Every finding on record at William Penn Care Center

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to reassess an elopement risk and implement interventions to prevent elopement after displaying exit-seeking behaviors, and the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Elopements and Wandering Residents dated 1/6/26, indicated the facility will ensure that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of are a dressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification, and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions as necessary. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent elopements. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of vascular dementia with mild behavior disturbance, adjustment disorder, and anxiety. Review of Resident R1's care plan dated 7/24/25, revised 12/3/25, indicated the resident is an elopement risk as evidence by disoriented to place, history of attempts to leave facility unattended, and impaired safety awareness due to vascular dementia. Interventions included to conduct welfare monitoring every 15 minutes, document wandering behavior and attempted diversional intervention in behavior log. It was indicated to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/2/26, indicated diagnoses were current. Review of Section C-Cognitive Patterns, revealed a Brief Interview for Mental Status should not be conducted because the resident is rarely/never understood. Review of Resident R1's elopement risk assessment dated [DATE], revealed the resident was at risk for elopement. It was indicated the resident's care plan was initiated/updated to reflect interventions. A review of Resident R1's care plan failed to include evidence it was updated. Review of Resident R1's progress note dated 6/11/26, revealed the resident attempted to exit the facility through the side door. Resident threw a cup of coffee at staff member. Redirection and reassurance was not effective. The Registered Nurse, physician, and family were notified of behaviors. Safety and comfort measures maintained, plan of care ongoing. The resident was provided with 2 milligram (mg) of Ativan. Review of Resident R1's clinical record revealed the facility failed to reassess resident for elopement risk and implement interventions to prevent resident from eloping after displaying exit-seeking behaviors. Review of Resident R1's progress note dated 6/19/26, revealed the resident was yelling, hitting and attempting to elope. Resident did make it out of the building was brought immediately back in by staff. Review of the Director of Nursing (DON) witness statement dated 6/19/26, stated Resident R1 was last seen a few minutes prior to elopement. The resident was agitated because the DON was trying to educate her about going out the door. Resident R1 ripped the DON's [NAME] out. Review of Licensed Practical Nurse (LPN), Employee E1 witness statement dated 6/19/26, revealed the morning of the start of the shift, Resident R1 was yelling and trying to exit the unit. She was stopped and tried to redirect but resident became irate and hitting staff. After trying to intervene and bring resident back to nurses stations she sat there for a while before continuing. LPN, Employee E1 began passing medications and heard another staff member yell she's outside. At that time, I ran to where they were to find two staff members trying to push her back in while she was physically hitting and trying to bite them. LPN, Employee E1 pulled her wheelchair from behind to bring her back down the hall when she began trying to grab the LPN's arms and scratch them. The supervisor stayed with resident until family arrived. Review of Nurse Aide (NA), Employee E2 witness statement dated 6/19/26, revealed during breakfast meal tray pick up, Resident R1 was wandering up and down the hall. She got to the emergency door and made it outside down the small part of the sidewalk. NA, Employee E2 and two other aides and a therapist and both cart nurses came down the hall to help get the resident back in the building. The supervisor was also notified. Review of incidents submitted to the State field office on 6/19/26, revealed Resident R1 eloped out the door on the west unit around 8:30 a.m. The resident self-propels in wheelchair and is an assist of one/ She can also ambulate very short distances independently. The resident was in the hall ambulating in her wheelchair and managed to open emergency exit door and cross the threshold. She was observed sitting outside the door on the sidewalk by staff. The resident stated she was going to get her car to go home. Resident was brought back inside, and assessed. Resident did not suffer any injuries or make it beyond sidewalk outside of door. During a phone interview on 6/30/26, at 10:08 a.m. LPN, Employee E1 stated on 6/19/26, Resident R1 was irritable, irate, and verbally yelling at staff. It was indicated staff was able to get her to calm down a little with redirection, but she started back up. As LPN, Employee E1 began passing medications, it was indicated she was notified Resident R1 went out the doors. LPN, Employee E1 stated Resident R1 kept saying she needed to see her mom, thought there was a building in across the street from us. It was revealed Resident R1 wasn't outside long and never made it off the sidewalk. LPN, Employee E1 was asked how staff prevent residents from eloping and stated there are certain residents that are elopement risks, and staff must check on them every 15 minutes. During an interview on 6/30/26, at 10:29 a.m. NA, Employee E2 confirmed she was assigned Resident R1 on 6/19/26. When NA, Employee E2 came in that day, Resident R1 was a little agitated. NA, Employee E2 was feeding another resident in their room, and seen Resident R1 approaching the exit doors. NA, Employee E2 redirected the resident and took her to the nursing station. NA, Employee E2 stated she was unsure if the nurses were aware she was headed for the door and the resident continued to yell, hit, and kick. During an interview on 6/30/26, at 10:47 a.m. NA, Employee E3 stated most of the time Resident R1 is easily redirected. On 6/19/26, she was aggressive and yelling. As NA, Employee E3 was exiting out of a residents room, he threw his linens in the laundry and turned to throw trash away when he seen Resident R1 was outside. He immediately yelled to other staff Resident R1 was outside and went to retrieve resident. During an interview on 6/30/26, at 12:13 p.m. the DON and admission Director, Employee E4 stated elopement risk assessments are completed upon admission, quarterly, and with any exit seeking behavior. During an interview with the DON and Nursing Home Administrator (NHA) on 6/30/26, at 2:15 p.m. it was determined that the facility failed to reassess Resident R1's elopement risk and implement interventions to prevent elopement after displaying exit-seeking behaviors, and the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to ensure a resident with a tracheostomy (trach- a surgical created opening in the neck that provides a direct secure airway) was monitored and documented as appropriate respiratory care for one of three residents (R3) and failed to provide appropriate respiratory care for four of six residents (Residents R11, R32, R67 and R69). Findings include: Review of the facility policy Administering Medications through a Small Volume (handheld) Nebulizer last reviewed 1/6/26, indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Obtain a physician order, review the residents care plan, current orders and diagnoses to determine resident needs, check the treatment record. Store in a plastic bag with the resident's name and date on it. Change equipment tubing every seven days. Review of the facility policy Continuous Positive Airway Pressure (C-PAP -keeps airways open when you sleep) / Bilevel Positive Airway Pressure (BIPAP- normalizes breathing by delivering pressurized air) Support last reviewed 1/6/26, indicated review the physician orders to determine the oxygen concentration and flow and the Positive End Expiratory Pressure (PEEP-pressure at the end of exhalation to prevent the collapse of small air sacs in the lungs) for the machine. Review of the facility policy Charting and Documentation last reviewed 1/6/26, indicated all services provided to the resident, progress toward the care plan goals, or any change in the residents medical, physical, functional, or psychosocial conditions, shall be documented in the residents' medical record. Documentation of procedures and treatments will include care-specific details including but not inclusive of: The date and time the procedure/treatment was provided The name and title of the individual who provided the care The signature and title of the individual documenting Review of the facility Respiratory Therapy Job description revealed assume primary responsibility for all respiratory care modalities, initiate and conduct therapeutic procedures, maintain resident records, select assemble check and operate equipment. Documents patient care services by charting patient and department records. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses of traumatic brain injury, respiratory failure, and high blood pressure. Review of physician orders dated 5/22/24, indicated to administer oxygen at 10 liters per minute continuously, titrate to maintain spO2 above 90% every day and night shift. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/26, indicated diagnoses were current. Section O- Special Treatments, Procedures, and Programs revealed the resident required tracheostomy care while a resident. During an interview completed on 5/6/26 at 10:18 a.m. upon asking the Director of Nursing (DON) concerning the Respiratory Therapist duties in the facility replied, respiratory remained in facility due to resident with a trach and to make sure the proper equipment is in the facility for the residents, they also change out the equipment as scheduled. During an observation on 5/6/26, at 11:24 a.m. Resident R3 was observed receiving 10 liters of oxygen via face mask to trach. The resident's pulse and oxygen saturation was being monitored. Review of Resident R3's clinical record on 5/6/26, at 11:26 a.m. failed to include evidence of monitoring and documenting the resident's respiratory rate, depth and quality each shift and as needed. During an interview on 5/6/26, at 11:32 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E6 stated, the nurses are responsible for knowing the resident's care plans and reviewing it for the specific condition they have to ensure care is monitored and documented. RNAC, Employee E6 confirmed the facility has two shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. RNAC, Employee E6 stated staff should enter a nurse's note if they notice a change in their respiratory rate, depth, and quality and complete vitals each shift. RNAC, Employee E6 confirmed the facility failed to document and monitor Resident R3's respiratory rate, depth and quality each shift and as needed. During an interview on 5/6/26, at 11:43 a.m. Registered Nurse Supervisor, Employee E18 stated documenting by exception does not provide evidence Resident R3's respiratory rate, depth and quality each shift and as needed. RN Supervisor, Employee E18 confirmed the facility failed to ensure a resident with a trach was monitored and documented as appropriate for Resident R3. During an interview completed on 5/6/26, at 1:41p.m. upon asking the DON for clarification concerning respiratory duties and the completion of the Medication Administration Record (MAR) replied respiratory changes all the equipment, the nurses are signing off as completed. Review of the clinical record revealed Resident R67 was admitted to the facility on [DATE], with the diagnosis of obstructive sleep apnea (causes the breathing to pause that reduces the flow of oxygen), heart failure (the heart doesn't pump the way it should and diabetes (high sugar in the blood). Review of Resident R67's physician orders dated 4/20/26, indicated C-PAP at hour of sleep at home settings. The order failed to include what the setting was or any care of the C-PAP machine. Review of Resident R67's current care plan failed to include the C-PAP settings or any care needed for the C-PAP machine During an observation completed on 5/4/26, at 10:31 a.m. Resident R67's C-PAP mask was sitting on top of the bedside stand not stored in a bag as required. During an interview completed on 5/4/26, at 2:15 p.m. Registered Nurse Employee E9 confirmed that Resident R67's C-PAP mask was not stored in a bag as required. During an interview completed on 5/8/26, at 10:04 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed that Resident R67's current physician orders did not include the settings or any care for the C-PAP, and Resident R67's current care plan did not include interventions for the settings or care for the C-PAP machine. Review of the clinical record revealed Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnosis of chronic lung disease emphysema (makes breathing difficult), anemia (low iron in the blood) and high blood pressure. Review of Resident R69's physician orders dated 8/12/25, indicated Albuterol Sulfate (relaxes airway muscles to improve airflow) Inhalation Nebulization solution 1.25 milligram/3milliliter inhale 1vial orally via nebulizer four times a day related to emphysema. During an observation completed on 5/4/26, at 2:10 p.m. Resident R69's handheld nebulizer (transfers liquid medication into a fine mist) was sitting on top of the machine not stored in a bag as required. During an interview completed on 5/4/26, at 2:15 p.m. RN Employee E9 confirmed Resident R69's nebulizer was sitting on top of the machine not stored in a bag as required. Review of the clinical record revealed Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/1/26, indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD- makes it hard to breath) and anxiety. Review of Resident R11's current physician orders dated 1/21/26, indicated change nasal cannula every two weeks on Wednesday's day shift for oxygen therapy. Review of Resident R11's current physician orders dated 2/3/26, indicated oxygen at 2 liters per minute (Lpm) via nasal cannula (N/C) at bedtime daily at bedtime for low oxygen saturations with sleeping. Review of Resident R11's Medication Administration Record (MAR) for April 2026, indicated the nasal canula was documented as changed on 4/1/26, by Licensed Practical Nurse (LPN) Employee E19, on 4/15/26 was documented as changed By LPN Employee E7, and was documented as changed on 4/29/26 by LPN Employee E20. During an interview completed on 5/8/26, at 10:12 a.m. upon reviewing Resident R11's nasal canula changes for April with LPN Employee E7 confirmed the changes on 4/1/26 and 4/29/26 were completed by other LPN's, I did sign off on 4/15/26. We sign it off on the MARS, but respiratory actually does it. Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's MDS dated [DATE], indicated the diagnosis of high blood pressure, diabetes and obstructive sleep apnea. Review of Resident R32's physician orders dated 6/28/22, indicated oxygen at 2LPM via NC continual every shift for hypoxia Review of Resident R32's physician orders dated 11/1/23, indicated to change nasal cannula every two weeks on Wednesdays for Oxygen therapy Review of Resident R32's MAR for April 2026, indicated the nasal canula was documented as changed on 4/1/26, and 4/29/26 by Registered Nurse (RN) E13 on 4/15/26 was documented as changed By LPN Employee E21. During an interview completed on 5/8/26, at 10:32 a.m. upon reviewing Resident R32's nasal canula changes for April 2026 with RN Employee E13 confirmed the changes on 4/1/26 and 4/29/26 were completed by me. The one on 4/15/26, was another nurse identified as LPN E21. RN Employee E13 further added that respiratory does the changes, the check indicates I did it, but I didn't. I don't want to check off something I didn't do, but I do go in and check to see the date it was done then I will check it, I don't know why they (respiratory) don't sign it. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of five residents (Resident R9, R24 and R78).Findings include: Review of the facility policy Hospice Program dated 1/6/26, indicated that coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/12/26, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump the way it should) and diabetes (high sugar in the blood). Section O- Special Treatments, Procedures, and Programs: K1- Hospice Care indicated Resident R9 received hospice while a resident. Review of Resident R9s medical record dated 12/8/25, indicated admission to local hospice with the diagnosis of hypertensive heart disease. Review of Resident R9's current care plans failed to include a care plan for hospice. During an interview completed on 5/7/26, at 12:16 p.m. Resident Nurse Assessment Coordinator (RNAC) Employee E6 stated Resident R9 went hospice with a local hospice provider and confirmed that the facility failed to implement a care plan for Resident R9's hospice needs. Review of the clinical record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's MDS dated [DATE], indicated diagnoses of high blood pressure, kidney disease, and hypokalemia (low potassium levels in the blood). Review of Resident R24s medical record included a physician order to admit to hospice services dated 4/29/26. Review of Resident R24's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. Review of the clinical record indicated Resident R78 was admitted to the facility on [DATE]. Review of Resident R78's MDS dated [DATE], indicated diagnoses of high blood pressure, kidney disease, and vitamin D deficiency. Review of Resident R78's medical record included a physician order to admit to hospice services date 4/12/2. Review of Resident R78's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 5/7/26, at 10:16 a.m. RNAC (registered nurse assess coordinator) Employee E11 confirmed that the facility failed to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system in the plan of care and that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of Residents R24 and R78. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 3 of 10 months (February 2026, March 2026 and April 2026).Findings include:Review of facility Infection Control Plan, Program and Committee policy last reviewed 1/6/26, indicated the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. An antibiotic stewardship program will be implemented as part of the overall infection control program. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. Review of the facility's Infection Control Program for February 2026, March 2026 and April 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring and ensuring appropriate usage was completed. During a telephonic interview completed on completed on 5/6/26, at 2:06 p.m. Registered Nurse (RN) Infection preventionist (IP) Employee E17 revealed that she took over the Infection Control program on 4/4/26, and stated I have been doing that as well as supervising the building, I just look at the records to see if any are reportable, I haven't been able to do it since I started, I do about 12 hours a week, I have not seen the binders. During an interview completed on 5/6/26, at 2:29 p.m. the Nursing Home Administration confirmed that the facility failed to implement an antibiotic stewardship program for 3 of 10 months (February 2026, March 2026 and April 2026). 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R24), failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for three of 10 months (February 2026, March 2026, and April 2026) and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 10 of 10 months. (July 2025 - April 2026).Findings include: Review of the facility Infection Prevention and Control Program last reviewed 1/6/26, indicated a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all resident, staff and volunteer's visitors and other individuals providing service under a contractual arrangement based upon a facility assessment and national standards. The Infection Preventionist serves as the leader surveillance and maintains documentation of incidents, findings, and corrective actions. A water management program has been established as part of the overall infection and prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. Review of the facility Water Management Program last reviewed 1/6/26 indicated the water management program will consist of including but not inclusive to the following areas: The water management program will identify the elements of a water management program. The water system will be described to show the flow of water throughout the building. A flow chart/diagram will show how the hot water is distributed throughout the building. The water management team will identify areas where Legionella could grow and spread throughout the building by marking it on the flow chart/diagram. The water management program will utilize control measures and corrective actions with the water system as identified when samples are outside of the control limits. Testing of the water will occur at three different sites every 6 months or as needed. Review of the clinical record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/26, indicated the diagnosis of Peripheral Vascular Disease (PVD- blood vessels narrow, spasm or become blocked limiting oxygen delivered to the limbs), Diabetes (high sugar in the blood and high blood pressure. Review of a physician order dated 4/27/26, indicated right lateral foot, cleans with normal saline, pat dry, apply Santyl ointment, cover with dry dressing daily and as needed. During a dressing change observation completed on 5/5/26, at 9:14 a.m. Licensed Practical Nurse (LPN) Employee E2 prepared a clean area utilizing Resident R24's over bed table in which a barrier and supplies were placed. LPN Employee E2 cleansed Resident R24's foot with the normal saline, she then placed the right foot directly on Resident R24's wheelchair seat without placing a barrier, applied the Santyl ointment and dry dressing. After completion of the dressing LPN Employee E2 gathered and discarded supplies, removed the barrier on the over bed table and exited the room. During an interview completed on 5/5/26, at 9:39 a.m. LPN Employee E2 confirmed not placing a clean barrier on Residet R24's wheelchair seat prior to placing his right foot on it. LPN Employee E2 also confirmed that she failed to clean the bedside table after removing the supplies and barrier and confirmed the failure to prevent cross contamination during a dressing change. Review of the facility's Infection Control documentation failed to reveal surveillance for tracking infections for residents for three of ten 10 months (February 2026, March 2026, and April 2026). During a telephonic interview completed on 5/6/26, at 2:00 p.m. upon asking Registered Nurse RN Employee E17 concerning a system of surveillance to identify possible communicable diseases or infections stated, I have not done anything since I took over the program on 4/4/26, I have not looked at the Infection Control Binders. During an interview completed on 5/6/26, at 2:29 p.m. the Nursing Home Administrator confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for three of 10 months (February 2026, March 2026, and April 2026). Review of the facilities Legionella water management plan that included monitoring or auditing of facility for potential Legionella failed to provide mapping of high opportunity areas where Legionella could be found in the facility water pipes. The plan also failed to include water temperature logs and evidence of preventative measures used to prevent water borne illness in areas that are not currently in use. During an interview completed on 5/7/26, at 11:19 a.m. upon asking Environmental Service (ES) and Maintenance Director (MA) Employee E23 concerning the water management plan and preventative measures revealed that the flow diagram did not include control measures or indicate what was hot or cold water. It was also revealed that Legionella testing is completed once a year. Upon asking ES MD Employee E23 concerning what the hot water tank holding temperatures should be was not able to provide an answer. ES MD Employee E23 stated, hot water for the rooms should be no more than 106 degrees and the laundry hot water temperatures are 140 degrees. Upon asking for temperature logs ES MD Employee E23 could not provide any. During an interview completed on 5/7/26, at 12:04 p.m. Maintenance Employee E24 revealed that he checks the hot water holding tanks every couple of weeks, he could not produce any logs. Maintenance Employee E24 also revealed that the water in facility rooms not being used is ran a couple of minutes and further stated we do the closed unit every two weeks. During an interview on 5/7/26, at 1:03 p.m. the Nursing Home Administrator (NHA) stated he was unable to provide the facilities Legionella water management plan that included monitoring or auditing of facility for potential Legionella and failed to provide mapping of high opportunity areas where Legionella could be found in the facility water pipes and confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 10 of 10 months. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of resident's medical information on one of four medication carts (East Medication Cart).Findings include: Review of facility policy Quality of Life - Dignity dated 1/6/26, indicated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26, at 11:38 a.m. the East Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 5/4/26, at 11:38 a.m. Registered Nurse Employee E9 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain a monthly weight for one of eight residents (Resident R8), and failed to individualize care plans to address the resident specific nutritional concerns for two of two residents (Resident R8, and R90).Findings include: Review of the facility policy Weight Policy dated 1/6/26, indicated that ongoing monthly weight will be obtained unless otherwise directed by the physician. Monthly weights will be obtained on the date of the first scheduled shower for the month; regardless of refusal of shower. Monthly weights will be obtained by the 7th day of each month. Weights will be documented in the resident's electronic medical record. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/5/26, indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and thyroid disorder. Review of Resident R8's clinical record revealed that no monthly weight was recorded for April 2026. During an interview on 5/6/26, at 1:46 p.m. Nurse Aide Employee E12 confirmed that the facility failed to obtain a monthly weight for Resident R8 in April 2026. Review of Resident R8's clinical record revealed the following physician's orders: Renal Diet (a diet for people with kidney disease), Mechanical Soft - ground meat texture to have a low fat diet for low protein dated 4/1/26. Magic Cup (a nutritionally dense ice cream) two times a day for additional nutrition with lunch and dinner dated 9/10/25. Review of Resident R8's care plan last revised on 5/7/26, indicated that resident has potential to have nutritional problems related to dysphagia (difficulty swallowing), and for requiring a mechanically altered and therapeutic diet weight loss and interventions include the following: Provide, serve diet as ordered dated 4/11/24 Provide and serve supplements as ordered dated 4/11/24. Review of Resident R8's care plan failed to include resident specific interventions for the physician ordered diet and supplements listed above. During an interview on 5/7/26, at 10:19 a.m. RNAC (registered nurse assess coordinator) Employee E11 confirmed that the facility failed to individualize care plans to address the resident specific nutritional concerns for Resident R8. Review of the clinical record indicated Resident R90 was admitted to the facility on [DATE]. Review of Resident R90's MDS dated [DATE], indicated diagnoses of high blood pressure, hypokalemia (deficiency of potassium in the bloodstream), and heart failure (a progressive heart disease that affects pumping action of the heart muscles) Section K0300 was marked that resident had loss of 5% or more in the last month or loss of 10% or more in 6 months, and is not on a physician-prescribed weight loss regimen. Review of Resident 90's clinical record revealed the following physician's orders: Regular diet, regular texture, lactose free for diet dated 4/13/26. Nutritional Juice with meals dated 4/14/26. Review of Resident R90's care plan last revised on 3/9/26, indicated interventions include the following: Serve diet as ordered dated 9/24/25 Review of Resident R90's care plan failed to include any focus to address the weight loss, and failed to include resident specific interventions for the physician ordered diet and supplements listed above. During an interview on 5/7/26, at 1:37 p.m. RNAC Employee E11 confirmed that the facility failed to individualize care plans to address weight loss, and the resident specific nutritional concerns for Resident R90. 28 Pa. Code 201.18(b)(1)( Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, facility policy, resident interview and staff interview, it was determined that the facility failed to treat each resident with respect by failing to address a resident by their preferred name for one of eight residents (Resident R61). Review of facility policy Resident Rights dated 1/6/26, indicated that residents will be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individually. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnoses, or care needs. Review of clinical record revealed that Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's care plan dated 11/21/25, revealed the name the resident prefers to be addressed as. Review of Resident 61's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/20/26, indicated diagnoses of high blood pressure, anxiety, and depression. Section A1300 D under the question Name by which resident prefers to be addressed, revealed a specific name the resident prefers to be called. During an observation and interview on 5/5/26, at 10:26 a.m. Resident R61's name tag located at the entrance of the door failed to indicate the resident's preferred name. When State Agency greeted Resident R61 by the name listed at the entrance of the door, Resident R61 stated she does like being called that and stated her preferred name. During an interview in 5/6/26, at 1:37 p.m. Activities Director, Employee E3 stated residents are asked upon admission what their name preferences are, and if a resident had a preferred nickname then it is included in their care plan. Activities Director, Employee E3 confirmed Resident R61's preferred name was listed in their care plan and indicated she was unsure who is responsible for ensuring preferred name is listed at the resident's door entrance. During an interview on 5/6/256, at 1:41 p.m. Nurse Aide (NA), Employee E4 indicated the nurses are usually responsible for placing the resident's name tag at the entrance of the door, but sometimes the aides do it. During an observation on 5/6/26, at 1:44 p.m. Resident R61's name tag at the entrance of their door failed to include the resident's preferred care name. During an interview on 5/6/26, at 1:45 p.m. the Assistance Director of Nursing, Employee E5 confirmed Resident R61's preferred name was not listed on the name tag at the entrance of their door. During an interview on 5/6/25, at 2:28 p.m. Director of Nursing confirmed that Resident R61's preferred name choice was not listed at the entrance of their door, and the facility failed to ensure that the facility respected Resident R61's preferences in their name choice.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a treatment cart while not in use for one of three treatment carts (East Hall Treatment Cart), failed to properly store medications in one of two medication storage rooms (East Medication Room) and in two of four medication carts (A Hall Medication Cart and C Hall Medication Cart).Findings include: Review of the facility policy Administering Medications last reviewed 1/6 /26, indicated during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse. When opening a multi-dose container, the date opened shall be recorded on the container. Review of the facility policy Storage of Medications last reviewed 1/6/26, indicated the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments containing drugs and biologicals shall be locked when not in use. Medications must be stored separately from food and must be labeled accordingly. During an observation completed on 5/4/26, at 9:49 a.m. the East side treatment cart was sitting in the hallway placed near room [ROOM NUMBER]. The treatment cart was unlocked and unattended. During an interview completed on 5/4/26, 9:56 a.m. Licensed Practical Nurse (LPN) Employee E14 confirmed the treatment cart placed near room [ROOM NUMBER] was left unlocked and unattended and that the facility failed to properly secure a treatment cart while not in use. During an observation completed on 5/5/26, at 9:40 a.m. the East Medication Room contained the following: A Purple Cup.A Styrofoam coffee cup.A black tote bag sitting on a chair.A black sweater, black pants and a leg rest bag hanging on the wall.Black pants and a wheelchair leg rest bag hanging on the wall. A grey blanket sitting on top of a pile of clothes in boxA light gray wheelchair cushion.A dark grey wheelchair cushion.A curved neck pillow and two blankets sitting on top of a box. A wheelchair leg rest bag sitting on the counter.The East first hall refrigerator contained 2 vials of Tubersol solution opened and not labeled with a date as required.The East second hall refrigerator contained 2 vials of Tubersol solution opened and not labeled with a date as required. During an interview completed on 5/5/26, at 9:54 a.m. LPN Employee E2 confirmed the above findings and stated, I don't know who the black tote bag or cups belong to. The blankets and clothing look like a donation and confirmed that the facility failed to properly store medications in the East Medication Room. During an observation completed on 5/5/26, at 9:56 a.m. the A hall medication cart contained the following:1 bottle of Nystatin liquid opened and not labeled with a date as required.1 bottle of Latanoprost eye drops opened and not labeled with a date as required.1 Trelegy Ellipta inhaler opened and not labeled with a date as required.The left side compartment of the medication cart contained a coffee cup, a strawberry pastry crisp bar, a bag of sliced red peppers and a personal cell phone During an interview completed on 5/5/26 at 10:03 a.m. LPN Employee E14 confirmed that above findings and stated the items in the left side compartment of the medication cart are mine and confirmed the facility failed to properly store medications in the A Hall Medication Cart. During an observation completed on 5/5/26, at 10:51 a.m. the C Hall Medication Cart contained: 2 bottles of Robitussin cough suppressant opened and not labeled with a date as required.1 bottle Milk of Magnesia opened and not labeled with a date as required.1 bottle of Miralax powder opened and not labeled with a date as required.1 bottle of lactulose liquid opened and not labeled with a date as required. During an interview completed on 5/5/26, at 10:51 a.m. LPN Employee E22 confirmed the above observations and confirmed that the facility failed to properly store medications in the C Hall Medication Cart. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, facility provided documentation, and staff interviews, it was determined the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for one of 10 months (April 2026).Findings included: Review of facility Infection Control Plan, Program and Committee policy last reviewed 1/6/26, indicated the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance and epidemiological investigations of exposures and infectious disease During an interview completed on 5/6/26, at 1:59 p.m. Human Resource (HR) Employee E15 revealed the former Infection Preventionist Employee E16 had resigned, with the last day of employment was 4/4/26. During a telephonic interview completed on completed on 5/6/26, at 2:06 p.m. Registered Nurse (RN) Infection preventionist (IP) Employee E17 revealed that she took over the Infection Control program on 4/4/26, and stated I have been doing that as well as supervising the building, I just look at the records to see if any are reportable, I haven't been able to do it since I started, I do about 12 hours a week. Upon asking RN IP Employee E17 concerning infection control training and certification replied, I did that so long ago, I can try to find it. Review of the facility provided certification courses for RN IP Employee E17 it was revealed that course training was completed in 2022, however there was not a certificate for the completion for Nursing Home Infection Preventionist Training Course. During an interview completed on 5/6/26, at 2:29 p.m. the Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections for one of 10 months (April 2026). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, closed resident records and staff interview, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of four resident hospital transfers (Resident R24 and Closed Resident Record CR87).Findings include: Review of facility policy Bed Hold Notice Upon Transfer dated 1/6/26, indicated that at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addressees information explaining the return of the resident to the next available bed. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policy. Review of the clinical record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/26, indicated diagnoses of high blood pressure, kidney disease, and hypokalemia (low potassium levels in the blood). Review of the clinical record indicated Resident R24 was transferred to the hospital on 3/31/26, and returned to the facility on 4/5/26. Review of Resident R24's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/31/26. During an interview on 5/7/26, at 11:49 p.m. Business Office manager Employee E10 confirmed that the facility failed to maintain documentation that resident or resident's representative were notified of the facility bed-hold policy for two of four resident hospital transfers (Resident R24, and R87). Review of Closed Resident Records CR87's admission record indicated he was admitted on [DATE]. Review of Closed Resident Records CR87's MDS assessment dated [DATE], indicated that he had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), congestive heart failure (a progressive heart disease affecting pumping action of the heart muscles impacting circulation, swelling and shortness of breath), and a right femur fracture. Review of Closed Resident Records CR87's clinical nurse note dated 2/6/26, indicated staff received venous doppler results and they are indicating nonocclusive thrombus in right common femoral vein (probable blood clot). These results were immediately sent to the certified registered nurse practitioner (CRNP) and orders were obtained to increase Eliquis temporarily and repeat ultrasound. Staff then received a message from the registered nurse that the Resident CR87's daughter called in and began screaming at her because her father has a blood clot. The daughter was very rude. Staff did relay that message to CRNP. Report called to hospital. Resident CR87 was sent to hospital on 2/6/26 around 5:50 p.m. Review of Closed Resident Records CR87's emergency room transfer form dated 2/6/26, indicated information provided to EMS staff. The information did not include the facility bed hold policy. Review of Closed Resident Records CR87's clinical nurse notes, physician notes and transfer documents failed to include documented evidence that Resident CR87 or Resident CR87's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/6/26. During an interview on 5/7/26, at 2:30 p.m. information disseminated to the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) Employee E5 that the facility failed to notify the resident or resident's representative of the facility bed-hold policy at time of hospital discharge for Closed Resident Records CR87 as required. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for incident or accidents for one of five residents (Residents R1).The facility Incident and Accident policy dated 1/28/25, indicated for staff to report, investigate, and review and accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Review of the clinical record indicated Resident R1was admitted to facility 10/18/24. Review of Resident R1s Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/18/26 included diagnoses of cardiomegaly (enlarged heart), hyperlipidemia and anxiety. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1' score to be 13, cognitively intact. Review of a progress note dated 2/17/26, at 11:36 a.m. indicated Registered Nurse was made aware that resident was outside in wheelchair by rehab. This nurse went outside to assess resident and was met by 2 another rehab staff, nurse found resident sitting in his wheelchair stating that he was trying to go to an appointment. He was found with newspaper and his wallet in hand. Resident was able to be redirected inside and taken into his room. Dr. and son made aware. Resident placed on 15 minutes checks and elopement assessment redone. Review of facility provided documents indicated one witness statement from the Director of Nursing. During an interview on 3/20/26, at 1:30 p.m. Nursing Home Administrator confirmed the facility did not conduct a through elopement investigation on Resident R1 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1)(3) Management28 Pa. Code: 211. 10(d) Resident care policies28 Pa. Code: 211.12(d)(3) Nursing services

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of five residents (Resident R1). Review of facility policy Elopements and Wandering Residents dated 1/28/25, indicated the facility ensures that residents which exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R1was admitted to facility 10/18/24. Review of Resident R1s Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/18/26 included diagnoses of cardiomegaly (enlarged heart), hyperlipidemia and anxiety. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1' score to be 13, cognitively intact. Review of Elopement/Wandering Risk 24 assessment dated [DATE], revealed Resident R1 was NOT at risk for elopement at this time and NOT at safety risk for wandering at this time and/or wanders but is easily redirected. Review of a progress note dated 2/17/26, at 11:36 a.m. indicated Registered Nurse was made aware that resident was outside in wheelchair by rehab. This nurse went outside to assess resident and was met by 2 another rehab staff, nurse found resident sitting in his wheelchair stating that he was trying to go to an appointment. He was found with newspaper and his wallet in hand. Resident was able to be redirected inside and taken into his room. Dr. and son made aware. Resident placed on 15 minutes checks and elopement assessment redone. Review of facility submitted documents on 2/18/26, indicated Receptionist saw resident get his newspaper and then receptionist took a phone call from a CNA student. She turned to get a phone number for the student and the resident was gone. Resident exited through the front door. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E2 dated 5/11/25, indicated upon returning from gas station, resident (R44) was found sitting in his power wheelchair in the back parking lot. Employee E2 called the Nursing supervisor and waited with resident until supervisor arrived. Resident was assisted back into building. Once inside, it was seen that resident had pushed the sliding doors off the hinge. Resident confirmed that is how he left. During an interview on 3/20/26, at 11:00 a.m., the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision resulting in an elopement for one of five residents Resident R1 as reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility policy Food Safety and Sanitation dated 1/28/25, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition department. During an observation on 6/2/25, at 10:00 a.m., of the walk-in cooler in the main kitchen, conducted with Certified Dietary Manager (CDM) Employee E1, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and ceiling immediately forward of the fans. CDM Employee E1 confirmed observation by surveyor when viewed. During an interview on 6/2/25, at 10:05 a.m., CDM Employee E1 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler, in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for three of three sampled resident records (Resident R20, R59, R67). Finding include: The facility Medication regimen review policy dated 1/28/25, indicated that the drug regimen review of each resident is at least monthly by a licensed pharmacist and includes a review of the resident's medical chart. A medication regimen review (MRR) or drug regimen review, is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes. Review of Resident R20's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R20's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 5/13/25, indicated she had diagnoses that included dementia (group of symptoms affecting memory, thinking, and social abilities that interfere with daily life), heart disease, and diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body). Review of Resident R20's care plan dated 4/14/22, indicated that pharmacy will review monthly as per protocol. Review of Resident R20's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for April 2025. Review of Resident R20's medication regimen reviews did not indicate a review for April 2025. Review of Resident R59's admission record indicated he was admitted on [DATE], and readmitted on [DATE]. Review of Resident R59's MDS assessment dated [DATE], indicated he had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), diabetes, and hyperlipidemia (elevated lipid levels within the blood). Review of Resident R59's care plan dated 11/29/24, indicated that pharmacy will review monthly as per protocol. Review of Resident R59's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for April 2025. Review of Resident R59's medication regimen reviews did not indicate a review for April 2025. Review of Resident R67's admission record indicated he was admitted on [DATE], and re-admitted on [DATE]. Review of Resident R67's MDS assessment dated [DATE], indicated he had diagnoses that included diabetes, emphysema (a chronic lung condition characterized by shortness of breath due to damage to the air sacs in the lung), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and cirrhosis of the liver (damage to the liver causing nausea and fatigue). Review of Resident R67's care plan dated 3/12/25, indicated that pharmacy will review monthly as per protocol. Review of Resident R67's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for April 2025. Review of Resident R67's medication regimen reviews did not indicate a review for April 2025. During an interview on 6/5/25, at 12:15 p.m. the Director of Nursing confirmed that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for Residents R20, R59, and R67, as required. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of four residents (Resident R65) records reviewed. Findings include: Review of facility's policy Nutritional Assessment, dated 1/28/25, indicated part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systemic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the residents at risk for or with impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/4/25, indicated diagnoses of traumatic brain injury, aphasia (disorder that affects how you communicate due to brain damage), and heart disease. Section K0300 was coded a 2, which indicated that Resident R65 had a weight loss of 5% or more in the last month or weight loss of 10% or greater in the last six months. Review of R65's medical record revealed a clinical Dietary - MDS Assessment note dated 3/8/25, that failed to identify parameters for significant weight loss, to include prior weights associated with identified loss, and specific time frames of the loss. Review of current nutritional plan of care initiated 4/11/24, updated 3/13/25, failed to indicate a nutritional focus/concern, goals, and interventions to address Resident R65's significant weight loss as identified in MDS dated [DATE]. During an interview on 6/6/25, at 11:07 a.m., Certified Dietary Manager (CDM) Employee E1 confirmed that clinical Dietary - Assessment note dated 3/8/25, failed to address parameters for Resident R65's significant weight loss as identified in MDS dated [DATE]. During an interview on 6/6/25, at 11:53 a.m., the Director of Nursing (DON) confirmed facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of four residents (Resident R65) records reviewed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R44). Findings include: Review of facility policy Elopements and Wandering Residents dated 1/28/25, indicated the facility ensures that residents which exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R44 was admitted to facility 3/6/19, readmitted [DATE]. Review of Resident R44's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/1/25, included diagnoses of heart disease, chronic kidney disease, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R44's score to be 12, moderate cognitive impairment. Review of Elopement/Wandering Risk 24 assessment dated [DATE], revealed Resident R44 was NOT at risk for elopement at this time, and NOT at safety risk for wandering at this time and/or wanders but is easily redirected. Review of Elopement/Wandering Risk 24 assessment dated [DATE], revealed Resident R44 was NOT at risk for elopement at this time, and NOT at safety risk for wandering at this time and/or wanders but is easily redirected. Review of Elopement/Wandering Risk 24 assessment dated [DATE], revealed Resident R44 was NOT at risk for elopement at this time, and NOT at safety risk for wandering at this time and/or wanders but is easily redirected. Review of a progress note dated 5/11/25, at 11:41 p.m., indicated Registered Nurse received a call from a staff member stating that resident was out in the parking lot. Staff member was coming back inside after taking a break when she noticed resident driving his electric wheelchair in the parking lot. Upon going out to parking lot resident seen sitting in electric wheelchair with a pile of belongings in his lap. Resident exhibits some confusion. Resident was assisted back into building and into his room. Resident was assisted into bed per his request. Resident denies pain, no skin issues noted. Vital signs were within normal limits. Upon reentering building, front doors were noted to pushed open and off of the tracks. Alarm notes to not be going off. Upon questioning staff, no alarm was heard this evening. Alarm checked for functioning: not functioning. Doors were placed back on tracks and locked, maintenance notified of door alarm not functioning. 15 minute safety checks were initiated. Review of facility submitted documents on 5/12/25, indicated On 5/11/2025 at 2141 (11:41 p.m.), resident was in his motorized wheelchair. He crashed the chair against the locked front lobby door causing the door to open. Staff responded and approached resident in the front of the building. Resident stated that he was trying to get out, but also stated that someone stole his wheelchair and that he was looking for the door to get in. Staff assisted resident back into the building. Resident had no overt injury, nor did he have complaints. Review of an employee statement written by Licensed Practical Nurse (LPN) Employee E2 dated 5/11/25, indicated upon returning from gas station, resident (R44) was found sitting in his power wheelchair in the back parking lot. Employee E2 called the Nursing supervisor, and waited with resident until supervisor arrived. Resident was assisted back into building. Once inside, it was seen that resident had pushed the sliding doors off the hinge. Resident confirmed that is how he left. During an interview on 6/3/25, at 1:10 p.m., Registered Nurse (RN) Employee E3 stated that she was the shift supervisor on 5/11/25. RN Employee E3 stated that she received a call from a staff member returning from her break, that Resident R44 was outside in the parking lot where the employee park. RN Employee E3 further stated that when she arrived outside, she found Resident R44 in the parking lot with LPN Employee E2. Employee E3 stated that Resident R44 was confused, uninjured, and required to be manually pushed back into facility for his electric wheelchair had no more power. Employee E3 further stated that she walked past the front doors and found them open, off track, and ajar, with no alarm sounding. Employee E3 next stated that she realigned, closed and locked the front doors, and checked the alarm to find that it was not functioning properly. Employee E3 stated that she notified the Director of Nursing (DON) and maintenance regarding the event and her findings. RN Employee E3 then stated that she has known Resident R44 for a few years, and this behavior was new and unaware of any prior indications by resident to leave facility. Employee E3 then stated that she returned to Resident R44's room to further interview him shortly after event, and found that he had no recollection of going outside. During an interview on 6/4/25, at 10:00 a.m., the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision resulting in an elopement for one of four residents (Resident R44) as reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical record review, and staff interview, it was determined that the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals and effectively transition them to post-discharge care for one of three residents (Resident R2). Findings include: Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/14/25, indicated diagnoses of encounter for surgical aftercare following surgery on the digestive system, colostomy (a surgical procedure that changes the way stool exits your body), and high blood pressure. Review of Resident R2's care plan dated 2/12/25, indicated to assist the resident with obtaining durable medical equipment (DME) and medical supplies prior to discharge. Review of a physician order dated 2/12/25, indicated to administer oxygen at two liter per minute (LPM) continuously. Review of a physician order dated 2/13/25, indicated to wean oxygen as tolerated. Review of a physician order dated 2/15/25, indicated to administer oxygen at two LPM, as needed via nasal cannula to maintain oxygen above 92%. Review of a progress note dated 2/22/25, revealed Resident R2 had increased respiratory effort observed on exertion. The resident has a dry cough and complaints of shortness of breath upon exertion. The resident's oxygen saturation was 90% on room air. Review of Resident R2's progress note dated 2/22/25, indicated the resident was positive for influenza A. Review of a progress note dated 2/23/25, revealed the physician was notified and orders were obtained for discharge on [DATE], at 9:00 a.m. The resident was ordered home health services and a wheeled walker. Resident R2's family member picked the resident up for discharge. Discharge instructions were provided to the resident and resident's family member. The facility sent all medications with the resident. The facility failed to order the resident oxygen. During an interview on 3/18/25, at 1:57 p.m. the Director of Nursing stated Resident R2's family member called the facility after Resident R2 discharged and confirmed the facility failed to ensure Resident R2 was ordered oxygen. During an interview on 3/18/25, at 2:24 p.m. the DON and Nursing Home Administrator confirmed the facility failed to implement an effective discharge planning process that focuses on the resident's discharge goals and effectively transition them to post-discharge care for one of three residents (Resident R2). 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on facility policy and staff interview it was determined that the facility failed to provide medical record access for one of four residents (Resident R1). Findings include: Review of Release of Medical Records dated 1/1/25, indicated medical records will be released with a valid request and in accordance with state and federal laws. Requests for records should be referred to the Director of Nursing or Administrator, or another staff member previously designated by the facility. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. The corporate office/risk manager should be notified of the request for records. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing of the cost for obtaining records and that records are available two days after the receipt of payment for the copies. Records should be assembled in chronological order. When documents are missing, the person assembling the record should make a notation of the items missing. Facility documentation indicated Resident R1 was admitted on [DATE]. Review of Resident R1's MDS (minimum data set a periodic assessment of basic needs) dated 1/24/24, revealed diagnoses of dementia (the loss of cognitive functioning-thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), anxiety disorder, and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills. It's the most common cause of dementia.) Review of Resident R1's MDS assessment dated [DATE], indicated the resident was discharged from the facility on 2/28/24. The resident ceased to breathe. During an interview on 3/26/25, at 9:15 a.m. the Nursing Home Administrator stated once the facility receives a medical request in writing, the facility informs the recipient of the cost associated. It was indicated a hard copy or flash drive can be provided for medical records as long as it is a legal request. If the medical request is from a law firm, the facility will obtain the necessary medical records and send it. The NHA stated the facility cannot send Resident R1's medical records because of how thick it is and the facility's copier is broken. The NHA stated the facility has another scanner that can be used off-site to send the records. During an interview on 3/26/25, at 9:25 a.m. the NHA indicated a law firm has been requesting Resident R1's medical records. During an interview on 3/26/25, at 9:40 a.m. the NHA confirmed it has been a few months since the facility received the initial request for Resident R1's medical records. The NHA confirmed the facility failed to provide medical record access for one of seven residents (Resident R1). 28 Pa. Code 201.29(a)Resident rights.

Based on review of clinical record review and staff interviews it was determined that the facility failed to follow physician orders for one of two residents (Resident R1). Findings include: Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnosis that included malignant neoplasm of upper lobe, right bronchus or lung, cyst of kidney and ischemic cardiomyopathy (a condition that occurs when the heart muscle is damaged by a lack of blood flow). Review of Resident R1's physician orders dated 1/8/25, indicated that Resident R1 is to be Nothing by Mouth(NPO) diet, NPO texture, NPO consistency, enteral feed every shift by j-port. A review of Resident R1's physician orders dated for January indicated two medications were ordered to be given by mouth. They include the following: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl),semi-synthetic narcotic analgesic, give 0.5 tablet by mouth every 6 hours as needed Claritin Oral Tablet 10MG (Loratadine), an antihistamine used to treat allergy symptoms, 1 tablet by mouth at bedtime for itching During an interview on 1/15/25, at 2:00 p.m. the Nursing Home Administrator confirmed that resident is not to receive medication by mouth and that the above orders are not appropriate for a resident that is NPO. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, resident clinical records, documentation provided by the facility, facility investigation, personnel records, family and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in actual harm as evidenced by right tibia (the anterior of two bones below the knee) fractures for one out of three residents (Resident R27). Findings include: The facility Safe resident handling/transfer policy dated 1/30/24, indicated that the facility will ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide a safe, secure, and comfortable experience. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts (a mechanical device used to transfer resident. Device is typically placed in front of the resident with staff assistance), or ceiling tracked mounted lifts. Two staff members must be utilized when transferring residents with a mechanical lift. The facility Abuse, neglect and exploitation policy dated 4/6/23, last reviewed 1/30/24, indicated that the facility will provide protections for the health, welfare and rights of each resident by implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R27's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE]. Review of Resident R27's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 5/21/24, indicated she had diagnoses that included a history of falling, chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), artificial hip joint, history of other fracture, and hyperlipidemia (elevated lipid levels within the blood). Section GG0170-Mobility/ bed-to-chair transfers indicated a 1-Dependent: the assistance of two or more helpers is required for the resident. Review of Resident R27's care plans dated 5/24/24, indicated that Resident R27 required a Sit-to-Stand Machine with assistance of two staff for transfers. Review of Resident R27's physician orders 6/20/23, indicated to transfer Resident R27 with sit-to-stand and assistance of two staff persons. Review of Resident R27's physician order dated 7/17/24, indicated to X-ray her right lower leg. Review of Resident R27's Kardex (electronic report detailing care and transfer status of resident) dated 7/18/24, indicated to transfer Resident R27 with sit-to-stand with assistance of two staff persons. Review of Resident R27's physical therapy discharge assessment dated [DATE], indicated and recommended to continued use of sit-to-stand lift for functional transfers. Documentation provided by the facility dated 7/17/24, indicated the following: on 7/17/24, Resident R27 was being transferred from the bed to the chair by two nurse aide staff members. Resident R27 was stood for transfer and put into the chair. Resident was to be an assist of two with a sit-to-stand lift. Registered Nurse (RN) Assistant Director of Nursing (ADON) Employee E11 went to see Resident R27 and found a bruise measuring 15cm x 13cm purple area on her right shin. Resident R27 did not remember bumping her leg. Doctor and family notified of area. Order for X-ray obtained to rule out any injury. Review of Resident R27's clinical progress notes dated 7/17/24, indicated that the Registered Nurse (RN) Assistant Director of Nursing (ADON) Employee E11 was called to Resident R27's room. She was observed with discoloration noted to right lower extremity shin to side of inner calf measuring 15cm x 13cm. Resident R27 did complain of discomfort when touching area, not on movement. Spoke to her daughter and notified her of area. Doctor notified with new orders obtained: physician order dated 7/17/24, indicated to X-ray her right lower leg. Review of incident report dated 7/17/24, indicated that Resident R27 gave the following statement: Two girls (Nurse Aide (NA) Employee E13 and Agency Nurse Aide (NA) Employee E14) lifted Resident R27 up, one on each side of her and stood Resident R27 up. They could not find the lift this morning, so the two girls lifted her up. Review of incident report signed and dated 7/17/24, Nurse Aide (NA) Employee E13 stated: I was searching for a sit-to-stand. Agency Nurse Aide (NA) Employee E14 told me we could do a two-person assist to transfer. Review of facility X-ray of Resident R27 right leg dated 7/17/24, indicated she had an acute to sub-acute proximal right tibial fracture. Review of Resident R27's clinical progress note dated 7/18/24, at 7:04 a.m. indicated her physician was made aware of X-ray results. Physician initially discussed an orthopedic consult as an outpatient, but he felt that she may see orthopedic quicker if she goes to the emergency room . Physician order was obtained to send to emergency room for evaluation. Review of Resident R27's clinical progress note dated 7/18/24, at 8:53 a.m. Resident R27 left facility via ambulance to hospital. Review of Resident R27's hospital MRI report dated 7/18/24, indicated she had a non-displaced comminuted proximal tibial fracture of right medial tibial plateau (the top of the two shin-bones, under the knee cap) and tibial spine (the anterior of two bones below the knee). Review of Resident R27's clinical progress note dated 7/18/24, at 4:52 p.m. indicated she returned on 7/18/24 from the Hospital where she was sent for post fall injury to right leg. Report from hospital reports that the MRI showed a fracture of proximal end of tibia, as well a tibial plateau fracture. Resident R27 was put in a long-leg splint (velcro wrapping to secure leg) today and will need follow-up. Review of Nurse Aide (NA) Employee E13 personnel records indicated she was hired 3/7/24, she was trained on safety and transferring residents during orientation, and she was trained on neglect. Review of Agency Nurse Aide (NA) Employee E14 personnel records indicated she was hired 1/3/24, she was trained on safety and transferring residents, and she was trained on neglect. During an interview on 7/18/24, at 9:44 a.m. Registered Nurse (RN) Assistant Director of Nursing (ADON) Employee E11 stated: Resident R27 is out to the hospital. We got an X-ray of her right leg. She has a acute fracture to her tibia. During an interview on 7/18/24, at 9:48 a.m. Resident R27's Family RF stated the following: As far as the care Resident R27 gets daily, its amazing. Other than what happened, I'm pleased with her care. She has specific favorite aides. She never had an injury before. I was told that one aide was on each side and that this is how they got her out of the bed yesterday. Registered Nurse (RN) Assistant Director of Nursing (ADON) Employee E11 told me that staff did not use a lift as there was not a lift available. During an interview on 7/18/24, at 10:10 a.m. (RN) Assistant Director of Nursing (ADON) Employee E11 stated: Yesterday, I do not recall the time, but there is a note. I was called to the Resident R27's room. One of the nurse aides, Nurse Aide (NA) Employee E12, told me there was bruise. Nurse Aide (NA) Employee E12 asked me to come back. I saw the bruise, on the right lower extremity and on the shin area. I asked Agency Nurse Aide (NA) Employee E14 what happened as it looked to me that it was from the sit-to-stand lift. I asked the Resident R27 if the bruise was from the lift. It started to progress. It did not look that big and it was starting to swell. As I asked her questions, Resident R27 stated the two girls lifted her up and she said they could not find the lift. after I got her full statement, she said they stood her up, one on each side. She said her pants were rolled down below her knee. She was moving from bed to the chair. Resident R27 said she took a step and she felt her knee buckle. I reviewed the order after she said the lift was not involved. I looked at the assignment sheet. I saw that Nurse Aide (NA) Employee E13 was assigned. Agency Nurse Aide (NA) Employee E14 went in to assist Nurse Aide (NA) Employee E13. I asked them how Resident R27 was transferred, Agency Nurse Aide (NA) Employee E14 said no. the order was a stand-up lift or two-person assist. But the order does not say stand-up lift or two-person assist. It says to use the sit-to-stand lift. I had everyone write the statements. From what I understand. the aides are trained. Transfer information is available in the Kardex in their tasks. Nurse Aide (NA) Employee E13, came in at 10:00 a.m. yesterday. They are not her usual assigned aides. The regular aides pretty much know everyone. They should have known her transfer status and they know to look at the orders before doing a transfer. And there were three sit-to-stands over there and they said they could not find one. During an interview on 7/18/24, at 10:55 a.m. the Director of Rehabilitation Employee E15 stated: I am familiar with Resident R27. She was just on Occupational therapy recently, but not for transfers. She was discharged on [DATE]. There were no changes to the use of a sit-to-stand lift. She was discharged from Physical therapy on 2/7/23. The recommendation was to use sit to stand lift for transfers. During an interview on 7/18/24, at 11:03 a.m. Nurse Aide (NA) Employee E13 stated the following: yes, I knew Resident R27 had to be gotten up with a sit to stand. I was not able to find one. My coworker (Agency Nurse Aide (NA) Employee E14 ) told me she was a sit to stand and a two-person assist as well. We did a two-person assist with her. She was moved from bed to chair transfer. We sat Resident R27 down and Resident R27 stated her leg was bothering her. We should have looked at her leg. Agency Nurse Aide (NA) Employee E14 told me she would report it to the nurse. I believe when I left the room, we started passing trays. I have never had anything like this happen before. I am very remorseful and sorry. I would never hurt anyone, especially the residents. This occurred between 10:30 a.m. and 11:00 a.m. Staff can find information about transfer status in the care plan. I did not look at the information before moving Resident R27. I just went by Agency Nurse Aide (NA) Employee E14 word. I was trained on using sit-to-stand and reviewing the care plan or Kardex before transfer. During an interview on 7/18/24, at 11:11 a.m. Agency Nurse Aide (NA) Employee E14 stated the following: I did not have Resident R27 section yesterday. I do have it sometimes. I was asked for help to transfer her. I was asked by Nurse Aide (NA) Employee E13 to transfer Resident R27. We went into Resident R27 room. Resident R27 complained about her leg hurting before we moved her from the bed. We did not check or anything if there was a problem. We lifted her from her bed to her chair. I touched her leg. and then that was it, and I went back to her residents. I told them that we two-person assisted her. I thought it was two-person assist or sit to stand. I went back and looked. I was wrong for not using the sit-to-stand. I was also wrong for not questioning if we could use the sit-to-stand. I was wrong and I am not going to say I did not do something wrong: I did. When you have a good bit of residents and you are trying to get your own work done. I am always the first to help. It was my negligence to not do the right thing. I would never hurt or do something wrong to endanger them. This occurred around 10:30 a.m. I know I was going into another resident room. and right after that I was right back in another resident room. it was less then two minutes. The transfer status information is in the charting. it asks about the transfer and if the procedure was followed. I did not review information prior to moving resident, when I charted on the patient before. I just assumed. I did not know it read sit to stand with 2-assist, because Resident R27 can stand with two staff persons present. I was trained on using sit to stand through my agency and I had orientation and training in the past. I had courses with using sit-to stand, Hoyer lift and sliding board. During an interview on 7/18/24, at 11:30 a.m. Nurse Aide (NA) Employee E12, nurse aide stated the following: Resident R27 was in my care yesterday. I had another aide, Nurse Aide (NA) Employee E13, bed bath her and get her up. Nurse Aide (NA) Employee E13 and Agency Nurse Aide (NA) Employee E14 got her up. After lunch, Resident R27 rang her call bell to lay back down. I went into the room. Nurse Aide (NA) Employee E13 and Agency Nurse Aide (NA) Employee E14 were laying her down. When we took her ted hose off, we saw the bruise on her leg. It was about soft ball size bruise. Resident R27 said her right leg was hurting. We went out and got the nurse that was in the hall. Resident R27 stated her leg started to hurt when they got her out of bed. Information found related to transfers is in the charting. Staff are all trained on using the sit to stand and Hoyer lift. If an aide does not know transfer status they should ask a nurse, and if they do not know, look in the charting. During an interview on 7/18/24, at 11:46 a.m. Nurse Aide (NA) Employee E16 stated that she was trained on use of sit to stand, two staff help residents with sit to stand lifts, transfer information for residents is found in the Kardex, and if staff you don't know the transfer status, they will go find out first by looking at the Kardex. During an interview on 7/18/24, at 11:53 a.m. Nurse Aide (NA) Employee E17 stated that she was trained on use of sit to stand, two staff help residents with sit to stand lifts, information found related to resident transfers is in the charting on the electronic kiosk and in the Kardex, and if staff don't know the transfer status to look at the Kardex. During an interview on 7/18/24, at 2:06 p.m. Licensed Practical Nurse (LPN) Employee E6 stated that she was trained on use of sit-to-stand, transfer information for residents is found in the ADL (activity of daily living) in the computer for status, two staff help residents with any mechanical lift, and if staff don't know the transfer status to speak with her as she is familiar with Resident R27. During an interview on 7/19/24, at 9:15 a.m. Registered Nurse (RN) Assistant Director of Nursing (ADON) Employee E11 stated: Resident R27 came back yesterday. She currently has a splint to her right leg. Orthopedic consultant was considering her getting a cast. During an interview on 7/19/24, at 9:19 a.m. Licensed Practical Nurse (LPN) Employee E18 stated she was trained on use of sit to stand, transfer information for residents is usually found in the Physican's orders, staff discuss status during report in the morning. She stated that if staff don't know the transfer status to staff and look on morning report. Never assume. Two staff persons are used for using mechanical lift. And she was familiar with Resident R27 and Resident R27 usually uses a sit-to-stand to transfer. During an interview on 7/19/24, at 9:21 a.m. Nurse Aide (NA) Employee E19 stated that she was trained on use of sit-to-stand, two staff help residents with sit to stand lifts, information found related to resident transfers is in the charting on the electronic kiosk and in the Kardex, and she was familiar with Resident R27 and Resident R27 usually uses a sit-to-stand to transfer. During an interview on 7/19/24, at 11:12 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that Resident R27 was free from neglect as required, which resulted in actual harm as evidenced by right tibia fractures. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for eight of 16 residents reviewed (Residents 3, 4, 11, 12, 13, 14, 15, 16). The facility's failure created a situation in which four of these residents (Residents 12, 13, 14, 16) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents. Findings include: Pennsylvania Health Alert Network (PAHAN) - 570, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-Term Care Facilities, dated May 10, 2021, revealed that residents needed to be cohorted to separate units in three zones, based on test results: 1. COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. 2. Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. 3. Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. Staff should be designated by zone as much as possible to minimize risk to exposed (Yellow) and non-exposed (Green) residents. Guidance from the Centers for Disease Control (CDC - a national public health agency), dated April 30, 2020, included that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. The facility's policy regarding COVID-19, revised May 12, 2021, indicated that the facility would respond promptly upon suspicion of illness associated with COVID-19 in an effort to identify, treat, and prevent the spread of the virus. The implementation of infection control measures, along with prevention and identification of symptoms associated with COVID-19 would be based on available information from the Centers of Disease Control (CDC) and the Offices of the Department of Health, Infectious Disease in Pennsylvania, Secretary of Health, as well as guidance from the Centers for Medicare/Medicaid (CMS) services. In the event that a resident tested positive for COVID-19, the facility would implement Cohorting Zones and follow the guidelines set forth from the Pennsylvania Department of Health, CMS, and the CDC recommendations. A COVID-19 test result for Resident 3, dated September 22, 2021, revealed that the resident was positive, and a COVID-19 test result for Resident 16, dated September 23, 2021, revealed that the resident was positive. Daily census information revealed that Residents 3 and 16 were roommates at the time that Resident 3 had a positive test result on September 22, 2021, and there was no documented evidence that either resident was moved following the positive test result for Resident 3. A COVID-19 test result for Resident 4, dated September 22, 2021, revealed that the resident was positive, and a COVID-19 test result for Resident 13, dated September 22, 2021, revealed that the resident was negative. Daily census information revealed that Residents 4 and 13 were roommates at the time that Resident 4 had a positive test result on September 22, 2021, and there was no documented evidence that either resident was moved following this positive test result for Resident 4. A COVID-19 test result for Resident 13, dated September 28, 2021, revealed that the resident was now positive. A COVID-19 test result for Resident 11, dated September 26, 2021, revealed that the resident was positive, and a COVID-19 test result for Resident 12, dated September 22, 2021, revealed that the resident was negative for COVID-19. Daily census information revealed that Residents 11 and 12 were roommates at the time of Resident 11's positive test result on September 26, 2021, and there was no documented evidence that either resident was moved following Resident 11's positive test result. A nursing note for Resident 12, dated September 28, 2021 at 4:38 p.m. revealed that the resident continued to be asymptomatic, but expressed a concern about being in the Red Zone when he was COVID-19 negative. The resident was reassured (by staff). A COVID-19 test result for Resident 14, dated September 22, 2021, revealed that the resident was positive, and a COVID-19 test result for Resident 15, dated September 13, 2021, revealed that the resident was negative for COVID-19. Daily census information revealed that Residents 14 and 15 were roommates at the time of Resident 14's positive test result on September 22, 2021, and there was no documented evidence that either resident was moved following Resident 14's positive test result. Observations of Residents 14 and 15 on September 28, 2021, at 2:27 p.m. revealed that they resided in the same room with no type of barrier between them. Interview with the Infection Preventionist on September 28, 2021, at 12:33 p.m. revealed that because there was no room in the facility, COVID-19 positive residents were being isolated in place with roommates who were COVID-19 negative. The Infection Preventionist stated that staff were to change personal protective equipment (PPE) between resident care, and a barrier should be between the residents. Interview with Pennsylvania Department of Health Epidemiology Research Associate 1 on September 28, 2021, at 1:27 p.m. revealed that in some cases (usually in facilities with severe staffing shortages or in smaller facilities that do not have distinct units), there were not enough available units or sections of a facility to make two distinct Red and Yellow Zones with separate dedicated staff for each. In that case, the facility should subcohort within a unit, placing exposed Yellow Zone residents on one end of the hall and positive Red Zone residents on the other. Ideally, a temporary barrier should be placed between the Red and Yellow Zones to create a physical division and prevent wandering across zones. Resident doors should be closed on both zones unless there was a safety risk for the resident (e.g., residents with dementia), and all staff should care for Yellow and Red Zone residents in full PPE. Private rooms were preferred for each resident in Red and Yellow zones, but if not possible, Yellow Zone residents must be placed with other Yellow Zone residents, and Red Zone residents should be placed with other Red Zone residents. Interview with the Nursing Home Administrator on September 29, 2021, at 2:03 p.m. confirmed that the facility did not follow their infection control policy regarding COVID-19. On September 28, 2021, at 3:30 p.m. the Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The facility submitted and implemented an immediate action plan that included ensuring that each resident's most recent COVID-19 test result was reviewed. Residents who tested negative were moved out of the rooms where they were previously residing with residents who tested positive, and a designated Red Zone was created. Residents were placed in the Red and Yellow Zones according to their most recent COVID-19 test results. The facility developed an infection control education plan for all current and future staff, including agency staff, and staff who were currently off work related to testing positive for COVID-19. The education included cohorting positive and negative residents in the proper infection control zones. The Immediate Jeopardy was lifted on September 29, 2021, at 5:32 p.m. when it was confirmed that the facility moved all residents into the correct infection control zones in accordance with their COVID-19 test results, educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow physician-ordered and care-planned interventions for two of eight residents reviewed (Residents 2, 6), resulting in a fall with an ankle fracture for Resident 2; and failed to complete a thorough investigation and assessment of falls to determine if physician-ordered and care-planned interventions were in place at the time of the fall for one of eight residents reviewed (Resident 5). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2019, revealed that the resident could understand and be understood by others, had moderate cognitive impairment, and required the extensive assistance of two staff for transfers. A physician's order, dated October 31, 2019, and the resident's care plan dated November 26, 2019, revealed that she was at risk for falls and included that she was to transfer with a sit-to-stand mechanical lift (a device that uses hydraulic power to lift and move a resident while in a standing position and supported by a sling) and the assistance of two staff. Nursing notes for Resident 2, dated December 31, 2019, at 2:00 p.m. and 3:41 p.m. revealed that the resident complained of pain in her left leg and ankle after being transferred to her wheelchair. The physician was notified and an order was received to X-ray the resident's left ankle, which showed an acute (recent) fracture. An investigation report for Resident 2, dated December 31, 2019, revealed that Nurse Aide 3 had the resident wrap her arms around her neck and transferred the resident into her wheelchair. The resident heard her ankle crack and it began to hurt. An X-ray revealed that the resident had a fractured left ankle. It was found that Nurse Aide 3 did not follow the resident's care plan for transfers and was non-compliant with the facility's policies and protocols. A witness statement completed by Nurse Aide 3, dated January 1, 2020, revealed that on December 31, 2019, at 10:45 a.m. she sat Resident 2 on the side of the bed and transferred her into a wheelchair using a stand and pivot transfer, and after the resident was in her wheelchair she complained of pain to her left foot. A witness statement completed by Registered Nurse 2, dated December 31, 2019, revealed that Resident 2 told her that Nurse Aide 3 pulled her off the side of the bed and had her wrap her arms around her neck, and then she heard her ankle crack and it started to hurt. Resident 2 indicated that Nurse Aide 3 did not use the sit-to-stand lift. Interview with the Director of Nursing on January 8, 2020, at 4:16 p.m. confirmed that on December 31, 2019, Nurse Aide 3 failed to transfer Resident 2 with a sit-to-stand mechanical lift, with the assistance of two staff, in accordance with the resident's care plan and physician's orders. A quarterly MDS assessment for Resident 6, dated November 12, 2019, revealed that the resident was cognitively intact, could understand and be understood by others, and required extensive assistance from staff for daily care tasks, including transfers. The resident's care plan, dated June 6, 2019, indicated that she was to transfer with a front-wheeled walker and the assistance of one staff. A nursing note for Resident 6, dated January 1, 2020, at 2:07 p.m. revealed that the resident reported that two days ago a nurse aide stepped on her foot while transferring her from her bed to the wheelchair. The resident reported that she usually used a walker when transferring, but the nurse aide picked her up instead of using the walker and stepped on her foot during the process. Resident 6 reported that her foot had been hurting ever since the incident. The physician was notified and an order was received to obtain an X-ray of the left foot, which showed a fracture of the second toe of indeterminate age. A witness statement completed by Nurse Aide 4 on January 1, 2020, confirmed that on December 29, 2019, at 11:00 a.m. he transferred Resident 6 from her wheelchair into bed without using a front-wheeled walker. Interview with the Director of Nursing on January 8, 2020, at 4:15 p.m. confirmed that during the incident on January 1, 2020, Resident 6 was not transferred with a front-wheeled walker as care planned. The facility's policy regarding incident/accident reporting, dated March 26, 2019, revealed that an incident/accident form was to be completed by licensed nursing staff when an event occurred, and an investigation form was also to be completed at that time. The form was to include any further details surrounding the event, any suggestions to prevent reoccurrence, and any new interventions that were implemented at the time of event. The investigation was also to include when the resident was last observed and if the resident had any needs met at that time. These events/occurrences were to be reviewed at morning meeting with a multi-disciplinary approach by discussion and suggestion to prevent future occurrences. The quality assurance nurse/designee was to review the incident report to ensure that it was completed and that the resident's care plan remained appropriate. An annual comprehensive MDS assessment for Resident 5, dated October 8, 2019, revealed that the resident was understood and could understand, required extensive assistance from staff for daily care tasks, including transfers, and had medical diagnoses that included [CONDITION(S)] to her right eye. The resident's care plan, dated April 10, 2019, and a physician's order dated October 30, 2019, revealed that she was at risk for falls and was to transfer with the assistance of one staff and a wheeled walker. A nursing note for Resident 5, dated December 9, 2019, and completed by a registered nurse, revealed that a nurse aide called for help in the resident's room, and the nurse saw that the resident was stuck between her wheelchair and a bedside commode with no body parts touching the floor. The bedside commode was moved, the resident was carefully laid on the floor, then she was pulled up and onto the commode. There were no injuries noted at that time. The resident complained of knee pain and Tylenol (an over-the-counter pain medication) was administered. A witness statement completed by Nurse Aide 1, dated December 10, 2019, revealed that Resident 5 was last seen at 2:55 p.m., the incident occurred at 3:00 p.m., and the resident was in her wheelchair at the time of the incident. She indicated that the resident was being transferred from her wheelchair, which was locked, to the shower chair, which was locked and facing the wheelchair. Staff helped the resident stand up and turn to sit in the shower chair. The resident was not able to make the turn and had to be lowered gently to the floor on her knees. There was no documented evidence that the witness statement, and/or the facility's investigation, determined if Resident 5's physician-ordered and care-planned intervention of transferring with a wheeled walker was in place at the time of the fall. Interview with the Director of Nursing on January 8, 2020, at 5:00 p.m. confirmed that Resident 5's physician's orders included that she was to use a wheeled walker during transfers. The Director of Nursing could not provide any documented evidence to show that the facility's investigation determined if the wheeled walker was used at the time of the fall. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/9/19. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/6/19, 5/9/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/6/19, 5/9/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/6/19, 10/15/19, 5/9/19. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 11/6/19, 5/9/19. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/6/19, 5/9/19. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/6/19, 10/15/19, 5/9/19.

Based on review of policies, clinical records, accident/incident reports, and information submitted by the facility, in addition to staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were assessed and used for four of four residents reviewed (Residents 1, 2, 3, 4) who used a sliding board transfer technique, which resulted in a fall with a fractured leg bone for one resident (Resident 2). Findings include: The facilty's policy regarding the use of shower chairs (a specialized chair that can be taken into a shower), dated (MONTH) 2, (YEAR), indicated that the resident was to be transferred in and out of the shower chair using the transfer method indicated on his/her care plan. The facility's policy regarding the use of a sliding board (a piece of equipment that is placed between two surfaces and used by the resident to slide across from one surface to the other), dated (MONTH) 2, (YEAR), indicated that when performing a sliding board transfer, the wheelchair was to be placed parallel to the surface being transferred to or from, with the brakes locked, and the wheelchair arm removed. The policy did not address the use of a sliding board to transfer into a shower chair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated (MONTH) 29, (YEAR), revealed that the resident was alert and oriented and was dependent on two staff for transfers. physician's orders [REDACTED]. A nursing note for Resident 2, dated (MONTH) 5, 2019, at 1:35 p.m. revealed that the resident was lowered to the floor during a transfer from the bed to a shower chair. The resident complained of pain in her right hip, leg and toes, and it was noted that the resident's left great toe was bleeding and the toenail was separated completely from the nail bed and was found on the floor. The nurse practioner (a registered nurse with advanced education, training and the authority to diagnose and prescribe medication and treatments) was notified and gave orders to obtain an x-ray of the right leg and to apply an antibiotic ointment to the right toe. An x-ray report for Resident 2, dated (MONTH) 5, 2019, revealed that the resident had an acute (recent) distal femoral fracture ([MEDICAL CONDITION] bone in the upper leg, near the knee) and the physician was notified and requested that the resident be sent to the emergency department for evaluation. The facility's investigation report, dated (MONTH) 5, 2019, revealed that Resident 2 was being transferred from her bed to a shower chair by two nurse aides, without using a sliding board, when the two aides were not able to support her weight any longer and lowered her to the floor. A statement obtained from Resident 2 on (MONTH) 7, 2019, revealed that on (MONTH) 5, 2019, Nurse Aides 1 and 2 were preparing to transfer her to the shower chair with Nurse Aide 1 under her left arm and with Nurse Aide 2 under her right arm. The resident did not feel as though Nurse Aide 2 was strong enough to support her and the resident said, I think I am going down. She felt her right leg buckle and her knee cap hit the floor. The nurse aides then laid her down the rest of the way to the floor. In response to a question about if her knee hit the floor hard, the resident replied, I think I hit it semi-hard enough. I felt it right away and was in pain. The resident confirmed that a sliding board was not used for the transfer. The investigation report indicated that it was determined that a sliding board transfer could not be performed when transferring residents to a shower chair, because the arms of the shower chair were fixed and could not be removed to make a clear path from one surface to the shower chair. Therefore, staff had been lifting residents manually or using a mechanical lift (device that uses hydraulic power to lift and transfer a person from surface to surface while supported in a sling) for residents who were ordered and care planned to use sliding boards for transfers. There was no documented evidence that an assessment was completed to determine safe transfer methods for transferring Resident 2 into a shower chair. Interview with Registered Nurse 3 (the quality assurance nurse and also the nurse who performed the investigation of the incident on (MONTH) 5, 2019) on (MONTH) 8, 2019, at 11:30 a.m. revealed that she was not aware that nurse aides informed anyone about not being able to use a sliding board when transferring residents into a shower chair. Therefore, residents who were ordered and care planned to use a sliding board for transfers were not assessed to determine the safest method for transferring them into a shower chair. She indicated that direct care staff should have notified the registered nurse supervisor that transfers into a shower chair using a sliding board were not able to be completed, so that an assessment could be performed to determine what alternative transfer methods were appropriate and safe. Interview with Registered Nurse 4 (the nurse responsible for teaching the facility's nurse aide training course) on (MONTH) 8, 2019, at 4:31 p.m. revealed that nurse aide students and new hires were taught to follow each resident's individualized care plan for transfers, and they were permitted to make the decision to downgrade the method used to transfer a resident (use a method that requires less physical participation on the resident's part and more dependence upon staff) if they felt uncomfortable at the time of a transfer; however, they were to notify licensed staff when this was done. Registered Nurse 4 indicated that she was very familiar with Resident 2's care needs and abilities, and indicated that the resident had no use of her lower extremities, and due to her body size she should have been transferred into a shower chair using a mechanical lift. A comprehensive admission MDS assessment for Resident 1, dated (MONTH) 13, (YEAR), revealed that the resident was alert and oriented and was dependent on two staff for transfers. physician's orders [REDACTED]. A quarterly MDS assessment for Resident 3, dated (MONTH) 5, (YEAR), revealed that the resident was alert and oriented and was dependent on two staff for transfers. physician's orders [REDACTED]. A comprehensive admission MDS assessment for Resident 4, dated (MONTH) 11, (YEAR), revealed that the resident was alert and oriented and was dependent on two staff for transfers. physician's orders [REDACTED]. There was no documented evidence that assessments were completed to determine safe transfer methods for transferring Residents 1, 3 and 4 into a shower chair. Interview with Registered Nurse 3 on (MONTH) 8, 2019, at 11:30 p.m, confirmed that Residents 1, 3 and 4 had orders to use a sliding board for transfers and used a shower chair for showers. She confirmed that the residents were not assessed to determine the safest method for transferring them into a shower chair, as the facility had just become aware that a sliding board could not be used for transferring residents into a shower chair with fixed arm rests. Interview with the Assistant Director of Nursing on (MONTH) 8, 2019, at 1:45 p.m. confirmed that there had been no communication between the nurse aides and the licensed staff regarding being unable to complete sliding board transfers into a shower chair; therefore, no assessments for safety were performed to determine the most appropriate means of transferring Residents 1, 2, 3 and 4 into a shower chair. She indicated that all four residents were assessed on the morning of (MONTH) 8, 2019, and it was determined that for safety purposes, all four residents were to use a mechanical lift for transfers into a shower chair. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/7/18, 9/11/17, 5/4/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/15/18, 6/7/18, 5/17/18, 5/4/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/7/18, 5/17/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 6/7/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/15/18, 6/7/18, 11/9/17, 5/4/17. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 8/15/18, 6/7/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/15/18, 6/7/18, 9/11/17, 5/4/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/15/18, 6/7/18, 5/17/18, 9/11/17, 5/4/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/2/18, 8/15/18, 6/7/18, 5/17/18, 9/11/17, 5/4/17.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about changes in condition, which caused a delay in treatment for two of 41 residents reviewed (Residents 66, 109) and resulting in a lack of improvement requiring surgery and the development of a [MEDICAL CONDITION] embolism for Resident 109. Findings include: The facility's policy regarding changes in condition, dated (MONTH) 2, (YEAR), revealed that the nurse supervisor/charge nurse was to notify the resident's attending physician or on-call physician when there was a significant change in the resident's condition, such that it would not resolve itself. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated (MONTH) 23, (YEAR), revealed that the resident was alert and oriented, required extensive assistance with activities of daily living, and had [DIAGNOSES REDACTED]. A nursing note for Resident 109, dated (MONTH) 20, (YEAR), at 7:30 p.m. revealed that Registered Nurse 1 was called to the room to assess the resident's left leg. The resident complained of groin pain that radiated to her ankle, and the resident's left lower extremity was reddish/purple in color, cool to the touch, with +2 [MEDICAL CONDITION] (occurs when an indentation is left from the finger pressing against the skin when there is swelling). Registered Nurse 1 indicated that she would alert the oncoming registered nurse to call and get a Doppler (an ultrasound test used to identify blood clots) ordered per the resident's request; however, there was no documented evidence that the physician was notified about the resident's change in condition. A nursing note for Resident 109, dated, (MONTH) 21, (YEAR), at 7:27 a.m. revealed that the resident stated, I cannot feel my left foot. The resident's left leg at the mid-thigh was dark purple and changing to a dusky blue/purple at the left foot. The resident also complained of pain to the left leg, and a pulse could not be felt to the left foot or behind the knee. The resident requested to go to the hospital, the physician was notified, and an order was received to transfer the resident to the hospital for evaluation and treatment. Hospital records for Resident 109, dated (MONTH) 21 through 25, (YEAR), revealed that the resident was admitted with pain, swelling and a bluish discoloration of the left leg. The resident was found to have extensive [MEDICAL CONDITION] ([MEDICAL CONDITION]- the formation of a blood clot in a deep vein, most commonly in the legs) on the left lower extremity, underwent a Thrombectomy (surgical procedure used to remove deep [MEDICAL CONDITION], or blood clots that have formed in the deep veins), and a CT scan (computerized diagnostic test) of the chest showed a [MEDICAL CONDITION] embolism (PE - happens when a blood clot gets caught in an artery in the lungs, which can cause serious problems such as lung damage, low oxygen levels, and even death) in the left upper lobe of the lungs. An interview with the Director of Nursing on (MONTH) 6, (YEAR), at 4:35 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 109's change in condition on (MONTH) 20, (YEAR), which resulted in a delay in treatment. A quarterly MDS assessment for Resident 66, dated (MONTH) 9, (YEAR), revealed that the resident was confused, was unable to make her own decisions, and required staff assistance for her care. A nursing note for Resident 66, authored by Licensed Practical Nurse 4 and dated (MONTH) 19, (YEAR), revealed that the resident's left foot and calf were swollen and warm and that she would monitor the area. A nursing note authored by Registered Nurse 5 and dated (MONTH) 21, (YEAR), revealed that the resident's left calf/foot was swollen. A nursing note authored by Registered Nurse 5 and dated (MONTH) 22, (YEAR), revealed that the resident had a [MEDICAL CONDITION] ([MEDICAL CONDITION] - a blood clot) in her left leg. There was no documented evidence that the physician was notified about the resident's change in condition until physician's orders [REDACTED]. An interview with the Director of Nursing on (MONTH) 7, (YEAR), at 3:40 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 66's change in condition, which resulted in a delay in treatment for a [MEDICAL CONDITION]. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/17/18, 9/11/17, 5/4/17, 3/1/17, 7/6/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/18, 9/11/17, 5/4/17, 4/20/17, 3/1/17, 1/11/17, 11/20/16, 7/6/16, 5/19/16.

Based on clinical record reviews and staff and resident interviews, it was determined that the facility failed to ensure that a resident's wound care was provided as ordered by a consulting physician, resulting in a dressing adhering to the wound and requiring an extremely painful removal for the resident for one of three residents reviewed (Resident CR2). Findings include: An admission assessment for Resident CR2, dated January 28, 2017, revealed that the resident was alert and oriented, required assistance with his care, and he had a surgically debrided wound (surgical removal of dead tissue caused by [DIAGNOSES REDACTED] - a bacterial skin infection that spreads rapidly and kills soft tissue) on the right buttock that measured 28 x 26 centimeters (cm), with undermining (tunneling or being open underneath the lip of the wound) at four o'clock and ten o'clock (the location of the tunneling in relation to clock hands). A physician's discharge summary from the hospital, dated January 28, 2017, revealed that the resident had a surgical wound debridement and placement of a wound vac (a machine used to treat advanced wounds that are difficult to heal, which uses a pump to suction fluids from the wound), and he was to follow-up with the consulting wound doctor on January 30, 2017. The physician's orders [REDACTED]. A physician's consultation and discharge instructions for Resident CR2, dated January 30, 2017, revealed that the wound clinic gave an order for [REDACTED]. Also, a piece of green foam was to be cut into half of the thickness and placed on the right peri-anal area (around the anus, the opening of the rectum)/distal (away from) right buttocks wound bed, and it was to be changed three times a week. However, there was no documented evidence that a physician's orders [REDACTED]. [REDACTED]. Resident CR2's treatment records revealed that the original dressing that was ordered on January 28, 2017, was completed on January 30, 2017. The original dressing was then changed again on February 1, 2017, due to the dressing leaking, and was changed again on February 4, 2017. There was no documented evidence that the dressing that was ordered by the wound clinic physician on January 30, 2017, was applied. A consulting wound physician's progress note for Resident CR2, dated February 6, 2017, revealed that the wound clinic found that the resident's wound vac was adhered (attached) to the underlying tissue, that the wound was completely engrafted (indicating that the wound had begun to heal into the treatment material) into the sponge of the wound vac, that a selective debridement (to remove the treatment material - the sponge) that took 25 minutes was performed in order to remove the wound vac, and that it was painful for the resident. An interview with Physician 1, the consulting wound clinic physician, on February 24, 2017, at 3:00 p.m. revealed that when Resident CR2 was seen at the clinic office for wound vac care on February 6, 2017, she found that the wound dressing sponge was not applied as ordered, that there was no [MEDICATION NAME] on the base of the wound as ordered, and that the wound vac sponge was adhered to the wound with the wound tissue actually grown into the sponge. She indicated that the removal of this sponge from the resident's wound was, very painful and traumatic to the resident, and that if the underlying [MEDICATION NAME] had been applied as ordered this significant pain with his dressing change would have been 100 percent avoidable. An interview with Resident CR2 on February 28, 2017, at 9:50 a.m. revealed that the dressing removal at the wound clinic caused so much pain that he was actually crying. The resident indicated that on a scale of 1-10 (with 10 being the worst pain) he would have to describe the pain of the dressing removal as severe, and he rated the pain as a 90 even with the pain medication that was used during the procedure. An interview with Registered Nurse 4 on February 22, 2017, at 11:10 a.m. confirmed that the wound care orders that were given by the consulting physician on January 30, 2017, were not followed. 42 CFR 483.24, 483.25(k)(1) Provide Care/Services for Highest Well Being. Previously cited 7/6/16, 5/19/16, 12/19/15. 28 Pa. Code 211.5(f) Clinical records. Previously cited 1/11/17, 5/19/16, 12/19/15, 7/8/15, 6/4/15. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/19/16, 6/4/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/6/16, 12/19/15, 7/8/15, 6/4/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/11/17, 11/20/16, 7/6/16, 5/19/16, 2/27/16, 12/9/15, 7/20/15, 7/8/15, 6/4/15.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned for one of 35 residents reviewed (Resident R5) who fell and suffered a fracture. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R5, dated March 8, 2016, revealed that the resident required extensive assistance with transfers and ambulation. The resident's care plan, dated March 10, 2016, revealed that the resident was at risk for falls and was to use leg rests on both sides of her wheelchair and was to use Dycem (material used to prevent sliding) to her wheelchair seat. A facility investigation report and nursing note, dated April 19, 2016, at 7:50 p.m., revealed that Resident R5 had a fall from her wheelchair while being pushed from the bathroom to her bed. The report indicated that the wheelchair leg rests were removed to transport the resident to the bathroom, and while being pushed in the wheelchair back to her bed, the resident slid out of her wheelchair onto the floor. There was no documented evidence that there was Dycem on the resident's wheelchair seat. The report indicated that the resident was admitted to the hospital with [REDACTED]. Interview with the Quality Assurance Nurse on May 19, 2016, at 12:10 p.m., confirmed that when Resident R5 was being pushed in her wheelchair from the bathroom and fell , the leg rests were not on the chair as care planned. Interview with the Director of Nursing on May 19, 2016, at 1:12 p.m., revealed that he did not know if Resident R5 had Dycem on her wheelchair seat when she fell . He indicated that staff should have put the leg rests on the resident's wheelchair when they were pushing her to her bed. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 6/4/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/27/16, 12/19/15, 7/20/15, 7/8/15, 6/4/15, 12/12/14, 5/15/14.

Based on review of manufacturer's information and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors, resulting in a decline in condition for one of 25 residents reviewed (Resident R16). Findings include: Manufacturer's information regarding [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] - a medication used to treat [MEDICAL CONDITION], which is a disease of the nervous system), undated, indicated that possible side effects of the medication included back pain, depression, decreased mental acuity, memory impairment, and weight loss. Admission physician's orders [REDACTED]. A physician's progress note dated April 24, 2016, the day before the resident's admission to the facility, indicated that the resident had no major complaints and could eat with supervision, and a nursing note, dated April 26, 2016, indicated that the resident was alert and oriented upon admission. Nursing notes, dated April 26, 2016 at 8:30 p.m.; April 27, 2016 at 2:26 a.m.; and April 28, 2016 at 6:02 a.m. and 10:37 p.m., revealed that Resident R16 complained of back pain, and an order was obtained for, and the resident received, Tylenol (an over-the-counter pain medication). Nursing notes, dated May 1 and 2, 2016, indicated that the resident was alert but needed assistance with eating. A dietary note, dated May 3, 2016, indicated that the resident now needed to be fed, and she experienced a significant weight loss of 12 pounds in the eight days since her admission. A social services note, dated May 3, 2016, revealed that a change was noted in the resident's cognitive abilities, and she declined from being independent to being moderately impaired. A psychology note, dated May 5, 2016, revealed that the resident was diagnosed with [REDACTED]. Observations during medication administration on May 16, 2016, at 9:15 p.m., revealed that Licensed Practical Nurse (LPN) 5 pulled a medication packet from a drawer on the medication cart to administer to Resident R16. The packet was labeled [MEDICATION NAME]/[MEDICATION NAME] 25-100 milligram, give one-half tablet three times a day. However, the packet contained one and one-half tablets of [MEDICATION NAME] and LPN 5 administered the contents of the packet to Resident R16. Interview with LPN 5 on May 16, 2016, at 10:50 p.m., revealed that he looks at the medication packet to ensure that the resident's name on the packet matches the resident he intends to give the medication to, but he trusts the pharmacy to correctly fill the medication packet with the medications as ordered by the physician. Interview with the Director of Nursing (DON) on May 17, 2016, at 11:00 a.m., confirmed that all nurses administering medications should check to ensure that the correct medications, in the correct doses, are administered to residents. Interview with the DON on May 17, 2016, at 2:30 p.m., revealed that the facility's pharmacy confirmed that the wrong dosage of [MEDICATION NAME] was administered to Resident R16 starting with the first dose administered on April 26, 2016, at 9:00 a.m., and continuing for a total of 63 doses until May 16, 2016, at 9:00 p.m. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/15/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/27/16, 12/19/15, 7/20/15, 7/8/15, 6/4/15, 12/12/14, 5/15/14.