initiate CPR in an effort to revive resident. Further, she could not state why Employee 2 RN was unaware of the procedure for identification of residents and their code status at the time of the incident. The Nursing Home Administrator indicated that Employee 2 was terminated as a result of the failure to correctly identify the resident's code status and perform life sustaining measures. This delay by facility staff to perform life sustaining measures of CPR may have contributed to Resident CR1's subsequent death. The failure to follow proper emergency response protocols and accurately verify the resident's code status placed the resident in immediate jeopardy and represents a systemic failure to ensure the health and safety of residents requiring emergency care. These failures placed residents who desired CPR in the event of cardiac arrest in immediate jeopardy. As a result of the failure of licensed staff to promptly initiate CPR for a resident, immediate jeopardy to the health and safety and substandard quality of care was identified at the facility on [DATE]. A review of the job description for the Administrator of the facility revealed the Administrator leads and directs the overall operations of the facility in accordance with the community, policies and procedures, customer, and resident needs and both state and federal guidelines. To maintain excellent care for the residents/patients and achieve the facility's business objective. The Administrator delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties. The administrator is responsible for carrying out the operational core responsibilities established by the company and facility. The NHA is responsible for the oversite of the resident care policies established by the facility. A review of the job description for the Director of Nursing (DON) indicated it is the responsibility of the DON is to organize, develop and direct the overall operations of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern the facility. The Director of Nursing is to work directly with the Administrator and the Medical Director to ensure the highest degree of quality of care is always maintained for each resident. The Director of Nursing is delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties. In the absence of the Medical Director, the DON is responsible to carry out the resident care policies established by the facility. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Life (F678) 483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives, revealed the Administrator and DON failed to fulfill the essential job duties for ensuring the health and safety of the residents and adherence to regulatory guidelines. Refer F678 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1) Management 28 Pa. Code:211.12(a)(b)(c)(d)(1) Nursing Services

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interviews with staff and the resident's family it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of six residents sampled (Resident 1) resulting in serious injuries, a fractured thumb and closed head injury. Findings include: The facility's policy entitled Abuse Policy dated as reviewed by the facility August 30, 2023 revealed that The facility will not tolerate abuse, neglect, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses of cerebral infarction (stroke), dysphagia (difficulty swallowing) requiring enteral feeding through a PEG tube (gastric feeding tube receiving liquid feeding provided through a rubber tube inserted into the stomach) and diabetes, and the need for maximum assistance with personal care. A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 6, 2024, indicated that the resident required the assistance of two staff member for transfers, bed mobility and toileting and was moderately, cognitively impaired with a BIMS score of 12 (BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment, a score of 8-12 indicated moderate cognitively impaired). A review of the resident's current plan of care, initially dated March 27, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit related to cerebral infarction and weakness. Resident 1 could answer questions with one /two words. Planned interventions, upon admission, indicated that the resident required the use of a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with the assistance of two staff for transfers, was dependent on two staff for bed mobility and toileting, and was non-ambulatory. A facility investigation report dated May 21, 2024, revealed that Resident 1, had a BIMS score at the time of the incident 14 out of 15, indicating cognitively intact, and reported that he rolled out of bed while a nurse aide was providing his care. The resident stated that Employee 1, a nurse aide, was providing his care and he fell out of bed. Employee 1 then left the room to get another staff member and they both assisted him back into bed. A review of a witness statement dated May 22, 2024 (no time indicated) Resident 1 answered the following questions asked by the Nursing Home Administrator (NHA) and the RN corporate consultant: -Do you remember when you fell ? Yes -Do you know who picked you up off the floor? Yes -You previously stated, it was Employee 1, nurse aide. Is that correct? Yes -Did she have help? Yes -Do you know who helped her? Yes -Did you ever see the person before the night that she assisted you off the floor? Yes The facility reviewed their surveillance camera footage, revealed to ascertain who entered and left Resident 1's room. A new employee (Employee 5, a nurse aide orientee) started on the 11 PM to 7AM shift and a nurse aide on the 3 PM shift worked that hallway and had not worked in that hall before. Following the facility's review of the footage, they asked Resident 1 the following questions: -Can you tell me if the employee was black or white? Black -Did she have light or dark hair? Dark Resident 1 was unable to convey whether his fall occurred on the 3 PM to 11 PM shift. - Did the nurse come to assess you after you fell ? No - Did Employee 1 provide care for you by herself? Yes -Do you have any pain? No -Do you feel safe? Yes A review of a witness statement dated May 21, 2024, (no time indicated) from Employee 1, a nurse aide, revealed that While providing care to {Resident 1}, I saw a red swelling on his forehead. I continued to wash him up and when I was done, I told Employee 3 (RN Supr), when I did not see the nurse (the LPN assigned to the unit). I did not observe {Resident 1} on the floor at any time. I did not assist {Resident 1} off the floor. I reported to Employee 3 (RN Supr) and the Director of Nursing (DON) when she came in the morning. The NHA and corporate nurse consultant asked Employee 1 on May 22, 2024: -What time did you provide care? Later in the evening -What time did you see the swelling? Later in the evening when washing him up -Who did you provide care with you, to this resident? Employee 2 a nurse aide -How many times did you provide care to Resident 1 on the 11 PM to 7 AM shift and who was with you each time? I don't remember A review of a witness statement dated May 21, 2024, at 11:19 A.M., Employee 2 stated, I assisted Employee 1 to provide care for Resident 1. While providing care, Employee 1 noticed a red mark and swelling on his forehead. We finished care and Employee 1 reported this to Employee 3 (RN Supr), the supervisor. Additional questions asked of Employee 2: -What time did you provide care? Sometime after dinner -What time did you and Employee 1 report the red area? Employee 1 reported, but not sure what time A review of a witness statement dated May 21, 2024, at 12:20 PM Employee 5, nurse aide orientee, indicated that Monday May 20, 2024, 11 PM to 7 AM shift was my first physical shift of nurse aide training. I was assigned with Employee 1. I did not witness any resident falls, injuries or incidents during that time. Additional questions asked of Employee 5 during the interview: -Did you provide care to Resident 1 with Employee 1? I shadowed Employee 1 on the 11 PM to 7 AM shift and I do not know the residents yet by name or initials. I accompanied Employee 1 in each room that shift. A review of a witness statement dated May 21, 2024, from Employee 3 (RN Supr) revealed that Employee 3 stated that Employee 1 came to me and told me he (Resident 1) has a little red area on his head. I checked his chart (clinical record) and there was nothing charted of anything that might have happened. I then came to his room to assess and at that moment there was slight reddened to his head. No hematoma present. He did not complain of any pain. The facility's administrative staff asked Employee 3 the following additional questions: -Did you ask the resident how he got the red area? No, I asked him if it hurt. He stated no and smiled. -Did you interview the nurse aides if anything happened to him? No A witness statement no date or time indicated from Employee 6 LPN, revealed that the employee stated I was on duty Monday May 20, 2024, on the 3 PM to 11 PM shift. I went to give meds to {Resident 1} twice, around 5:30 PM to 6 PM and 8 PM. The resident was fine, without any bruises or marks at any parts of his body. If anything happened during my shift, it was not reported to me. A witness statement dated May 21, 2024, from Employee 4, nurse aide, stated Around 10:30 AM (May 21, 2024) My co worker and I went to provide ADLs to {Resident 1}. We noticed swelling and bruising to left eye and forehead injury and left leg and right finger injury. The RN supervisor and DON notified immediately. A witness statement dated May 21, 2024, (no time indicated) from Employee 7, a nurse aide, stated my coworker and I were about to do ADLs and noticed swelling and bruising to his {Resident 1} left eye and forehead, injury to left leg and right finger. This was immediately reported to the Supervisor and DON. A witness statement dated May 29, 2024 (no time indicated) Employee 8, LPN, stated that on May 21, 2024, she was called to {Resident 1's} room by nurse aide staff at approximately 10:30 AM Upon entering the room, this nurse observed multiple discolorations and lacerations, swelling on the left side of his head and face. The NHA was notified. Employee 8 stated that she had been in the resident's room perviously on that shift at 9 AM to administer his medications through the g-tube. He was covered up and his head was turned at that time when the meds were given, stating I did not observe anything at that time. He was sleeping at that time. A review of the resident's clinical record revealed that there was no nursing documentation entered on May 20, 2024, during the 3 PM to 11 PM or May 21, 2024, on the 11 PM to 7 AM shifts. A review of facility staffing documents revealed that Employee 1 worked May 20, 2024, on the 3 PM to 11 PM shift and May 20th into May 21, 2024, 11 PM to 7 AM shift. Employee 3 (RN Supr) worked May 20, 2024, 7 PM to 11 PM and May 20th into May 21, 2024, 11 PM to 7 AM shifts. There was documented evidence that the licensed and professional nursing staff had conducted a thorough nursing assessment, including neuro checks, on May 20, 2024, during the 3 PM to 11 PM and 11 PM to 7 AM shifts in response to the resident's reported fall and observed facial and head injuries. A review of a nursing wound summary report dated May 21, 2024, at 10:45 PM revealed the resident sustained the following injuries: - a bruise to the right thumb, measuring 1.5 cm x 2 cm -a bruise to the left forehead measuring 4 cm x 3 cm -a bruise to the left eye, measuring 4 cm x 1,5 cm -a laceration to the left cheek, measuring 2 cm x 0.1 cm -a skin tear to the left shoulder measuring 0.9 cm x 0.7 cm -a skin tear to the right, top of the foot, right medial skin tear measuring 2 cm x 0.5 cm -skin tear to the left knee measuring 3.8 cm x 0.9 cm -a skin tear to the left lateral knee measuring 2.5 cm x 0.8 cm There was no additional description of these wounds in the resident's clinical record at the time of the survey ending June 4, 2024, to include the characteristics/appearance of the skin condition or any bleeding. A review of nursing documentation dated May 21, 2024 at 10:50 AM Resident was interviewed, feels safe while in facility and pleasant, no pain noted, will continue to monitor. MD aware. Wife was called and still awaiting a call. Multiple areas noted as well as a hematoma to his left forehead. RN provided a full body assessment. Tylenol was immediately offered, resident did not accept and stated he was fine but accepted Tylenol a few hours later. The physician was notified and gave new orders for ice pack and x-rays of resident's right hand and left shoulder. Resident stated that he rolled out of bed as he was being cared for during the night time hours. Resident stated a NA was providing care while he rolled out of bed onto floor. She left the room to get another staff member and they assisted him back into bed. Resident was unsure of the other person who assisted the CNA. An immediate investigation with statements was initiated from all staff that had come in contact with resident. Resident then notified us of the name of the NA that he stated was changing resident. A review of a social services note dated May 21, 2024, at 2:33 PM revealed SS paid resident a supportive visit following a fall incident. Resident expressed that he was upset about the fall and in discomfort. The nurse came in and gave resident pain relief and he denied any further concerns or pain. A nurse's note dated May 21, 2024, at 1:57 PM revealed Resident to be sent out to the Hospital to evaluate for status post fall. A nursing entry May 21, 2024 at 4:21 PM revealed, resident being sent out to evaluate for self-reporting a fall on May 20, 2024. Resident has multiple skin tears, a bump and bruise on his left head, a black left eye, and a bruise on his right thumb with edema and pain. X-ray of left shoulder negative for fracture. X-ray of right hand cannot rule out fracture. Resident complained of intermittent headache, right hand pain, left shoulder pain, does not like ice pack due to cold. Spouse requesting resident be sent out for evaluation. Physician notified. EMS arrived to bring resident to Emergency department. Sent to the hospital. A review of hospital documentation dated May 21, 2024, revealed that the resident's diagnoses included a displaced fracture of distal phalanx of right thumb, a closed head injury, contusion of left orbital tissues, neck and left shoulder pain. The resident received a CT scan (Uses several X-ray images and computer processing to create cross sectional images) of the head, cervical spine, chest, hand and shoulder X-Rays. Tylenol was administered and a dressing and splint applied. Right thumb swollen and bruised, patient tender to palpation, particular with palpation of the distal portion. Small abrasions not amenable to repair noted to the right foot as well as the left knee, significant tenderness to palpation of those areas. Presentation as above with fracture of the distal phalanx of the right thumb as well as shoulder pain and neck pain and contusion of the left orbit and closed head injury status post fall. Vital signs and examination as above. A nurses note dated May 21, 2024 at 10:40 P.M. revealed Resident returned from the hospital and wife present. Resident diagnosis with displaced fracture of distal phalanx of right thumb. Resident arrived with splint to right thumb. Resident is to follow up with Ortho. During an interview on June 4, 2024, at 12 PM, Resident 1's wife stated that she visits her husband daily. She stated that he told her that the nurse aide rolled him out of bed. He fell to the floor and rolled underneath the bed. The nurse aide left him on the floor and returned with another nurse aide. The two nurse aides then picked him up from the floor, without using the mechanical lift (as is his transfer status, mechanical lift and assist of 2 staff). She stated that she felt that the multiple cuts and skin tears he sustained were due the two nurse aides pulling him out from under the bed. Employee 1 was caring for the resident, while he was in bed, without the assistance of another nurse aide, and the resident rolled out of bed. Employee 1 failed to report the resident's fall and sought the assistance of another nurse aide to put the resident back to bed, without the use of a mechanical lift. These nurse aides did not report the resident's fall. Upon report of the resident's head and facial injuries, licensed and professional nursing staff failed to promptly assess the resident and initiate checks of the resident's neurological status An interview with the Nursing Home Administrator and Director of Nursing on June 4, 2024, at approximately 2 PM confirmed that the facility's nursing staff failed to provide resident Resident 1 with the care and services necessary to avoid physical harm. The NHA and DON confirmed that Employee 1 was aware that the resident's bed mobility and transfer were to performed with two people but neglected to assure the presence of a second person for the resident's care, and did not use the mechanical lift to assist the resident back to bed after the fall, and failed to report the incident to assure the resident received timely and necessary care. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A Review of a facility policy entitled Food and Nutrition Services: Food Production and Food Safety that was last reviewed by the facility on April 21, 2023, revealed that all items must be stored at least six (6) inches above the floor and all food removed from the freezer will be labeled with a pull date. The initial tour of the kitchen was conducted with the certified dietary manager (CDM) on February 21, 2024, at 8:44 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified: Observations of the walk-in produce/dairy refrigerator revealed that there were several cases of juices that were directly on the floor. Inside of the walk-in freezer there were several cases of frozen foods that were blocking the walkway and directly on the floor. Observations of the dry storage area revealed several cases of dry foods on the floor. An interview with the CDM confirmed that when food/food items are received that they should not be directly on the floor and should be stored 6-inches off the floor. Observation of the cold production reach-in cooler revealed a full sheet tray of thawed 4-ounce shakes, which lacked a thaw or discard date. According to manufacturer's directions, the product had a 14-day shelf life after thawing. The CDM confirmed at the time of the observation that the tray of 4-ounce shakes should have included a thaw date and/or a discard date. An interview with the Nursing Home Administrator (NHA) on February 21, 2024, at 2:15 p.m., confirmed that foods and beverages should be stored off the floor and labeled to ensure acceptable use. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on a review of clinical records and select facility policy, observations and staff and resident interviews, it was determined that the facility failed to timely assess and consistently provide recommended treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores, which resulted in the development of pressure sores for two of 6 residents reviewed with pressure ulcers (Resident 7 and Resident 30). Findings include: According to the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians ([ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. A review of the facility's policy entitled, Pressure Injury Prevention and Treatment Policy, last revised by the facility September 18, 2020, indicated that new pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Residents will be assessed for pressure injury risk on admission, quarterly and with significant change of condition. Wounds identified will be assessed initially and at least weekly thereafter, until closed, to include the following elements: location and stage, size, exudate (if present), pain, wound bed, appearance of surrounding tissue and any evidence of infection. A review of the clinical record revealed that Resident 7 was readmitted to the facility on [DATE]. The resident's admission skin check revealed that the resident was admitted with numerous bruises to various parts of his body and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) to his right buttocks with an open area measuring 8 cm (centimeters) x 14 cm and another area measuring 3 cm x 0.1 cm. The resident's left buttocks was also noted to be macerated with an open area measuring 10 cm x 9 cm and another area measuring 3.5 cm x 0.1 cm. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 24, 2021, revealed that Resident 7 was at risk for developing pressure sores and required assistance of two staff members for activities of daily living to include bed mobility, transfers and toilet use. Section M0110 (determination of pressure ulcer/injury risk section) of the resident's MDS indicated that the resident was at risk for pressure ulcers and no pressure ulcers were present upon readmission to the facility. MDS Section M1200 (skin and ulcer/injury treatment) indicated that no turning and repositioning program was in place. The resident also had an indwelling urinary Foley catheter in place and was frequently incontinent of bowel. According to the MDS there was no bowel program being used to manage the resident's bowel incontinence. At the time of the survey ending May 21, 2021, the facility was unable to provide documented evidence of consistent ongoing monitoring and/or tracking of the condition, status and healing of all the above noted wounds and skin impairments that were identified upon the resident's readmission on February 17, 2021. There was no documented evidence of the measures and interventions implemented upon the resident's readmission to the facility on [DATE], to promote healing of the resident's skin breakdown, prevent worsening of existing skin impairments and prevent pressure sore development. A weekly skin evaluation dated April 30, 2021, revealed documentation of redness to the resident's right buttock. A weekly skin evaluation dated May 1, 2021, revealed documentation of redness to resident's buttocks. A review of the resident's Braden scale assessment (a tool developed to assess a resident's risk of developing a pressure ulcer) dated May 14, 2021, revealed a score of 16, indicating the resident was at low risk for developing pressure sores. During an interview with the facility's Corporate Nurse on May 20, 2021, at 10:00 AM she acknowledged that the Braden scale is not a true reflection of the resident's current skin conditions. A review of a weekly wound assessment dated [DATE], revealed that the resident had a facility acquired Stage III pressure area (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) measuring 2.5 cm x 3.5 cm by 0.1 cm to the resident's right buttocks, with a small amount of sanguineous (bloody) drainage. The wound bed was yellow with slough (dead wound tissue, usually cream or yellow in color) and a pink periwound appearance. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat Dry. Apply [MEDICATION(S)] (medical grade Manuka honey). Cover with dry dressing daily and PRN (as needed) every day shift for tx (treatment) for the pressure ulcer. The resident's care plan was updated on May 14, 2021, to include the approach of turning and repositioning the resident every two hours and the application of an air mattress to the bed. At the time of the survey ending May 21, 2021, the facility was unable to provide evidence that these planned interventions of turning and repositioning and air mattress had been initiated. A review of a wound specialist wound care initial evaluation dated May 19, 2021, revealed documented evidence of a Stage III pressure wound on the right buttocks, measuring 0.5 cm x 1.5 cm by 0.1 cm, light serous with 80% granulation (healing) tissue. The treatment plan included to treat the wound with Leptosperum honey (medical grade honey used for wound healing) daily for 30 days. The plan also included that the resident should be repositioned per facility protocol; turn side to side and front to back in bed every 1-2 hours, if able, off load (remove pressure) wound and a gel cushion to chair. At the time of the survey ending May 21, 2021, the facility was unable to provide documented evidence that the repositioning, off loading and gel cushion recommended by the wound care specialist had been implemented to promote healing of the resident's Stage III pressure sore. Observation of the resident on May 21, 2021, at approximately 1:00 PM, revealed that the resident's wound appeared consistent with the description noted by the wound care specialist on May 19, 2021, but there was moderate drainage observed at the time. The facility failed to demonstrate timely and adequate measures to prevent development of the Stage III pressure sore and failed to implement recommended approaches to promote healing of pressure sores. According to interview with Nursing Home Administrator (NHA) on May 19, 2021, at 2:00 PM, the facility conducted an, in house sweep of all the residents for skin checks on May 14, 2021, after Resident 7 was found with a Stage III area to his buttocks. A review of Resident 30's clinical record revealed that the resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission MDS assessment dated [DATE], revealed that Resident 30 required assistance of two staff members for activities of daily living to include bed mobility, transfers and toilet use. MDS Section M0110 of the resident's MDS indicated that the resident was at risk for pressure ulcers and no pressure ulcers were present upon readmission to the facility. Section M1200 indicated that preventative measures were in place to prevent the development of pressure sores. A review of a biweekly skin check dated May 5, 2021, revealed that the resident was found with an open area to the buttocks, discoloration of his great right toe and discoloration to his left heel. The skin check form was incomplete and did not describe the appearance and size of these areas. Review of the residents clinical record and care plan revealed no documented evidenced of the measures taken in response to the above noted skin impairments to promote healing and prevent further skin breakdown. A review of a pressure ulcer investigation dated May 14, 2021, revealed that upon assessment the resident had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough/eschar [tan, brown or black]) pressure ulcer to the resident left heel measuring 3.0 cm x 3.0 cm by undetermined depth. The wound bed appearance was necrotic (tissue is dead or devitalized tissue. This tissue cannot be salvaged and must be removed to allow wound healing to take place) and the periwound appearance was pink. An observation of the resident on May 19, 2021, at 9:38 AM revealed that the resident was in bed. The resident was not wearing heel protection and blood was observed on the sheets near the foot of the resident's bed. While interviewing the resident, the resident stated he told staff that his, bedroom slippers while showing the surveyor what appeared to be diabetic shoes on the floor of the resident's room, hurt his feet further stating, no one listens or helps, they don't even come when you ring the call bell. There was no dressing in place during the observation and the wound was observed to be necrotic and bloody. The facility was unable to demonstrate the consistent implementation of prescribed approaches and sufficient preventative measures for the above mentioned residents. The facility failed to timely identify declines in the resident's skin integrity and failed to promptly implement adequate measures to prevent the development of new pressure sores, for residents identified at risk for pressure sore development. During an interview with the NHA and the facility's Corporate Nurse on May 21, 2021, at 11:10 AM, it was revealed that the facility was unable to provide evidence that the recommendations by the wound care physician specialist of turning and repositioning the residents and an air mattress were promptly implemented to promote healing and prevent worsening of pressure sores. 483.25(b)(1)(i)(ii) Treatment/Services to prevent/heal pressure ulcers Previously cited 8/9/19, 2/21/20 28 Pa. Code 211.5(f) Clinical Records Previously cited 8/9/19, 10/31/19, 2/21/20, 2/3/21 28 Pa. Code 211.5(g)(h) Clinical Records Previously cited 8/9/19, 2/21/20, 2/3/21 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services Previously cited 8/9/19, 9/24/19, 10/31/19, 2/21/20, 2/3/21 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 8/9/19, 9/24/19, 2/21/20, 2/3/21 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 8/9/19, 10/31/19, 2/21/20, 2/3/21

Based on review of clinical records, hospital records and documentation from emergency management services and staff, physician and family interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate consistent clinical monitoring and provision of person-centered care in response to changes in resident condition, resulting in delays in these residents receiving the necessary level of care and services, which compromised their clinical condition for two residents out of two residents reviewed who experienced changes in condition requiring hospitalization (Resident 125 and Resident 127). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete 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 Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the clinical record of Resident 125 revealed admission to the facility on [DATE], with diagnoses, which included [MEDICAL CONDITION] lung disease (group of lung problems related to [MEDICAL CONDITION] arthritis. The condition can include blockage of the small airways, fluid in the chest, high blood pressure in the lungs), [MEDICAL CONDITION] ([MEDICAL CONDITION] is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing) and [MEDICAL CONDITION] (a chronic progressive condition that affects the pumping power of your heart muscles. While often referred to simply as heart failure, [MEDICAL CONDITION] specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently). A review of interdisciplinary progress notes dated January 27, 2020, for 10:20 AM, but written at 6:05 PM, revealed that staff responded to the resident's room with EMS (emergency medical services, medical professionals who respond to 911) when the resident called 911. The resident stated that she wanted to return to the hospital because she wasn't happy in the facility. Staff noted that the resident stated no one would give her water and if she didn't get ginger ale, she would go to the hospital to get it. The resident received a drink and declined to go the hospital. However, a review of an EMS ambulance report dated January 27, 2020, revealed that the ambulance was dispatched to the facility at 10:24 AM and attended to the resident at 10:32 AM. The report indicated that that ambulance was dispatched due the resident stating she felt as if she was being neglected. The resident had complaints of trouble breathing. The resident's oxygen bottle was empty and her nasal canula (device used to deliver supplemental oxygen) was lying on the floor next to her bed. The resident's oxygen level was found to be 75% (normal levels are 90% or above). The ambulance crew placed the resident on 3 liters of oxygen. The EMS report further indicated that the facility staff acknowledged the resident's low oxygen level and that her oxygen tank was empty. The facility staff stated to the EMS crew they would bring the resident an oxygen concentrator and keep her on oxygen. At that time the resident had no further complaints and did not desire EMS assistance and they left the facility. Review of facility documentation for January 27, 2020, revealed no documentation of the resident's oxygen tank being empty or the resident having a low oxygen level of 75% as noted in the EMS report. A review of an interdisciplinary team meeting progress note dated January 29, 2020, at 11:43 AM revealed that the team discussed that the resident called 911 due to her wanting water. No documentation was found that the team discussed the resident low oxygen level or having an empty tank of oxygen. A nursing progress note dated January 30, 2020, at 7:45 AM revealed that the resident had a change in condition. The resident was complaining of being short of breath. The resident had abnormal lung sounds. Nursing noted at that time that the resident's oxygen level was 90% on room air. A physician order [REDACTED]. A review of a facility Change in Condition evaluation dated January 30, 2020, at 7:45 AM revealed that the resident had audible wheezing and shortness of breath was noted. The resident received an [MEDICATION NAME] nebulizer treatment. A review of a nursing progress note dated January 30, 2020, at 8:30 AM revealed the resident was complaining of being short of breath. The resident's lung sounds were diminished in the bases (lung sounds that are decreased and harder to hear due to poor air flow) and was noted to have a moist nonproductive cough. Further documentation revealed that the nurse was unable to obtain an oxygen level due to the resident's cold hands. A review of a progress note dated January 30, 2020, at 10:27 AM revealed the resident called 911, stating that she was on the floor and needed to go to the hospital, but nursing noted that the resident was observed lying in bed and had no difficulty breathing. A review of an EMS ambulance report dated January 30, 2020, revealed that the ambulance was dispatched to the facility and attended to the resident at 10:31 AM. The report indicated that the resident called 911 due to the resident needing medical attention. However, the facility staff then called and cancelled the ambulance. Subsequently, the resident's daughter then proceeded to call 911 stating that her mother could not breathe and requested EMS go to the facility. Further review of the ambulance report revealed that EMS arrived at the facility on January 30, 2020, 10:28 AM to find the resident unattended in her room. The resident was noted to be tachypneic (abnormally rapid breathing) and in obvious distress. The resident was only able to speak in short sentences. The resident stated to the EMS crew she had been short of breath all morning. The resident's vital signs were obtained and was noted to have a respiratory rate of 36 breaths per minute (normal 12 to 20 breaths per minute) and her oxygen level was 83% on 4 liters of oxygen. A review of facility documentation dated January 30, 2020, at 10:27 AM revealed that Employee 7 RN (registered nurse) noted that the resident was sent to the hospital because her needs were unable to be met due to the resident stating she had respiratory distress after several attempts to convince the resident and educate her on her condition. An interview with the DON (director of nursing) on February 21, 2020, at approximately 10:30 AM revealed that she was not aware that the facility cancelled the ambulance when the resident called 911 to go to the hospital on January 30, 2020. The DON was unable to identify the employee who cancelled the ambulance. The DON stated if the resident wanted to go to the hospital then she should have been allowed to go. An interview with Employee 6, LPN (license practical nurse) on February 21, 2020, at 11:00 AM revealed that this nurse stated that the resident was complaining of being short of breath. She stated the resident's vital signs at that time were okay. The employee informed the Employee 7, RN, of the resident's change and notified the physician to get an order for [REDACTED]. The employee stated then either the resident or the resident's daughter called 911 again and the facility sent the resident to the hospital. An interview with Employee 7, RN, on February 21, 2020, at 11:08 AM revealed the employee stated the resident called the ambulance but claimed all the resident wanted was a ginger ale so the employee cancelled the ambulance. The employee stated the resident's daughter called 911 back and requested they take the resident to the hospital. Employee 7 stated he did not see the resident in respiratory distress. He further stated the note he wrote on January 30, 2020, at 10:27 AM indicated he was trying to convince the resident she was stable and in no distress and did not need to go the hospital. An interview with the resident's sister on February 21, 2020, at 11:37 AM revealed that she spoke with the resident on the day she was transferred to the hospital on January 30, 2020. The resident's sister stated that the resident called her that morning stating she could not breathe. The resident's sister further stated her sister told her that she had been feeling bad for days and the facility won't let her go to the hospital. The resident's sister stated that while speaking with the resident you could tell she was short of breath. She was having trouble speaking sentences and you can hear she was short of breath. The sister stated when she found out the facility had cancelled the ambulance the resident had called, she called the resident's daughter to call 911. The sister further stated she had spoken with the facility before and was told that the facility can do whatever a hospital can do, and she doesn't need to go to the hospital. A review of emergency department records dated January 30, 2020, at 11:05 AM revealed that the resident presented to the emergency department with shortness of breath. The resident was short of breath and 911 was called, but the facility canceled the 911 call. 911 was called again and the resident was transported to the hospital. Upon physical examination the resident was noted to appear ill and in respiratory distress. The resident's lungs were assessed and was noted to have rales (abnormal lung sounds the sound crackly or wet depending on the amount of fluid in the lungs) and rhonchi (rattling sound in the lungs often cause by an obstruction or secretions) throughout her lungs. The resident was diagnosed with [REDACTED]. No documentation was found in the resident's clinical record that the resident was in any physical/respiratory distress on the day she was transferred to the hospital. Further review of documentation in the resident's clinical record revealed that the facility's nursing documented the resident's oxygen level was 90% on room air at 10:36 AM, which was not consistent with the ambulance report. The EMS crew were already present in the facility with the resident, assessing her at 10:31 AM and found that the resident had an oxygen level of 83% on 4 liters of oxygen. An interview with the resident's daughter on February 24, 2020, at approximately 7:00 PM revealed that she received a frantic phone call from the resident's sister on January 30, 2020. The daughter stated she was told the resident was having trouble breathing and the facility would not let her go to the hospital. The daughter indicated at that time she called 911 to have an ambulance take her mother to the hospital. The daughter further stated she met the resident at the hospital. When the daughter saw the resident, she stated she looked really sick. The resident was having trouble breathing and could barely make sentences because she was so out of breath. The daughter further indicated her mother had passed away on February 6, 2020, because her body could not fight the illnesses. Interview with the Director of Nursing on February 21, 2020 at approximately 2:15 PM confirmed that the facility staff failed to provide nursing services consistent with professional standards of quality to ensure that this resident received timely and necessary treatment and services at the level required to address the resident's clinical condition. A review of the clinical record revealed that Resident 127 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning). A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 27, 2019, indicated that the resident was moderately cognitively impaired. The resident required staff assistance for activities of daily living which included bed mobility and transfers. Review of information dated October 7, 2019, submitted by the facility revealed that on October 4, 2019, Resident 127 had a witnessed fall in front of the nurses station. Nursing assessed the resident and no pain or shortening (of the leg) was noted. Nursing noted that on October 6, 2019, the resident complained of pain. An x-ray and pain medication were ordered. On October 7, 2019, an x-ray showed a foreshortening of the left femoral neck (hip area) which was suspicious for an impacted [MEDICAL CONDITION]. The physician was notified and ordered to follow up with ortho according to this information. The family was made aware and requested that the resident be transferred to the emergency room for evaluation. The resident had a current physician order [REDACTED]. for [MEDICATION NAME] 325 mg two tablets by mouth as needed every 8 hours for severe pain. Review of the resident's October Medication Administration Record [REDACTED]. [MEDICATION NAME] 650 mg was administered and noted to be effective. The resident's pain level increased to an 8 on October 6, 2019, at 5:37 AM. [MEDICATION NAME] 650 mg was administered and noted to be effective. Review of the resident's recorded pain levels also noted that on October 6, 2019, at 6:26 AM the resident had a pain level of 2 (mild pain) and at 9:10 AM had a pain level of 4 (moderate pain). A nurses note dated October 6, 2019, at 7:40 PM indicated that the resident was status [REDACTED]. The physician was contacted and ordered [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] medication) 15 mg by mouth once daily for pain. The resident's responsible party was notified. A physician order [REDACTED].>An x-ray completed October 6, 2019, and reviewed by the radiologist October 6, 2019, at 9:59 PM noted the exam was limited by positioning. The conclusion was foreshortening of left femoral neck suspicious for an impacted fracture. A nurses note dated October 7, 2019 at 1:00 AM indicated that the resident was received in bed, alert, and in no distress. X-ray received. Physician notified and order to keep on pain medications and schedule an orthopedic appointment. Registered nurse supervisor made aware. A nurses note dated October 7, 2019, at 11:00 AM indicated that the resident's responsible party requested that the resident be sent to the emergency room . A nurses note dated October 7, 2019, at 11:20 AM indicated that the resident was transferred to the emergency room . Review of the hospital discharge summary dated October 11, 2019, revealed that the resident was admitted to the hospital on October 7, 2019, with a [DIAGNOSES REDACTED]. It is used for serious fractures which cannot be treated with a cast or splint). Interview with the Director of Nursing on February 21, 2020, at approximately 10:00 AM failed to provide documented evidence that the physician was timely notified of the resident's reported pain, which was initially noted on October 5, 2019, in an effort to provide appropriate and timely services and treatment following the resident's fall on October 4, 2019. During interview with the resident's physician on February 21, 2020, at 11:00 AM the physician stated that he did not recall being made aware of Resident 127's x-ray result, as noted in the facility's documentation. The physician stated that the timely and appropriate response, based on the results of the resident's x-ray results, would have been to transfer the resident to the hospital and not to schedule an ortho appointment. 28 Pa. Code §211.5(g) Clinical records 28 Pa. Code §211.5(h) Clinical records 28 Pa. Code §211.12(c) Nursing services 28 Pa. Code §211.12(d)(1) Nursing services 28 Pa. Code §211.12(d)(3) Nursing services 28 Pa. Code §211.12(d)(5) Nursing services

Based on review of select facility policy and clinical records, observations and staff interviews it was revealed that the facility failed provide services consistent with professional standards by failing to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) by one of two residents reviewed (Resident 18). Findings include: A review of the facility's policy entitled Pressure Ulcer Policy last reviewed by the facility on (MONTH) 23, 2019, indicated it is the facility's policy to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure sore from developing. The first step in prevention will be through identification of the resident at risk of developing pressure ulcers. This will be followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. A review of the clinical record revealed that Resident 18 was admitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. A review of an Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 11, 2019, revealed that Resident 18 was at risk for developing pressure sores and required assistance of staff for all activities of daily living, including bed mobility, transfers and toileting. Section M (skin section) of the MDS indicated that the resident was at risk for pressure sores and interventions were noted to include pressure reducing devices to bed and chair. A review of the resident's admission evaluation/Braden assessment scale (a tool that was developed to assess a patient's risk of developing a pressure ulcer. The Braden Scale uses a scores from 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury) dated (MONTH) 4, 2019, revealed the resident's scored 14 with moderate risk for skin breakdown. According to interview with the facility's corporate nurse consultant on (MONTH) 8, 2019, a resident at moderate risk for skin breakdown will have physician orders [REDACTED]. The admission assessment also indicated that the resident had an abductor pillow (A pillow or cushioned wedge placed between the legs of a patient to maintain proper positioning and prevent dislocation of the hip joint) in place. The facility was unable to provide documented evidence, by end of survey of (MONTH) 9, 2019, that staff was placing the abductor pillow between the resident legs as noted in the resident's admission evaluation. A bi-weekly skin check dated (MONTH) 4, 2019, revealed that the resident had no skin impairment present on admission to the facility. The admission MDS assessment dated (MONTH) 11, 2019, also indicated no pressure areas noted on admission. A review of a progress note dated (MONTH) 12, 2019, at 12:12 PM, revealed the presence of an intact fluid filled blister on resident's left heel. The wound was in-house acquired, measuring 3.0 cm in length x 3.0 cm in width by 0 cm in depth. It was noted that skin impairment was not present on admission, that no drainage no odor, the periwound appearance was pink and the resident's pain level was an eight (on a scale of 1-10). It was noted that the heel protector was applied. Will continue to monitor, apply skin prep, float heel when in bed using pillows, and use heel protector when in bed. A review of the facility's wound assessment dated (MONTH) 13, 2019, revealed an in-house acquired wound, which measured 3.0 cm in length x 3.0 cm in width x 0 cm in depth, intact fluid filled blister to the resident's left heel. The wound appearance was pink in color The assessment was signed off by Employee 1 (Licensed Practical Nurse) who noted in the comment section continue to monitor, apply skin prep, float heels when in bed using pillows and use heel protectors while in bed. A review of the facility's wound assessment, dated (MONTH) 21, 2019, indicated that the resident's wound had increased in size and measured 3.5 cm in length x 4.8 cm in width and 0 cm in depth and was unstageable. It was noted that the blister was larger and more fluid filled since previous past wound assessment, was red in color surrounding the area and deteriorating. This assessment was also conducted by Employee 1, a licensed practical nurse. A review of the facility's wound assessment dated (MONTH) 26, 2019, indicated that the resident's wound measured 4.0 cm in length by 4.5 cm in width and 0 cm in depth, unstageable left heel wound. It was noted that the wound was intact, darkly discolored blister, and also identified as pink in color and unchanged. The assessment was signed off by Employee 1 (Licensed Practical Nurse). There was no documented evidence that the resident's treatment regimen, care and services to promote healing were evaluated on (MONTH) 26, 2019, with the noted worsening of the pressure sore. According to the Pennsylvania Code, Title 49. Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing, Responsibilities of the registered nurse, subsection 21.11 General Functions (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals for families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions (1) Collects complete and ongoing data to determine nursing care needs(3) Analyses the health status of the individuals and families and compares the data with the norm when possible in determining nursing care needs (6) Evaluates the effectiveness of the quality of nursing care provided. Further review of the Pennsylvania Code, Title 49. Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145 Functions of the LPN revealed that resident assessment was not within the scope of practice of an LPN. The facility made a referral to the wound specialist on (MONTH) 27, 2019, for a thorough wound assessment and evaluation. Resident 18 was seen by the wound specialist on this date to evaluate the resident's left heel wound. The wound specialist noted the wound to be an unstageable DTI {deep tissue injury (a pressure-related injury to subcutaneous tissues under intact skin)} measuring 2.5 cm in length by 3.0 cm in width with recommendations were to float heels in bed, off load wound, reposition per facility policy. A review of the resident's admission orders [REDACTED]. There was no documented evidence that a heel boot was ordered until after the pressure sore was found on (MONTH) 13, 2019. A review of the resident's care plan initiated on (MONTH) 6, 2019, revealed an intervention to implement a heel boot to left heel when in bed. At the time of the survey ending (MONTH) 9, 2019, the initiation and consistent application of the heel boot could not be ascertained. A review of the (MONTH) 2019 treatment records indicated that resident's heels were to be elevated, as tolerated, every shift for prevention and the resident was to be turned and repositioned every two hours as tolerated while in bed. The facility was unable to provide evidence that the resident had been turned and repositioned every two hours as tolerated. Once each shift nursing staff noted that the resident had been repositioned at the scheduled frequency, but failed to specifically indicate the times this repositioning had been performed and the staff member(s) responsible during the shift. Observation of Resident 18's pressure sore on (MONTH) 9, 2019, at 11:25 AM, revealed a wound, which appeared 90 % slough and 10 % granulation. A review of the wound specialist note dated (MONTH) 9, 2019, revealed that the wound surface area measured 5.52 cm, with 90 % slough and 10 % granulation tissue. The wound specialist note dated (MONTH) 9, 2019, revealed the wound was documented as a stage 3 pressure ulcer, measuring 2.4 cm in length by 1.8 cm in width by 0.1 cm in depth, with moderate serous (a thin clear watery substance) drainage. Recommendations were to floats heels in bed, , use heel up pad (a therapeutic heel elevating cushion) if available or multiple pillows to achieve complete floatation of heels, off-load wound, use leg cradle while in wheelchair, reposition per facility policy. During an interview with the resident on (MONTH) 9, 2019, at 11:25 AM, she stated the facility staff had not been elevating her heels while she was in bed until she complained of foot pain when the wound had developed back in March. The facility was unable to demonstrate that they had timely identified declines in the resident's skin integrity and had implemented prompt and adequate measures to prevent the development and worsening of a pressure sore on the resident's heel for a resident identified as a moderate risk for pressure sore development upon admission to the facility on (MONTH) 4, 2019. The facility failed to provide services consistent with professional standards of nursing practice for the wound assessments and healing evaluation of the resident's pressure sore. 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited 1/27/19, 1/3/19, 7/20/18 28 Pa. Code 211.12(a) Nursing services Previously cited 1/27/19, 1/3/19, 7/20/18 28 Pa. Code 211.12(c) Nursing services Previously cited 1/27/19, 1/3/19, 7/20/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 1/27/19, 1/3/19, 7/20/18 28 Pa. Code: 211.12(d)(3)(5) Nursing Services Previously cited 1/27/19, 1/3/19, 7/20/18

Based on review of clinical records, facility event summary reports and information submitted by the facility and staff interview, it was determined that the facility failed to provide staff assistance as planned to safely perform activities of daily living and implement sufficient supervisory measures and/or individualized safety interventions to prevent falls with serious injuries (fractured elbow and spine) for two of nine residents reviewed with falls (Resident B2 and Resident 2A). Findings include: Resident 2A was admitted to the facility on (MONTH) 29, 2014, with a [DIAGNOSES REDACTED]. (sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. [MEDICAL CONDITION] also referred to as a stroke) with left sided [MEDICAL CONDITION]/[MEDICAL CONDITION] ([MEDICAL CONDITION] is weakness on half of the body, while [MEDICAL CONDITION] refers to paralysis that affects just one side) left sided weakness and muscle weakness. According to review of Resident 2A's most recent MDS Assessment, an annual assessment dated (MONTH) 28, (YEAR), (Minimum Data Set Assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) the resident required the extensive assistance of two staff members for toileting and transfers. The residents BIMS (brief interview for mental status-test to determine cognitive status) score was 15, which indicated that the resident's cognition was intact. A review of the resident's comprehensive plan of care, which was last revised on (MONTH) 28, (YEAR), revealed that the resident required the extensive assistance of two staff members for toileting and transfers and had range of motion deficits to her left arm related to her diagnoses. A review of the resident's clinical record revealed that on (MONTH) 5, 2019, Employee 4 (a nurse aide) was transferring the resident from the wheelchair to the toilet when the resident bumped her left arm/shoulder on the grab bar in the bathroom. The resident was examined and no bruising, or deformity was found, but the resident complained of pain at a 4 out of 10 level (scale of 1-10 with 10 being highest level of pain). The resident's attending physician was notified and ordered an X-ray of the resident's left arm and shoulder. A review of the x-ray results radiology report (January 6, 2019) indicated the resident had an acute [MEDICAL CONDITION] humeral neck (an injury to the bone of the upper arm that connects the shoulder to the elbow) with moderate displacement (In a displaced fracture, the bone snaps into two or more parts and moves so that the two ends are not lined up straight), angulation (a specific type of fracture displacement where the normal axis of the bone has been altered such that the distal {situated farthest from the center, median line, or point of attachment or portion of the bone} points off in a different direction) and demineralization (reduced content of mineral substances the bone). The resident's physician ordered an orthopedic (the branch of surgery concerned with conditions involving the musculoskeletal system) appointment for the resident and a pain management regimen that included both narcotic and non-narcotic pain medications, non-steroidal anti-[MEDICAL CONDITION] drugs and nerve medications used to treatment chronic pain as the resident continued to complain of severe pain throughout the month of (MONTH) 2019, according to nursing documentation and medication administration records. A review of the facility investigation into the incident revealed that when Employee 4 was interviewed by the facility, she stated that she was not aware of the resident's transfer status because she was not able to access the facility's computerized documentation system. Employee 4 stated that, although she had been employed at the facility since (MONTH) (YEAR), she did not have her own personal access code and had been documenting in the system using the codes of other employees. However, Employee 4 had been accessing the facility computerized documentation system since her employment, under the names of other nurse aides using their codes to gain access, having the means to access Resident 2A's transfer status. Employee 4 admitted that she had transferred the resident without the assistance of another staff member. There was no indication that Employee 4 had informed the facility that she did not have her own personal access code to access resident care information and had been using other staff's codes to document the provision of care. When interviewed by the facility as part of their investigation into the injury, the resident confirmed that Employee 4 had transferred her by herself and she had bumped her arm on the hand rail in the bathroom. A review of the clinical record review revealed that Resident B2 was admitted to the facility on (MONTH) 14, 2019, with [DIAGNOSES REDACTED]. According to a nursing admission assessment dated (MONTH) 14, 2019, at 9:15 PM the resident was admitted to the facility with change in mental status was alert, but hard of hearing and required the use of hearing aides. This assessment included a fall assessment, which indicated that the resident was at high risk for falls and in the past 90 days had 1 -2 falls, required assistance with elimination and had difficulty ambulating and was not steady on his feet. A nursing assessment dated (MONTH) 15, 2019, at 12:15 AM entitled 72 Hour Post Admission Nursing Note indicated that the resident required extensive assistance with two persons for transferring between surfaces, bed mobility and toileting. At the time of this assessment, the resident had been attempting to get out of bed and was brought by nurse's station. It was noted that the resident was hard of hearing. Nursing communicated with him by notes, which revealed that the resident's hearing aides were not working. Nursing noted he had no safety awareness. Nursing documentation indicated that the resident continued to stay awake and attempt to ambulate and was redirected multiple times. The staff toileted him and assisted him back to bed, but he attempted to get back out of bed and was returned to be close to the nursing station for supervision. A plan of care was initiated for this resident on (MONTH) 15, 2019, with interventions to include call light within reach, assistance of one person for ADL's (activities of daily living- dressing, grooming, toileting, feeding, hygiene) implement preventative fall interventions and devices. However the care plan did not identify the specific fall interventions and devices, that were planned for this resident's use. Nursing documentation dated (MONTH) 16, 2019, at 4:00 AM indicated a nurse aide Employee 1 was doing morning rounds and noticed the resident was wet and soiled in bed. The resident became combative, yelling and screaming. The nurse aide walked away from resident to allow him to calm himself down. The resident was then witnessed standing in his room holding on to the wall and walking when he put himself on the floor. Employee 2, LPN (licensed practical nurse) entered the room and the resident was sitting in the middle of the room with his legs crossed screaming and yelling. The resident was swinging his arms not allowing care to be rendered. The resident did not sustain any injury. The resident was placed on frequent checks every 15 minutes according to a post fall note written by Employee 2 on Janaury 17, 2019, at 2:00 AM. After the resident was observed to place himself on the floor on (MONTH) 16, 2019, the resident's care plan was updated to include the approach that staff will check on the resident and anticipate his needs and an order for [REDACTED]. Nursing documentation dated (MONTH) 19, 2019, indicated at 11:30 AM Employee 3, LPN, was called to this resident's room by a housekeeping staff member (no name identified in report). The resident was found on the floor lying on his right side with an abrasion to the right side of his forehead. The resident was sent to the emergency room for evaluation. The facility documentation indicated that he was assisted up from the floor and returned to his wheelchair from which he had apparently fallen. However, the facility's report failed to clearly denote if the resident had fallen from his wheelchair or from the bed. The resident was sent to the hospital at 12:10 PM on (MONTH) 19, 2019, and returned to the facility on this same date at 7:00 PM. A report provided to the facility from the hospital at 6:30 PM on (MONTH) 19, 2019, indicated that the resident had no broken bones. However, upon the resident's return to the facility the hospital discharge summary indicated that the resident had a nondisplaced fracture (term used for broken bone that remains in place) of his L1-L2 vertebrae (lowest portion of the spine), a [MEDICATION NAME] process fracture (each vertebra has two [MEDICATION NAME] process, spine/vertebra supports the back and protects nerves that supply the arms and legs). Nursing documentation dated (MONTH) 19, 2019, at 11:15 PM indicated that the resident was to be seen for follow up with an orthopedic physician, which occurred on (MONTH) 25, 2019. It was not until after the fall of (MONTH) 19, 2019, resulting in a fractured spinal vertebrae that the facility implemented safety alarms to the resident's bed and chair, to alert staff when the resident attempted to ambulate or get out of bed on his own. Clinical record review and observation of this resident on (MONTH) 27, 2019, at approximately 3:00 PM in his room, revealed that upon admission until the time of the survey, the resident resided in the room located the farthest from the nursing station. The resident was observed seated in a wheelchair and did respond to conversation with the surveyor. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on (MONTH) 27, 2019, regarding the appropriateness of the resident's room placement and the resident's need for increased staff supervision and timely response to safety alarms, revealed that both staff members stated that the location of the resident's room did not matter as there was an expectation that every room was safe and supervised regardless of location. The facility was aware of this resident's poor safety awareness and high risk for falls upon admission of (MONTH) 14, 2019, but the resident sustained [REDACTED]. There was no evidence the facility had provided adequate and increased supervision at the frequency and level required and/or effective safety measures to promote this resident's safety and prevent repeated falls. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 1/3/19 28 Pa. Code 211.11(d) Resident care plan Previously cited 1/3/19, 7/20/18, 8/10/17 28 Pa. Code 211.12(a) Nursing Services Previously cited 1/3/19, 7/20/18, 4/27/18, 8/10/17 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 1/3/19, 7/20/18, 4/27/18, 1/19/18, 8/10/17

Based on a review of clinical records and select facility policy and staff and family interviews, it was revealed that the facility failed to provide timely and necessary care and services to promote adequate bowel activity for two residents (Residents 14 and 27) and prevent constipation and resultant fecal impaction for one resident (Resident 14), failed to promptly identify and act upon clinical signs and symptoms of disease exhibited by one resident (Resident CR1) resulting in an exacerbation of the resident's clinical condition, failed to perform diabetic and blood pressure management as ordered by the physician for two residents (Residents CR1 and 27) and failed to coordinate the care of one [MEDICAL TREATMENT] resident (Resident 31) out of 16 sampled residents. Findings include: A review of the clinical record of Resident CR1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts of the body) of his foot. Upon admission the resident presented with leg swelling and a physician's orders [REDACTED]. The nursing documentation noted that the resident had 3 plus [MEDICAL CONDITION] in his bilateral legs and was non-compliant at times with leg elevation. (Pitting [MEDICAL CONDITION] is a physical examination finding that occurs when you press on a patient's skin, usually the shins, ankles, or feet, and a pit forms at the site of pressure. The [MEDICAL CONDITION] is graded on a scale from 1 to 4, which is based on both the depth the pit leaves and how long the pit remains. A score of 3 is deeper yet (6 mm {millimeters}), and can last longer than a minute; in stage 3 [MEDICAL CONDITION] the extremity also looks grossly swollen, stage 4 is the most severe with deep pitting (8 mm or greater in depth) that may last more than 2 minutes). The resident was weighed at the facility on April 11, 2015, and weighed 240 pounds. The nursing documentation dated April 14, 2015, indicated that the resident had a cough and was wheezing. The physician was made aware and ordered [MEDICATION NAME] pearls (cough medication) 200 mg (milligrams) by mouth three times a day, a [MEDICATION NAME] Dose Pack (steroid use to decrease inflammation) and Nebulizer treatments (mist inhaled into the lungs to treat asthma) every four hours as needed for cough and wheezing. The resident's wife stated during an interview on July 24, 2015, at 2:00 p.m., that the facility told her the resident had asthma and that is why the above medications were ordered. A progress note written by the resident's attending physician dated April 23, 2015, indicated that the resident had a [DIAGNOSES REDACTED]. The terms [MEDICAL CONDITIONS] or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. The signs and symptoms commonly include shortness of breath and leg swelling). On May 7, 2015, the resident was seen at an appointment at the vascular surgeon for a consult due to the swelling in both of his legs and [MEDICAL CONDITION] of his left leg. During this physician visit, the resident's weight was noted as 239 pounds. The consulting physician indicated that the resident was to have his fluid overload (too much fluid in the blood which leads to swelling in the extremities and difficulty breathing) managed by his (attending) medical doctor and also ordered [MEDICAL CONDITION] ([MEDICAL CONDITION] is a condition in which blood clots (or thrombi) form in deep veins in the legs or other areas of the body) [MEDICATION NAME] (preventative). The veins are the blood vessels that carry blood from the body's tissues to the heart. The deep veins are located deep in the body, away from the skin's surface) and leg elevation. The nursing documentation dated May 10, 2015, at 4:30 a.m., indicated that the resident was heard wheezing and had an oxygen saturation level of 88% (amount of oxygen in the blood, normal range is between 97-99%). A physician's orders [REDACTED]. The clinical record revealed the resident's oxygen saturations were documented only on a daily basis with readings ranging from 85% to 95%. There was no documented evidence that the facility consistently assessed the resident's lung sounds to evaluate the potential for fluid in the lungs when his oxygen saturation levels were not in the normal range. There was also no documented evidence that the resident was checked for increased swelling other than documentation indicating the presence of bilateral (both sides) [MEDICAL CONDITION] (fluid accumulation due to swelling). A review of the nursing documentation and attending physician's orders [REDACTED]. physician was made aware of the consult report. Upon physician notification of the consult report, a diuretic/blood pressure medication (diuretic promotes the production of urine) [MEDICATION NAME] 2.5 mg by mouth (decreases blood pressure prevents excess fluid accumulation in patients with heart failure) was ordered for seven days along with the anticoagulant medication [MEDICATION NAME], 5000 units twice daily, to be injected under the skin to prevent blood clots. The physician continued the order for the administration of oxygen at two liters per minute via nasal canula, as needed, to keep the resident's oxygen saturation levels at 90% or greater. Interview with the Nursing Home Administrator (NHA) on July 23, 2015, at 9:30 a.m., failed to explain why the facility did not promptly act upon the medical consult recommendations and did not inform the resident's attending physician until three days after the resident was seen by the consulting physician. A review of the resident's weight record indicated that on May 12, 2015, the resident weighed 259.5 pounds, which was an increase of 19.5 pounds from his admission weight of 240 pounds on April 10, 2015. The facility's current policy for resident weights, dated as reviewed by the facility June 2015, indicated that if a resident had a 5 pound or greater weight loss or gain, the resident would be reweighed within 24 hours. A review of the Nutrition at Risk Progress Notes by the facility dietitian dated May 14, 2015, indicated that the resident's weight was elevated, his (meal) intakes were variable and his family brings in snacks. At the time of the entry, the dietitian was waiting for a reweight of the resident according to facility policy, but further review of the resident's clinical record revealed that the reweight was not completed. On May 14, 2015, the dietitian discharged this resident from the facility's nutritional at risk program (a program which directs more frequent monitoring of the resident's nutritional status). The Certified Dietary Manager confirmed during an interview on July 21, 2015, at 2:00 p.m., that the resident was not re-weighed as indicated by the facility policy. Additionally, the resident's attending physician was not notified of the resident's significant increase in weight. The resident's weight was documented as 280 pounds on May 18, 2015, which, was indicated that the resident had gained another 20.5 pounds in four (4) days and for a total weight gain of 40 pounds since the resident's admission on April 10, 2015. The resident was not reweighed at the facility on May 18, 2015, as he was scheduled to attend an appointment with a consulting physician. A review of a progress note written by the consulting physician on May 18, 2015, also noted that the resident had experienced a 40 pound weight gain and required hospitalization to manage the swelling (due to fluid overload). The resident was directly admitted to the hospital, from the consulting physician's office, for fluid overload. The resident was treated at the hospital for a [DIAGNOSES REDACTED]. The resident did not return to the skilled nursing facility. The facility failed to identify and promptly act upon the resident's signs and symptoms of [MEDICAL CONDITION], to include excessive weight gain, shortness of breath and swelling of extremities. The Director of Nursing stated during multiple interviews conducted during the survey ending July 23, 2015, that the resident did not have a [DIAGNOSES REDACTED]. This same resident had a physician's orders [REDACTED].{glucose} in the blood) to be done one hour before each meal, three times a day, with coverage (administration of insulin based on the amount of glucose according to the results of the Accucheck testing) with [MEDICATION NAME]to be given as follows based on the Accucheck results: 0-100= no coverage 101-150=10 units [MEDICATION NAME] 151-250=15 units [MEDICATION NAME] Greater than 250 Call MD A review of the resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. An interview with the Nursing Home Administrator on July 23, 2015, at 9:30 a.m., confirmed that the incorrect amount of insulin was administered to this resident on May 14, 2015. The NHA stated that the reading on May 16, 2015, was, not in the 150s, it was in the 130's and the correct insulin was given, however, an Accucheck result of 157 was documented on the resident's MAR. A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses, which included a knee joint replacement (a surgical procedure in which damaged parts of the knee joint are replaced with artificial parts) and [MEDICAL CONDITION] (low levels of sodium in the blood). The resident was prescribed 1000 cc (cubic centimeters) of fluid in 24 hours for her low sodium. The resident was also prescribed Sodium Chloride Tablets 450 mg by mouth two times a day and then three times a day, beginning April 28, 2015. The resident also received [MEDICATION NAME] 10 mg (an opioid pain medication which can cause side effects of constipation and loss of appetite) by mouth every eight hours as needed for pain and iron tablets, one tablet every other day to supplement her iron (a potential side effect of iron supplementation is constipation). The resident was also prescribed a bowel management protocol which included: prune juice 120 cc if no bowel movement (BM) in 2 days, if no bowel movement give Milk of Magnesia (a laxative, medication used to promote bowel movement) 30 cc (one ounce) by mouth on the third day, if no BM give [MEDICATION NAME] 10 mg suppository (a stimulant laxative) suppository (rectally) by day 4 at bedtime, if ineffective give an enema disposable (lubricant laxative) 19 G-7 G/118 rectally as needed on day five without a bowel movement. A review of the resident's weight record revealed that on April 28, 2015, the resident weighed 121 pounds. On April 29, 2015, her weight was recorded as 114.5 pounds and a reweight on April 30, 2015, confirmed the 114.5 pound weight. On May 5, 2015, the resident's weight was recorded at 105.5 pounds and a reweigh on May 6, 2015, confirmed the weight of 105.5, which represented a weight loss of 15.5 pounds in one week. A review of the resident's meal intakes for April 24 through April 30, 2015, revealed that the resident consumed 0% to 75% of meals. The facility was unable to locate the resident's meal intake records for May 2015, during the survey ending July 23, 2015. A review of documentation by the facility's dietitian revealed that the resident was receiving nutritional supplements and [MEDICATION NAME] (drug used to stimulate appetite) 400 mg by mouth twice daily. The dietitian also noted that as per the resident's daughter, the resident had a history of [REDACTED].{eating to excess} and then vomiting). The nursing documentation of April 28, 2015, at 3:00 p.m., revealed that the resident complained of nausea and pain in her rectal area and complained of constipation (infrequent bowel movement). The entry indicated that the resident had a bowel movement on April 27, 2015. Upon nursing assessment of the resident at that time, the resident did not have abdominal pain and had bowel sounds (bowel sounds are made by the intestines while pushing food through them, a lack of bowel sounds indicate the intestines are not pushing out feces and can be a sign of constipation). The prune juice was given to the resident as per the bowel regimen. Nursing noted that at 5:00 p.m. on April 28, 2015, an enema was administered to this resident and a small amount of brown loose feces was observed in response. The nursing documentation on this date further indicated, Mobilex (mobile x-ray company) was called for an x-ray of the abdomen (KUB an x-ray which shows kidneys, ureters and bladder). The results of the KUB revealed that a moderate amount of rectal stool was present. A second enema was given to the resident at 6:00 p.m., as ordered by the physician (a [MEDICATION NAME] enema was ordered; this type of enema decreases the ammonia level in the body and treats constipation). The nurses' note of April 28, 2015, at 6:00 p.m., indicated that the resident was passing loose and watery stools since the first enema and was, yelling in pain since 4:00 p.m., on April 28, 2015. The resident continued on the 1000 cc fluid restriction as ordered by the physician for low sodium levels and received multiple medications for pain due to her newly replaced knee. The resident received approximately 16 doses of the pain medication [MEDICATION NAME] 10 mg (a side effect of this narcotic medication is constipation) from April 28, 2015, through May 12, 2015. According to the resident's weight and meal intake records from admission through May 2015, the resident had decreased food intake and experienced a significant weight loss. The resident's weight record indicated that she weighed 105.5 pounds on May 6, 2015, revealing a 16 pound weight loss since admission to the facility, eight (8) days prior. Nursing noted that on May 11, 2015, the resident's daughter was concerned that the resident was declining as the resident displayed weakness and had vomited after breakfast. A nursing note dated May 11, 2015, at 12:15 p.m., indicated that the physician planned to speak to the resident's daughter regarding an enteral tube feeding (a feeding tube is a medical device, a flexible tube surgically inserted into the stomach, used to provide nutrition to patients who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) or hospice (special care for the terminally ill {end of life care}). On May 12, 2015, at 2:00 p.m., according to nursing documentation, the resident was transferred to the hospital via the emergency room for placement of an enteral tube feed and the resident and daughter were in agreement. A review of the hospital consultation report dated May 13, 2015, at 1:43 p.m., the resident was admitted to the emergency room with a complaint of abdominal discomfort, nausea, vomiting, failure to thrive (insufficient weight gain), diminished appetite and dysuria (painful or difficult urination). The report noted that the resident recently had knee surgery and according to the consult, the resident's daughter reported that prior to surgery, she was doing well. The consult continued that the resident presented with a change in mental status for several days prior to the admission to the emergency room along with abdominal discomfort. The resident underwent [REDACTED].). The resident was then disimpacted (removal of stool from rectum) of a large amount of stool and then began to have bright red blood pass through her rectum. During an interview with the resident and her daughter on July 22, 2015, at 11:55 a.m., it was revealed that when the staff in the hospital's emergency room rolled the resident over, the resident had a very large amount of stool protruding from her rectum. The resident's daughter stated that the resident had not been eating due to this fecal impaction and lost a lot of weight. Both the resident and her daughter reported that the bowel movements that the resident had at the facility, prior to being diagnosed with [REDACTED]. However, a review of the resident's bowel movement record failed to reveal the consistency of the stool described by the resident and her daughter (loose stool can seep around a fecal impaction). The resident's bowel records did not include documentation of the consistency of the stool to determine if the resident was evacuating her bowels as normal for this resident. The resident subsequently refused tube feed insertion after disimpaction and the resident's appetite returned to normal and her weight began to increase based on a review of her clinical records. An interview with the Director of Nursing and Nursing Home Administrator on July 22, 2015, at 2:00 p.m., failed to provide evidence that the facility had accurately and effectively monitored the resident's bowel activity and timely identified and appropriately acted upon the resident's lack of normal bowel activity to prevent a fecal impaction. A review of the clinical record of Resident 31 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] (a method of removing waste from the blood to treat kidney disease) services three times weekly at a [MEDICAL TREATMENT] center. An admission Minimum Data Set assessment (MDS - an assessment conducted periodically to plan resident care) dated June 1, 2015, revealed that the resident was cognitively intact and required assistance from staff with activities of daily living. A review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. blood pressure) by mouth twice a day, give at 10 a.m., [MEDICATION NAME] 75 mg (a blood thinning medication) daily at 10 a.m., [MEDICATION NAME] 100 mg (a stool softener) every day at 10 a.m. and Isosurbide ER (an extended release form of the high blood pressure medication, intended to be slowly released over a 24 hour period), 30 mg every day at 10 a.m. A review of the resident's MAR indicated [REDACTED]. However, during an interview conducted with the Director of Nursing on July 22, 2015, at 2 p.m., the Director of Nursing confirmed that the facility had not consulted with the resident's attending physician to confirm that the above medications may be administered to the resident prior to a [MEDICAL TREATMENT] treatment. A review of Resident 27's clinical record revealed current physician's orders [REDACTED]. If the Milk of Magnesia is ineffective by day four insert one [MEDICATION NAME] ([MEDICATION NAME]) suppository rectally. If no bowel movement by day five and the [MEDICATION NAME] ([MEDICATION NAME]) suppository is ineffective give a Fleet enema. If the Fleet enema is ineffective contact the physician. According to documentation of the resident's bowel activity, Resident 27 had no bowel movement from the 11 p.m. to 7 a.m. shift on July 1, 2015, until the 7 a.m. to 3 p.m. shift on July 4, 2015. There was no evidence that prune juice was given on the second day of no bowel movements or Milk of Magnesia administered on day three without a bowel movements as ordered by the physician. Review of the resident's bowel activity revealed that the resident had no bowel movements from July 5, 2015, until July 10, 2015, during the 7 a.m. to 3 p.m. shift. There was no evidence that prune juice was given on the second day without a bowel movement, that Milk of Magnesia was administered on day three without a bowel movement, that a [MEDICATION NAME] suppository was administered on day four of no bowel movement and no evidence that a Fleet enema was administered on day five without a bowel movement. The resident had no bowel movements from July 11, 2015 to July 15, 2015, on the 7 a.m. to 3 p.m. shift. There was no evidence that the resident was provided prune juice on day two without a bowel movement or that Milk of Magnesia was administered on day four of no bowel movement. An interview with the Director of Nursing on July 23, 2015, at 11:05 a.m., confirmed that the physician's orders [REDACTED]. A review of the clinical record of Resident 58 revealed a physician's orders [REDACTED]. blood pressure reading). A review of the resident's blood pressure (BP) readings obtained on the following dates revealed that on the 7 a.m. to 3 p.m. shift on July 10, 2015, the resident's BP was 179/92 mmHg, on July 14, 2015, the resident's BP was 160/80, on July 15, 2015, the resident's BP was 160/78, on July 19, 2015, the resident's BP was recorded as 161/64, and on July 21, 2015, the resident's BP was 170/70. On the 3 p.m. to 11 p.m. shift the resident's blood pressure on July 15, 2015, was 151/71 and July 16, 2015, the resident's BP was 151/75. On the 11 p.m. to 7 a.m. on July 16, 2015, shift the resident's blood pressure was 175/77. There was no documented evidence that the physician was notified of these instances when the resident's systolic blood pressure was greater that 150 mmHg. An interview with the Director of Nursing on July 23, 2015, at 12:41 p.m., confirmed that the nursing staff failed to follow the physician's orders [REDACTED]. 483.25 Quality of Care Previously cited 2/26/15, 10/31/14, 9/4/14 28 Pa. Code 211.5 (f) Clinical records Previously cited 3/24/15, 2/26/15, 9/23/14 28 Pa. Code 211.5 (h) Clinical records Previously cited 3/24/15, 9/23/14 28 Pa. Code 211.10(a) Resident care policies Previously cited 5/20/15, 3/24/15, 2/26/15, 10/10/14 28 Pa. Code 211.10(c) Resident care policies Previously cited 5/20/15, 2/26/15, 10/10/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 5/20/15, 3/24/15, 2/26/15, 10/31/14, 10/10/14 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 5/20/15, 3/24/15, 2/26/15, 12/12/14, 10/31/14, 10/10/14, 9/23/14 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 5/20/15, 3/24/15, 2/26/15, 10/31/14, 10/10/14, 9/23/14

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely identify and act upon individual risk factors, promptly identify declines in skin integrity and implement adequate preventative measures to deter pressure sore development for one resident (Resident CR1) out of five residents sampled. Findings include: A review of the facility policy for Skin and Wound Care Guidelines revised by the facility September 2014, revealed that the facility will provide pressure sore prevention for those at risk for skin breakdown. Pressure sore prevention interventions provided for those at risk for skin breakdown include to offload /suspend heels. Wound and dressing care included measuring wounds weekly and conducting an assessment of the wound prior to each dressing change and document the findings. A review of the clinical record revealed that Resident CR1 is moderately, cognitively impaired resident and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Minimum Data Set assessment (MDS - a federally mandated assessment process conducted periodically to plan resident care) dated March 31, 2015, revealed that the resident required assistance with his activities of daily living (ADLs) and was at risk for developing pressure areas. A review of the monthly recapped physician's orders and plan of care dated March 2015, revealed an order for [REDACTED]. help reduce friction) to bilateral (both) heels daily. The physician's order was increased to apply skin prep to bilateral heels every shift for heel redness on March 19, 2015. A physician's order dated March 27, 2015, noted to apply Prevalon boots (Pressure Relieving Heel Protector boots help minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory patients) to bilateral lower extremities while in bed and wheelchair, and to remove the boots for transfers and skin care. Staff were to monitor the resident's skin integrity every shift. According to the resident's treatment record of services provided, there was no evidence at the time of the survey that the Prevalon boots were applied from the time of the physicians order on March 27, 2015 through March 31, 2015. The treatment records for the months of March 2015 and April 2015 indicated that the boots were applied beginning on April 1, 2015. Nursing documentation dated March 29, 2015, at 1 PM, revealed that a dark area with brownish drainage was identified on the resident's left heel. The physician was notified at that time and a new treatment was ordered. Staff were to monitor the integrity of the resident's skin every shift, but the treatment record for March 2015 revealed that there was no documentation of the status of the resident's legs or lower extremity skin integrity from March 27, 2015 through March 31, 2015. Further, there was no documentation of any skin changes on March 29, 2015, when, according to nursing documentation, the dark area with drainage was found. There was no documented evidence that the Prevalon boots had been in use as a preventative measure on March 29, 2015, when the dark area was found on the resident's left heel.. A review of weekly wound evaluation flow sheets indicated that on March 3, 2015, Resident CR1 had a Stage I pressure area (intact skin with non-blanchable redness of a localized area usually over a bony prominence), reddened area on his left heel measuring 10 cm x 4 cm. The weekly wound tracking indicated that the pressure area remained the same until March 29, 2015, when it was noted as a 4 cm x 8 cm x 0.1 cm, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (dead skin) or eschar (thick, leathery dead skin) in the wound bed. Until enough slough or eschar is removed from the wound bed, the true depth and therefore stage cannot be determined) with a moderate amount of bloody drainage noted). The wound care specialist was consulted. A review of a wound care specialist evaluation dated April 2, 2015, revealed that the reddened areas noted upon admission to the resident's left heel were resolved. However, there was a new pressure area on the resident's left heel measuring 3.5 cm x 8 cm x 0.1 cm, described as unstageable necrosis with light bloody drainage. The facility's weekly wound evaluation sheet was inaccurate. The weekly wound tracking form failed to indicate that the original Stage 1, reddened area on the resident's left heel, present upon admission had healed and that a newly acquired unstageable pressure area was found on the resident's left heel on March 29, 2015. During an interview May 20, 2015 at 1:15 PM, the facility wound nurse confirmed the inaccuracies on the weekly wound evaluation tracking form. During an interview May 20, 2015 at 1 p.m., the Director of Nursing stated that all new pressure areas are investigated in an attempt to determine the cause. She stated that Resident CR1's heel pressure areas were noted upon admission and therefore no investigation in possible causative factors was conducted. After reviewing the wound specialist physician documentation during the survey, she confirmed that the unstageable, left heel pressure area was a new pressure area and the facility should have investigated its potential cause. The Nursing Home Administrator confirmed that there was no evidence that the preventative Prevalon boots were in place as ordered from March 27, 2015, through March 31, 2015, prior to the pressure area development. There was also no evidence that staff were consistently and accurately monitoring the resident's lower extremity skin integrity every shift. There was no evidence at the time of the survey that the facility had timely identified the failure to carry out physician orders for the use of Prevalon boots prior to the resident's skin breakdown, nor did the facility evaluate potential causative factors for the newly acquired skin breakdown. 483.25(c) Treatment/Services To Prevent/Heal Pressure sores Previously cited 10/10/14 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 10/10/14, 3/24/15, 2/26/15, 12/12/14 28 Pa. Code 211.10 (a)(c)(d) Resident care policies previously cited 10/10/14, 2/26/15, 12/12/14

Based on review of clinical records and select accident/incident reports and staff interviews it was determined that the facility failed to devise and implement measures designed to prevent and deter pressure ulcers for one(Resident A2) out of ten residents reviewed. Findings include: A review of Resident A2's comprehensive care plan initially devised by the facility's interdisciplinary team on May 13, 2014, revealed that the facility s identified the resident as being at risk for the development of pressure ulcers due to impaired mobility and fragile skin. According to review of the resident's clinical record, the physical therapy department made recommendations on August 12, 2014, which were approved by the resident's attending physician, for the use of a multipodus boot to the left foot at all times; may remove for activities of daily living and care. The therapeutic device was to be checked every shift to monitor the resident's skin integrity. On August 21, 2014 an additional recommendation was made and a physician's orders [REDACTED]. flexion tightness. The splint was to be removed for activities of daily living and care. Additionally the resident's skin was to be checked every shift, to promptly identify any areas of concern. A review of the resident's comprehensive plan of care in place at the initiation of the devices through September 29, 2014, revealed no indication that the use of these devices was included along with interventions to ensure that staff consistently monitored the devices and underlying skin to prevent pressure and maintain adequate application and appropriate fit. To address the resident's knee flexion tightness the physical therapy department devised a restorative nursing program utilizing passive range of motion techniques, with the intent to increase the resident's left knee extensions and left ankle dorsiflexion to provide the most benefit from the orthotic splinting. Training was provided to caregivers in positioning interventions to prevent further contractures and for pressure relief techniques to prevent the development of pressure ulcers. A review of the treatment records for the month of September 2014, revealed that the licensed staff was consistently documenting application of the orthotic knee extension splint and the multipodus boots, and signifying that these devices were removed for activities of daily living as well as care. Additionally it was documented that the resident's skin integrity was checked on each of the three shifts. Restorative range of motion documentation for the month of September 2014, was reviewed and it was determined that the restorative nursing interventions had been completed on September 17, 2014, with no further evidence that this planned program was completed again until September 29, 2014. A review of nursing progress notes revealed that at 11:00 a.m. on September 29, 2014, a restorative nursing assistant and a representative of the physical therapy department notified the licensed nurse assigned to the resident, that multiple areas of impaired skin integrity had been discovered. The impaired areas where identified beneath the orthotic devices and the location where it had been applied, when the devices were removed to provide in-service training to the restorative aide. An open area to the resident's left calf was identified and measured 5 cm x 5 cm with a depth of 0.8 cm. An unstageable blackened area, which was identified by the facility as a stage IV area (according to The National Pressure Ulcer Advisory Panel a stage IV pressure ulcer is full thickness tissue loss with eschar-dry hard black dead tissue present) was in the center which measured 2 cm x 2 cm. An abrasion was discovered on the resident's left knee measuring 1 cm x 4 cm. Additional open areas were identified to the resident's left posterior mid thigh (0.8 cm by 0.8 cm) and left lateral mid thigh (0.5 x 1.4 cm.) A scabbed area was discovered on the resident's left lateral mid thigh, which measured 0.8 cm x 0.8 cm. Three additional abrasions were identified on the resident's left posterior mid thigh, which measured 6 cm x 0.4 cm, 6 cm x 0.5 cm and 3 cm x 0.4 cm. A review of the facility's investigation (which was signed by the Director of Nursing Services and the Licensed Administrator as complete) into the discovery of multiple areas of impaired skin integrity including the unstageable necrotic area, revealed that there was no indication that the nursing assistant who provided morning care to the resident on September 28, 2014, was identified or questioned regarding the removal of the devices and the resident's skin condition the morning of the discovery. There was also no indication that those caregivers who had been assigned to the resident on shifts prior, had been queried regarding the procedure utilized for checking the skin integrity of the resident. There was no indication that the facility determined if the standard caregiver practice had been to check the resident's skin under the device nor was there any evidence that any attempts were made to determine when the devices had last been removed, and by whom. A summary of the facility's investigation revealed that when the multipodus boot was removed there was "old dried blood" on it. It was the impression that the metal insert of the boot adjacent to the calf rubbed on the "groove" of the resident's calf and caused the open areas. When interviewed on September 10, 2014 at 10:00 a.m., Employee 1 (the Director of Rehabilitation) stated that the nursing assistants had been trained in removing and reapplying splints and multipodus boots. A review of the resident's clinical record revealed that the only documented evidence of the removal of the devices and corresponding skin checks were limited to the treatment administration records which were completed by the licensed nursing staff who did not actually complete this intervention themselves. According to the facility's investigation and review of biweekly nursing skin assessments, the last documented skin assessment was completed by a licensed nurse on September 26, 2014 and revealed no skin impairment. When interviewed on October 10, 2014 at 10:00 a.m. the licensed nurse who had conducted this skin assessment stated that she had not observed any areas of impairment and the aides had not reported any skin issues. When interviewed on October 9, 2014 at 2:20 p.m., the licensed nursing home administrator admitted that the areas had been discovered under the ordered orthotic devices, with one pressure area blackened and unstageable. In response to this finding, the facility conducted assessments of the skin integrity of all residents according to the NHA. A review of the facility weekly wound tracking worksheet revealed that since September 29, 2014, eleven other residents were identified with various types of impaired skin integrity, which were not previously identified. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services. Previously cited: 9/23/14, 7/31/14, 3/19/14 .

Based on a review of clinical records and staff interviews it was revealed that the facility failed to ensure that one resident out of 16 sampled was free of significant medication errors resulting in an exacerbation of the resident's clinical condition (Resident CR1). Findings include: A review of clinical records revealed that Resident CR1 had multiple [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and a physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) is a loop diuretic (water pill) that prevents the body from absorbing too much salt, allowing the salt to instead be passed in the urine. [MEDICATION NAME] treats fluid retention ([MEDICAL CONDITION]) in people with [MEDICAL CONDITION], liver disease, or a kidney disorder. This medication is also used to treat high blood pressure (hypertension). A review of the resident's February 2014 MAR (medication administration record) revealed a handwritten order to "DC" discontinue the [MEDICATION NAME] 40 mg twice daily, dated February 20, 2014. The resident's February 2014 MAR indicated [REDACTED]"now" dose for the resident's shortness of breath. A review of nursing documentation from February 27, 2014, through March 7, 2014, revealed that the resident began to display signs and symptoms of [MEDICAL CONDITION], which progressively worsened. A review of the nurse's notes dated February 27, 2014, at 1:45 PM revealed that the resident developed three water filled blisters on the right lower limb; February 28, 2014 at 2:00 PM nurse's note indicated that the resident complained of shortness of breath and was placed on oxygen of 2 Liters/minute via nasal cannula; Nursing noted on February 28, 2014 at 10:25 PM that the resident complained of anxiety and shortness of breath oxygen saturation 98%. [MEDICATION NAME] was given for anxiety; On March 1, 2014, the resident complained of shortness of breath with an oxygen saturation of 83% the resident was placed on oxygen 4 liters/minute; March 3, 2014, at 1:30 PM nursing noted that the resident displayed confusion and had more lower limb blisters; March 5, 2014, at 1:00 PM nursing noted that the resident's oxygen saturation 94% and both of the resident's lower extremities were weeping; On March 5, 2014, at 5:00 PM, nursing noted that the resident experienced 10 minutes of shortness of breath and no palpable pulse was found. The physician was notified and the physician ordered that [MEDICATION NAME] 60 mg be given at 7:00 PM on that date. The resident was weighed on February 14, 2014, and was 253 pounds. Her weight on March 5, 2014, was 261.5 pounds, indicating a weight gain or potential fluid gain of 8.5 pounds in 19 days. March 7, 2014, at 7:30 AM, nursing noted that the resident complained of not feeling well, the resident's hands were trembling and she had an oxygen saturation of 84% on 3 liters of oxygen; after ten minutes her saturation had decreased and was 74%. The physician advised the facility to send the resident to the emergency room . The resident left the facility via ambulance on March 7, 2014, at 10:11 AM and was admitted to the hospital with [REDACTED]. Upon investigation by the facility, it was determined Employee 5 (RN) discontinued the resident's [MEDICATION NAME] on February 20, 2014, without a physician's orders [REDACTED]. The facility did not identify this medication error for thirteen days. Refer F281 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 10/9/13, 6/14/13, 4/25/13