Every finding on record at York South Skilled Nursing and Rehabilitation CTR

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of four pantry refrigerators and the ceiling in the kitchen area.Findings include: Review of facility policy, titled Safe Handling for Foods from Visitors, revised July 20298, read, in part, when food items are intended for later consumption, the responsible facility staff member will label foods with the resident name and the current date. Review of facility policy, titled Department Sanitation, revised September 2017, read, in part, all non-food contact equipment will be clean and free of debris. Observation of the ceiling to the right of the 3-compartment sink on June 15, 2026, at 10:05 AM, revealed there was a square opening without a cover. At that time, interview with the Employee 12 (Dining Services Director) revealed there was a leak in the ceiling several months ago and the flat cover wasn't replaced. Observation with Employee 2 (Director of Maintenance) on June 17, 2026, at 1:06 PM, revealed the aforementioned opening in the ceiling to the right of the 3-compartment sink remained. Interview at that time revealed there was a leak in the ceiling several months ago and the metal panel should've been hung. Observation in the 500/600-unit nourishment refrigerator on June 15, 2026, at 10:20 AM, revealed two plastic bags date marked June 13th; one containing half eaten chicken and rice and the second containing a portion of a quesadilla, both weren't marked with a resident identifier. At that time, interview with Employee 12 revealed that staff food items should be stored in the staff lounge and resident items should be marked with an identifier. Observation in the 700/800-unit nourishment refrigerator on June 15, 2026, at 10:26 AM, revealed a red dried liquid on the bottom shelf inside the refrigerator. At that time, interview with Employee 12 revealed the refrigerator should be clean. Interview with the Nursing Home administrator on June 17, 2026, at 1:07 PM, revealed there was a leak in the kitchen ceiling and are the area should be covered. A time frame regarding the leak was requested and not provided. It was also revealed that resident items should be marked with an identifier and the nourishment refrigerator should be clean. 28 Pa. Code 201.14 - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on facility policy review, record review, wound tracking form, and staff interview, it was determined the facility failed to maintain a method of accuracy for wound measurement assessments between facility staff and the wound provider specialist for one of 31 residents reviewed (Resident 5). Findings include: Review of the facility policy, titled Skin Integrity and Wound Management, last reviewed February 2026, state, the plan of care for the resident will be reflective of assessments findings from the comprehensive patient assessment and wound evaluation. Review of Resident 5's clinical record revealed diagnoses that included a facility acquired stage IV pressure ulcer (full skin loss that expose underlying muscle, tendons, joints, or bones) of the left heel and vascular dementia (decline in thinking and memory skills caused by restricted or blocked blood flow to the brain). A review of Resident 5's progress notes, care plan and observation of the Resident revealed the Resident was non-compliant with keeping heel boots in place or off-loading heals while in bed. Review of the facility documented wound measurements dated June 11, 2026, were 3.78 cm (centimeters) x 3.06 cm x 0 cm. Review of the wound care specialist documented wound measurements dated June 11, 2026, were 2.7 cm x 2.7 cm x 0.3 cm with no change documented from previous assessment. Review of the facility documented wound measurements dated June 4, 2026, were 3.16 cm x 2.81 cm x 0.2 cm. Review of the wound care specialist documented wound measurements dated June 4, 2026, were 2.7 cm x 2.7 cm x 0.3 cm with documentation of improvement from the previous assessment. Review of the facility documented wound measurements dated May 28, 2026, were 3.0 cm x 3.0 cm x 0.3 cm. Review of the wound care specialist documented wound measurements dated May 28, 2026, were 3.5 cm x 3.5 cm x 0.2 cm with documentation of improvement from the previous assessment. Further review of wound measurements revealed inconsistencies with measurements since the wound care specialist had initiated care on April 9, 2026. During an interview with the Director of Nursing (DON) on June 18, 2026, at 12:00 PM, the DON confirmed the measurements were not consistent because of the different methods of measurement utilized by facility and the wound care specialist. The DON stated that the wound care specialist manually measures the wound and the facility utilizes a camera that automatically enters measurements that are not consistent with the manual measurements. The DON stated that the facility utilizes the measurement, and other aspects that are documented by the wound care specialist that includes drainage, type and amount, but is unable to correct the system to the manual measurements of the wound care specialist. The DON added that all wounds that are managed by the wound care specialist are also photographed by the facility indicating the discrepancy in measurements would be evident with other residents. A review of the wound tracking sheet dated June 18, 2026, revealed the facility was documenting the facility measurements rather than the wound care specialist measurements on the form. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments, received at a certified dialysis facility for one of two residents reviewed for dialysis treatments (Resident 108).Findings Include: Review of the facility's policy, titled Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility, effective October 1, 2018, read, Patients who require HD services receive care consistent with professional standards of practice.Professional standards of practice include- Ongoing assessment and oversight of the patient before and after HD treatments. and Ongoing communication and collaboration with the certified dialysis facility regarding HD care and services. Dialysis is defined as a medical treatment that performs the function of the kidneys by removing waste, toxins, and excess fluid from the blood when the kidneys are unable to do so. Review of Resident 108's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end stage renal disease (the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment). Review of Resident 108's physician orders revealed an order for the resident to receive dialysis treatments, at an outside dialysis center on Tuesday, Thursday and Saturday. Review of the facility's form titled Hemodialysis Communication Record, revealed three sections for completion labeled Pre-Hemodialysis Record, Dialysis Center, and Post=Hemodialysis Treatment. The form is utilized to document a resident's pre and post dialysis weights, temperature, pulse, blood pressure, and any other complications such as nausea, fatigue and dizziness. Review of Resident 108's Hemodialysis Communication Record forms during the month of April 2026, revealed incomplete documentation of Resident 108's status while at the dialysis facility and post treatment upon return to the facility on April 28 and 30, 2026. Review of Resident 108's Hemodialysis Communication Record forms during the month of May 2026, revealed incomplete documentation of Resident 108's status while at the dialysis facility and post treatment upon return to the facility on May 5, 7, 12, 19, 21, 26, and 28, 2026. Review of Resident 108's Hemodialysis Communication Record Forms during the month of June 2026, revealed incomplete documentation of Resident 108's status while at the dialysis facility and post treatment upon return to the facility on June 4, 6, and 9, 2026. An interview with the Director of Nursing on June 17, 2026, at 1:22 PM, revealed Resident 108's Hemodialysis Communication Record forms should be accurately completed. 28 Pa. Code 211.12 (d) (1) (2) (3) (5) Nursing services

Based on facility policy review, facility document review, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner that enhances each resident's dignity for one of 31 residents reviewed (Resident 138). Findings include: Review of facility policy, titled ENV403 Personal Clothing Handling, with review date of February 6, 2026, revealed, in part, Resident/Patient clothing that is processed by the service location is cleaned and returned to the patient in a timely fashion. Review of facility policy, titled OPS208 Personal Property Patient's, with review date of February 6, 2026, revealed, in part, The patient will be allowed to use their personal belongings to the extent possible. Purpose is to protect the patient's right to retain their personal belongings and preserve the patient's individuality and dignity. Review of facility policy, titled OPS213 Treatment: Considerate and Respectful, with a review date of February 6, 2026, revealed, in part, Encourage and assist patients to dress in their ow clothes appropriate to time of day and individual preferences rather than hospital-type gowns. Review of facility policy, titled OPS204 Grievance/Concern, with review date of February 6, 2026, revealed, in part, When the grievance/concern is logged, the Administrator and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any patient right while the alleged violation is being further investigated. Review of Resident 138's clinical record revealed diagnoses that included cerebral infarction (ischemic stroke), hemiplegia (partial paralysis of one side of the body), affecting left nondominant side, and muscle weakness. Review of grievance logs and grievances for missing clothing/laundry from January 2026-June 2026 reveal 10 grievances filed for personal items sent to laundry and not returned. Items that were missing were located, replacements purchased by family/representative and reimbursed, or replaced by facility. All grievances were resolved. During a resident interview with Resident 138 in his room on June 15, 2026, at 11:22 AM, he revealed 6 shirts and 3 pairs of pants missing that had been sent to laundry. He reported that he had to go to physical therapy in a hospital gown due to not having his personal clothing returned to him. During a resident interview with Resident 138 on June 16, 2026, at 12:48 PM, revealed he has received all his clothing back except a pair of white, lightweight sweatpants. He revealed his clothing is labeled with his name. During an interview with staff on nursing unit 400 on June 16, 2026, at 12:48 PM, revealed washing machine in laundry has been out of order and laundry is considerably backed up. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 16, 2026, at 1:30 PM, the surveyor made them aware that Resident 138 had not received his pair of white, lightweight sweatpants back from laundry. NHA and DON confirmed that one washing machine had been down in laundry and there have been numerous issues with getting unit fully repaired and operational. Record review revealed a grievance was filed by Resident 138 on June 17, 2026, at 3:28 PM, for missing pants. Item not found in laundry and will be replaced by facility. During a staff interview with the NHA and DON on June 18, 2026, at 10:50 AM, the NHA reported acceptable laundry turn-round would be 3-4 days. The DON stated that Resident 138 has left sided paralysis, which causes frequent episodes of clothing change for him in his dependence with toileting. NHA and DON acknowledged residents should have personal clothing returned from laundry in a timely manner to ensure clothing is available to wear. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(3) Management.28 Pa Code 201.29(a) Resident rights.28 Pa Code 211.11(d)(1)(2) Nursing services.

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to improve or maintain upper extremity motion on a consistent basis for one of 31 residents reviewed (Resident 11).Findings include: Review of the facility policy, titled Restorative Nursing, last reviewed February 6, 2026, Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. Purpose: to promote the patient ability to adapt and adjust to living as independently as safely as possible. To help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Implement the restorative nursing program according to the specifics on the care plan. Review of Resident 11's clinical record revealed diagnoses that included Parkinson's Disease (progressive neurological disorder that primarily affects movement) and muscle weakness. On April 2, 2026, the physical therapist had recommended a Restorative Nursing Program (RNP) for maintaining the ability to move upper extremities freely with AM/PM care 15 minutes per day, six days per week. Review of Resident 11's restorative range of motion care plan, initiated April 2, 2026, stated, encourage resident to use rubber yellow band, requires supervision with task, and to assist as needed, encourage big movement during exercises as tolerated. Explain each step prior to doing it. Goal: to prevent contractures and maintain skin integrity During an interview with Resident 11 on June 15, 2026, the Resident stated that the staff have not been providing him with any therapy exercises, and the Resident could not remember the last time they performed the task with him. Review of the task section of the electronic health record failed to have any restorative task section to indicate the task was being provided to the Resident. On June 17, 2026, the Director of Nursing (DON) was requested to provide documentation that the restorative task was being provided to Resident 11 since April 2, 2026. No documentation was able to be provided. On June 17, 2026, review of the task section revealed that the restorative task was added on this date. During an interview with the DON on June 18, 2026, at 12:00 PM, the DON confirmed that the restorative task should have been present since April 2, 2026, and daily documentation of the task should be present. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store medications properly in one of three medication carts observed (400 Wing) and in one of three medication rooms observed (400 Wing).Findings include: Review of facility policy, titled Medication Storage-Storage of Medication, dated [DATE], revealed, in part, Medications and biologicals are stored properly following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Outdated, contaminated, discontinued or deteriorated medications are disposed of according to procedures for medication disposal (Refer to Section 5-Disposal of Medications, Syringes and Needles). Observation of the 400 Wing medication cart with Employee 9 (Licensed Practical Nurse [LPN]) on [DATE], at 9:25 AM, revealed a medication cup with 2 white capsules in top drawer. There were no observed markings on the medication cup. Employee 9 revealed medication was placed there while she was attempting to determine what was going on with a resident prior to administering or discarding. Observation of 400 Wing medication storage room with Employee 14 on [DATE], at 10:40 AM, revealed a bottle of Cetirizine 10 mg stock with an expiration date of February 2026, a bottle of Latanoprost 0.005% for Resident 72 having expired 12/23 in refrigerator, and a bottle of Xalatan 0.005% having expired [DATE] for Resident 146 that was discharged [DATE]. Employee 14 did confirm medications were expired and discarded them. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on [DATE], at 11:52 AM, the DON confirmed that she would expect medications to be labeled and properly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on observations, policy review, and staff interview, it was determined that the facility failed to ensure that waste is properly contained in the dumpster, and that the area surrounding the dumpster is free from debris for one of two dumpsters.Findings include: Review of facility policy, titled Dispose of Garbage and Refuse, revised February 2025, read, in part, the Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior of the dumpster is maintained in a manner free rubbish or other debris. All trash will be properly disposed of in externa receptacles (dumpsters) with lids covered when not in use. Observations of the trash area on June 15th and 16th, 2026, at 9:00 AM, revealed the first dumpster was full of trash and both lids were open. On June 16th, 2026, there was one small bag of trash at the base of the dumpster, and three used gloves on the ground. Observation with the Employee 12 (Dining Services Director) on June 16, 2026, at 10:32 AM, one lid was up and there were 3 used gloves and a small bag of trash in front of the dumpster. Interview at that time revealed that the lids should be closed and there shouldn't be any items on the ground. Interview with the Nursing home Administrator on June 17, 2026, at 1:04 PM, it was revealed that the trash is collected 2-3 times a week. It was confirmed that the lids should be closed and area should be free of rubbish. 28 Pa. Code 201.14 - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on review of select food service committee meeting minutes, resident and staff interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable and at appetizing temperatures.Findings include: Review of Facility Test Tray Evaluation form, dated May 1, 2023, read, in part, hot entree, vegetable, and starch should be served at 140 degrees Fahrenheit (F). Review of Resident council meeting minutes dated April 20, 2026, documented breakfast was cold. Interview with Resident 3 on June 15, 2026, at 11:25 AM, revealed the temperature of the food is often poor. Interview with Resident 7 on June 15, 2026, at 12:21PM, revealed the temperature of the food is not good. A test tray completed on June 16, 2026, revealed adequate portions size, and the food was palatable for taste and texture for a regular diet; however, the temperature of the Turkey, brussels sprouts, and baked potato weren't palatable for temperature. The test tray was placed on a meal cart and delivered to 700 unit with other trays being delivered at that time; 10 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 12 (Dining Services Director) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: Roast Turkey- 130 degrees FBrussels sprouts - 112 degrees FBaked potato - 122 degrees FPeach cobbler - 45 degrees Fcoffee - 130 degrees Fmilk - 48 degrees FApple juice- 48 degrees F At that time, interview with Employee 12 revealed that several months prior residents had concerns with food temperatures and the facility replaced the pellet warmer (equipment which warms a base placed under the plate helps keep the food warm). The surveyor felt the plate was slightly warm, and the heated base was barely warm and looked like it was worn (faded in color and coating). During an interview with the Nursing Home Administrator on June 18, 2026, at 1:30 PM, the surveyor revealed concern regarding food temperature of the turkey, brussels sprouts and baked potato. It was confirmed that the machine that heats the pellets was replaced but not the pellets. 28 Pa. Code 201.14 (a) - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive treatments and care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of 31 residents reviewed (Residents 9 and 109). Findings include: Review of facility policy, titled Procedure: Specimen Collection: Urine last reviewed February 6, 2026, read, in part, Verify order. Gather supplies. For indwelling catheter specimen: Sterile or non-sterile specimen with lid depending on the test ordered, sterile syringe, alcohol pad. Apply gloves, as needed, and other personal protective equipment. To collect an indwelling catheter specimen: Prepare tubing and sampling port. Disinfect the sampling port with alcohol pad and allow it to dry. Using a standard aseptic non-touch technique, attach the syringe to the sampling port to withdraw urine from tubing. Review of facility policy, titled Skin Integrity and Wound Management last reviewed February 6, 2026, read, in part, Purpose: To provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. The licensed nurse will: Evaluate any reported or skin changes or wounds. Perform daily monitoring of ulcer/wound site with or without dressing. Implement Skin/Wound Care Guidelines as applicable. Implement special wound care treatments/techniques, as indicated and ordered including, but not limited to: Negative Pressure Wound Therapy (NPWT also called vacuum-assisted wound closure VAC, is a treatment that uses suction to remove excess fluid and bacteria from a wound, helping it heal faster in a clean, moist environment). NPWT will be administered according to the specific manufacturer guidelines. Review of Resident 9's clinical record revealed he was admitted to the facility with diagnoses that included benign prostatic hyperplasia (enlarged prostate), muscle weakness, and mononeuropathy (damage or dysfunction of a single peripheral nerve, leading to loss of movement, sensation, or other nerve functions). Review of Resident 9's clinical record revealed a lab result note dated June 9, 2026, at 10:46 PM, that read, in part, Physician Notified (list name, date, time of notification): [Employee 10 (Certified Registered Nurse Practitioner)] 6/9/26. Labs Reviewed (list labs): CBC, Urinalysis. Physician Response/Other Action Taken/Resident Representative notified if applicable: Positive for urinary tract infection. Awaiting Culture. Hematuria (blood in urine) improving. No complaints of dysuria (pain or discomfort when urinating). During an interview with the Director of Nursing (DON) on June 17, 2026, at 2:30 PM, the surveyor asked if the urine culture had resulted and was available for review. Review of facility document dated June 16, 2026, revealed [Resident 9] Resident Condition/Concern: UC Contaminated- would you like to repeat urinalysis and urine culture? The response indicated no repeat labs and to monitor the Resident. It was noted that the urine culture that was contaminated and reviewed by the physician was dated May 13, 2026. During a follow up interview with the DON on June 18, 2026, at 10:17 AM, she revealed the urine culture that was contaminated was and older culture from weeks ago, and both the physician and Employee 13 (Infection Preventionist) that printed it for the physician to sign missed the old date. She further revealed the new culture was never ordered, a mistake was made at the time of the lab slip and it was filled out to only get a urinalysis. She further revealed the order was never put into the computer as per the facility process, and she would have expected the order to be put into the system and executed properly. Review of Resident 109's clinical record revealed she was admitted to the facility with diagnoses that included subsequent encounter for closed fracture with routine healing (when a patient is receiving routine care for a fracture during the healing or recovery phase), long term current use of anticoagulants (blood thinning medication), and difficulty in walking. Review of Resident 109's physician orders revealed an order for Wound vac settings per hospital setting 125mmhg (unit of measure) continuous. Change dressing Mon-Wed-Fri 7-3 every day shift every Mon, Wed, Fri for surgical wound, with a start date of June 5, 2025. Review of Resident 109's comprehensive care plan revealed a focus area Wound Management with an intervention for Provide wound care per treatment order with a start date of June 4, 2026. During an interview with Resident 109 on June 16, 2026, at 9:36 AM, she revealed she was wondering why her wound vac did not get changed per her physician order the day before. Review of Resident 109's June Treatment Administration Record revealed Employee 5 (Registered Nurse) signed off that the wound treatment was administered as ordered on June 15, 2026. Statement received from Employee 5 on June 16, 2026, revealed he thought the physician order read to only check the settings of the wound vac, not to change the dressing, so he did not change the dressing as ordered. During an interview with the DON on June 17, 2026, at 2:30 PM, she revealed she would expect that the wound vac would have been changed as ordered on June 15, 2026. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.11(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, and resident representative and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of five resident areas observed (400 Hallway). Findings include: Review of facility policy, titled Safe and Homelike Environment last reviewed February 6, 2026, read, in part, The resident has a right to a safe, clean, comfortable and homelike environment. This includes ensuring the patient can receive care and services safely and that the physical layout of the center maximizes patient independence and does not pose a safety risk. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During an interview with Resident 79's Representative on June 16, 2026, at 12:52 PM, she revealed she was upset with the condition of the wallpaper behind his bed. Observation of the wallpaper behind Resident 79's bed on June 16, 2026, at 12:52 PM, revealed it was scratched up and bubbling away from the wall. Additional observations of Resident 79's wall behind his bed on June 17, 2026, at 2:38 PM, and June 18, 2026, at 9:44 AM, revealed it was scratched up and bubbling away from the wall. During an interview with Resident 79's Representative on June 18, 2026, at 9:44 AM, she revealed she was upset with the metal bar that separates the floor under the doorframe of his bathroom from the rest of his room, and someone could trip over it and hurt themselves. Observation of the aforementioned metal bar on June 18, 2026, at 9:45 AM, revealed it was missing a screw and was sticking up from the floor on the left side. Observation in Resident 9's room on June 15, 2026, at 10:37 AM, and June 16, 2026, at 10:08 AM, revealed three strips of wallpaper ripped and dangling behind his bed, and ripped wallpaper under his window frame. During an interview with the Nursing Home Administrator on June 18, 2026, at 10:20 AM, she revealed the concerns the surveyor identified within Resident 9 and 79's rooms are being addressed by the maintenance staff, and she would expect residents to be provided with a safe, clean, comfortable and home-like environment 28 Pa. Code 201.18(e)(2.1) Management

Based on clinical record review, facility document review, and staff interview, it was determined that the facility failed to provide care and services consistent with the resident comprehensive plan of care, which resulted in harm as evidenced by a decline in health status for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin) and atrial fibrillation (irregular heart rate). Review of Resident 1's Pennsylvania Orders for Life-Sustaining Treatment (POLST - document identifying a resident's basic wishes if they become critically ill and/or enter cardiopulmonary arrest), revealed that section B: Medical interventions for a resident who has a pulse and/or is breathing, was marked as, Limited Additional Interventions, which the document defined as, .Use medical treatment, IV fluids and cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care if possible. Further, section C, Antibiotics, of Resident 1's POLST was marked as, Use antibiotics if life can be prolonged. Review of the POLST revealed it was signed and dated by Resident 1's Representative on [DATE]. Review of Resident 1's clinical interdisciplinary progress notes revealed that on [DATE], at 12:46 PM, staff documented that Resident 1 had experienced a temperature of 101.5 f (Fahrenheit [F]). Resident was provided acetaminophen, which decreased Resident 1's temperature to 98.7 F. Review of a change in condition note dated [DATE], at 8:31 AM, entered by Employee 1 (Registered Nurse) revealed that nursing staff noted Resident 1 had been experiencing a low-grade fever for 24 hours, and that nursing staff had reported foul smelling urine. Symptoms that could indicate possible urinary tract infection (UTI). Review of facility documentation revealed that a contracted on-call provider, CRNP 1 (Certified Registered Nurse Practitioner), was contacted and updated with Resident 1's status as identified in Employee 1's progress note. Review of the progress note dated [DATE], at 8:26 AM, by CRNP 1 stated, CC Patient is currently under comfort care measures only. No escalation of care per plan. HPI Initial temperature recorded at 101.7 F. Tylenol administered per protocol. Temperatures rechecked post-medication and noted to be 98.9f. Patient appears more comfortable following intervention. Assessment: Febrile episode managed effectively with antipyretic. Patient remains under comfort-focused care with no signs of acute distress at this time. Plan: Continue Tylenol administrations as needed to maintain patient comfort. Monitor temperature and overall comfort level. Continue with comfort care measures; no escalation of medical interventions per care directive. A request was made to the facility to obtain a statement from CRNP 1 as to the circumstances of documenting that Resident 1 was comfort measures; however, as of [DATE], at 12:00 PM, the facility was unable to procure a statement from CRNP 1. Review of Resident 1's physician orders and comprehensive plan of care revealed no indication that Resident 1 was comfort care measures as of [DATE]. Review of Resident 1's progress note revealed that the next day [DATE], at 12:23 PM, Employee 1 documented that Resident 1 continued with foul smelling urine and lethargy. Employee 1 documented that an on-call provider (CRNP 2) was contacted and at that time, orders for a urinary analysis (laboratory study of the urine to determine if a urinary tract infection is present), and a culture and sensitivity test (microbiological study of the urine to determine the type of bacteria present and effectiveness of antibiotics towards the bacteria) were provided. Review of CRNP 2's progress note from [DATE], stated, Chief complaint: foul smelling urine[.] Assessment: Patient is incontinent, family/nurse noticed foul smelling urine when changing patient today. He is on comfort care . However, review of Resident 1's clinical record revealed no indication that Resident 1 was on comfort care measures as of [DATE]. Review of a progress note from 2:39 PM on [DATE], stated, Resident continues to decline. Resident total feed this shift and coughing with thin liquids. Resident downgraded to [nectar thick liquids] per nursing judgement, which resident did well. Dietician [sic] made aware, requested [speech therapy] to [evaluate] . On the morning of [DATE], at 3:45 AM, facility staff documented that the results of Resident 1's urinary analysis confirmed the presence of a urinary tract infection. The progress note also stated, .Obtained lab orders from provider. complete a CBC [complete blood count] and CMP [comprehensive metabolic panel] on Tuesday [[DATE]]. Awaiting sensitivity and culture results before any antibiotic treatment is initiated. On Tuesday, [DATE], at 12:51 PM, Speech Therapist 1 documented a note which stated, Worse overall status compared to yesterday. Shallow respiratory cycles noted. Mouth breathing. Does not respond to tactile, auditory, or visual stimulation - eyes partially opened but does not appear to [be] receiving visual information. Still has occasional reflexive responses to pain with guttural utterances. Not deemed safe for [by mouth consumption] at this present time except for occasional 1/3 [teaspoon] of water. At 2:03 PM, on [DATE], Employee 6 (Nurse Manager) documented the following progress note, [Intramuscular] Cefazolin administered in bilateral upper extremities for UTI. [Unit manager] started IV and IV fluids started at this time at 100 [milliliters per hour] for 1 Liter then to have 75 [milliliters per hour] x2 liters . Review of a progress note entered on [DATE], at 5:25 PM, CRNP 3 documented, Patient seen at the request of staff for reports of lethargy and abnormal lab work today. On-call service was notified over the weekend with reports of fever and lethargy, on-call service ordered UA C&S on 5/25 a CBC and CMP for today. Over the last 2 days nursing documentation shows [Resident 1] has been lethargic with poor [by-mouth] intake. Patient was seen by speech therapy today speech therapy reports patient with mouth hanging open and fluids draining out of the side. Family at bedside reports they ran on Saturday patient was sitting up in a wheelchair talking and playing cards. Patient seen today lying in his bed nonresponsive. [No fever] today with a temp at 97.7. No [nausea or vomiting] or [difficulty breathing] .[Blood work] shows patient in [acute kidney injury] . Review of the interventions/plan section of the note revealed that CRNP 3 documented that Resident 1 was to have Cefazolin (an antibiotic) 2 grams intramuscular injection, then 500 milligrams via IV every 12 hours for two days, then review, as well as, If little to no improvement plan to discuss comfort measures with family. Resident 1 did not improve and on [DATE], Resident 1 expired at 11:25 AM. Based on Resident 1's clinical record review, the facility's contracted on-call provider incorrectly identified Resident 1's plan of care as comfort measures, which was identified as the basis not to provide further intervention after Resident 1 had experienced fever and foul smelling, mucousy presentation of urine. During a staff interview on [DATE], at approximately 12:00 PM, Director of Nursing (DON) confirmed that there was no indication that Resident 1 was on comfort care measures on [DATE]. During the interview, the DON confirmed that it is the facility's expectation that care and interventions are implemented that are consistent with the residents' advanced directives, or stated wishes as outlined by the POLST. 28 Pa code 201.18(b)(1) Management 28 Pa code 211.2(d)(7) Medical director 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and for one of three nourishment pantries. Findings include: Review of facility policy, Food Handling, last revised January 26, 2024, read, in part, Hazard Analysis Critical Control Points (HACCP- a food safety management system that identifies, evaluates, and controls hazards that could contaminate food) flow charts are used when handling, preparing, cooling, storing, reheating, and reserving food. Foods are cooked to the internal temperature specified in the recipe directions. Foods that are prepared and not placed into service are considered unused portions. And are to be handled according to the HACCP Food Flow Chart. Roasted meats are cooled according to HACCP flow charts. Employees are to wear disposable gloves when handling food. Disposable gloves are considered a single-use item and are discarded when damaged, soiled, and after each use. Appropriate utensils are used to serve food and vary according to the type of food served. Foods in dry storage are in closed, labeled, and dated containers; and opened not fully used items contain a use by date. Review of facility policy, HACCP Flow Chart for pork roast, revised June 15, 2018, read, in part, cook according to recipe direction [NAME] to a minimum internal temperature 145 degrees F, and record on the correct form. Cut large pieces into smaller pieces, cool to 135 degrees F then from 135 to 70 degrees F in two hours. Review of facility policy, Refrigerated/Frozen Storage, effective date May 1, 2023, read, in part, all storage racks and platforms are at least six inches off the floor; all foods are labeled with the name of the product, date received and use by date once opened. Review of facility policy, Use By Dating Guidelines, dated July 10, 2023, read, in part, bulk items such as flour and sugar use by 60 days once open and transferred to a storage bin; thickened liquids once opened use within 72 hours. Review of facility policy, Cleaning Schedule, effective date May 1, 2023, read, in part, employees clean the assigned equipment as scheduled on the Master Cleaning Schedule. Per the Master Cleaning Schedule, the exhaust hood and filters are to be cleaned weekly. Review of facility Chill Log, not dated, read, in part, hot foods need to be cooled within two hours from 135 to 70 degrees F, then within six hours from 135 to 41 degrees F. Documentation included the date, food description, temperature at the start, in 2 hours, and in 4 hour. Review of facility Cooling Chart log dated May 1, 2023, read, in part, tips for rapid cooling included to reduce size of the food. Review of the recipe Pork Roast with gravy, not date marked, read, in part, cooking temperature 325 degrees F, cook for 21/2 to 3 hours, roast until done (no final cooking temperature noted), let pork stand for 20 minutes before slicing. Observation in the kitchen on May 5, 2025, at 9:36 AM, a sheet pan containing cooked pork roasts was uncovered on top of the oven. During an interview with Employee 9 (Food Service Director) on May 5, 2025, at 9:36 AM, it was revealed that the pork was cooked that morning, and she was about to slice it. Additional observation in the kitchen on May 5, 2025, at 10:30 AM, revealed the pork remained on top of the oven, unsliced. During an interview with Employee 9 on May 5, 2025, at 10:30 AM, it was revealed that the pork was for lunch on May 6th, 2025. It was further revealed that the pork was cooked that morning, and it was taken out of the oven at 8:30 AM, and, when removed from the oven, the temperature of the pork was 175 degrees Fahrenheit (F). At 10:30 AM Employee 9 took the temperature of the pork, which was 120 degrees F. Employee 9 stated the final cooking temperature of the pork this morning was not recorded as there isn't a place to document final cooking temperature of food. Review of Food Temperature Log and Checklist (documentation of food temperatures on tray line at point of service) from March 24th, 2025, to May 5th, 2025, revealed nine meals that the food and beverage temperatures were not recorded. During an interview with the Nursing Home Administrator (NHA) on May 7, 2025, at 10:14 AM, the surveyor informed of the concern regarding the cooling process of the pork roasts on May 5th, 2025, and the monitoring of food temperatures at point of service. No further information was provided. Observation in the walk-in refrigerator in the kitchen on May 5, 2025, at 9:30 AM, revealed: two thawed nondairy whipped topping (the product shelf life once thawed 14 days), not date marked with a thaw date; and one crate of whole milk and one crate of 1% milk stored directly on the floor. During an interview with Employee 9 on May 5, 2025, at 9:35 AM, it was revealed that the topping should be date marked when pulled from the freezer and the milk should be off the floor. Observation in the main kitchen area on May 5, 2025, at 9:38 AM, revealed: one bag of white cake mix and one bag of brown sugar open and not date marked; the bulk sugar and flour bins not labeled, or date marked, and the flour bin contained a plastic cup inside; and floor drain cover missing at the beginning of the steam table. During an interview with Employee 9 on May 5, 2025, at 9:40 AM, it was revealed that the cake mix and brown sugar should be date marked, the plastic cup should not be in the flour, and she wasn't aware the drain cover was missing, and she would notify maintenance. Observation in the reach-in refrigerator on May 5, 2025, at 9:48 AM, revealed: one 46-ounce container of mild thick apple juice and one 32-ounce container of mild thick milk were opened with contents partially removed and not date marked; and a half case thawed individual servings of apple juice (product is to be used within 10 days of thawing) not date marked. During an interview with Employee 9 on May 5, 2025, at 9:50 AM, it was revealed the thickened beverages should be date marked when opened and the apple juice was pulled from the freezer yesterday and should've been marked with a date when removed from the freezer. Lunch meal observation on May 6, 2025, at 11:44 AM, in the kitchen, Employee 10 (Cook) was serving the roast pork with a gloved hand, then touched the lid on the plate warmer, and then touched a personal cellular phone and a personal beverage bottle and returned to serving the pork with the same gloved hand, without completing hand hygiene. During an interview with Employee 9 on May 6, 2025, at 12:35 PM, it was revealed that Employee 10 should've utilized tongs or a serving utensil to serve the pork; and changed gloves and completed hand hygiene after touching the cell phone and beverage bottle. Observation in the 400-unit nourishment pantry on May 8, 2025, at 11:08 AM, revealed: one container of mild thick lemon water opens with contents partially removed and not date marked; and one bowl Raisin Bran cereal, one bowl of [NAME] Krispie cereal and two bowls of Frosted Flakes not date marked. During an interview with Employee 11 (Licensed Practical Nurse) it was revealed that the mild thick water should be date marked when opened and the cereal usually isn't stored on the unit, but it should be date marked. During an interview with the NHA on May 7, 2025, at 10:14 AM, and May 8th, 2025, at 11:21 AM, it was revealed that items should be date marked once opened or pulled from the freezer, a new drain cover has been ordered, and hand hygiene should've been completed on the tray line. 28 Pa code 211.6(f) - Dietary Services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for three of four residents reviewed for respiratory care (Residents 17, 23, and 78). Findings include: Review of facility policy, titled Procedure: Nebulizer: Small Volume last revised November 1, 2023, read, in part, Upon completion of the treatment, check patient's heart rate, respiratory rate, pulse oximetry, and breath sounds. Rinse small volume nebulizer mouthpiece and 'T' piece with sterile water and dry. Place in treatment bag labeled with patient's name and date. Replace and date the set up daily, if used. Check compressor for air filters that require replacement and cleaning every 30 days. Follow manufacturer's instructions. Review of Resident 17's clinical record revealed diagnoses that included muscle weakness, need for assistance with personal care, and dysphagia (difficulty swallowing). Review of Resident 17's physician orders revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 6 hours as needed for shortness of breath, wheezing, with a start date of April 8, 2025. Observations in Resident 17's room on May 5, 2025, at 10:58 AM; May 6, 2025, at 12:13 PM; and May 7, 2025, at 9:33 AM; revealed a nebulizer machine with tubing and a mask, the mask was laying out directly on her bedside table and the tubing was dated April 7, 2025. Review of Resident 17's April 2025 MAR (Medication Administration Record- documentation for treatments/medication administered or monitored) revealed she received her albuterol treatment via nebulizer April 8-13, 2025. During an interview with the Director of Nursing (DON) on May 7, 2025, at 10:56 AM, the surveyor revealed the concern with the observations throughout the week of Resident 17's nebulizer mask laying out at bedside and tubing dated prior to noted albuterol administrations in April 2025. Follow up interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect respiratory care and treatment to be administered and stored consistent with professional standards. Review of Resident 23's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), fibromyalgia (a chronic condition that causes pain in muscles and soft tissues all over the body), and generalized anxiety disorder (a persistent feeling of worry, nervousness, or unease). Observations of Resident 23 in her room on May 5, 2025, at 12:11 PM; May 6, 2025, at 12:15 PM; and May 7, 2025, at 9:43 AM, revealed she was wearing oxygen via a nasal cannula (a device that delivers oxygen through a tube and into your nose) that was connected to an oxygen concentrator (medical device that contains oxygen). Review of Resident 23's clinical record failed to reveal a physician order for oxygen or a comprehensive care plan for oxygen use. Interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect Resident 23 to have physician order for oxygen and comprehensive care plan for oxygen use. Review of Resident 78's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), localized edema (swelling caused by too much fluid trapped in the body's tissues), and muscle weakness. Review of Resident 78's physician orders revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for COPD, with a start date of March 25, 2023. Observations in Resident 78's room on May 5, 2025, at 1:49 PM; May 6, 2025, at 9:36 AM; May 7, 2025, at 9:39 AM; revealed a nebulizer machine with tubing and a mask, the mask was laying out directly on her bedside table, and the tubing was not dated. Review of Resident 78's February 2025 MAR revealed she last received her albuterol treatment via nebulizer on February 15, 2025. During an interview with the DON on May 7, 2025, at 10:56 AM, the surveyor revealed the concern with the observations throughout the week of Resident 78's nebulizer mask laying out at bedside and tubing not dated. Follow up interview with the DON on May 8, 2025, at 10:16 AM, revealed she would expect respiratory care and treatment to be administered and stored consistent with professional standards. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of seven residents reviewed for pressure ulcers (Resident 4, 122, and 238). Findings include: Review of facility policy, titled Skin Integrity and Wound Management last revised May 1, 2025, read, in part, A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. To provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. The licensed nurse will: Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, with unanticipated decline in wounds, and at planned discharge. Further, subsection 6.6 of the aforementioned policy stated that the licensed nurse shall, Perform daily monitoring of wounds or dressings for presence of complications or declines .Document daily monitoring of ulcer/wound site with or without dressing. Monitor: Status of dressing (e.g., intact and clean); status of tissue surrounding the dressing (e.g., free of new redness or swelling); Adequate control of wound associated pain; Signs of decline in wound status .). Review of Resident 4's clinical record revealed a pressure ulcer left posterior heel from January 21st, 2025, and resolved April 8, 2025; pressure ulcer right great toe as of April 1, 2025; and pressure ulcer on sacrum as of April 30, 2025. Review of Resident 4's Physician orders included: left heel: cleanse with vashe (saline -based solution used to cleanse, irrigate, moisturize and debride wounds), apply skin prep to peri wound, honey gel and oil immersion to wound bed, cover with foam dressing every evening shift for wound healing and as needed, start date April 2, 2025; right great toe: cleanse with vashe, skin prep to peri wound, apply honey gel to wound bed, apply oil immersion dressing, secure with bordered foam every evening shift for wound healing and as needed, start date April 2, 2025; Phytoplex Z-Guard Paste (barrier medication used to treat and prevent minor skin irritation) 57-17 % (Petrolatum-Zinc Oxide) apply to open area on buttock topically every day and evening shift for wound healing cleanse with normal saline solution, apply zinc, cover with foam boarder, start date May 1, 2025. Review of Resident 4's May 2025 Treatment Administration Record (TAR - documentation of treatments that were completed) failed to document treatment to left posterior heel per physician orders on May 4th. Review of select facility documentation provided failed to reveal wound measurements were taken on Resident 4's right great toe on April 29, 2025. Review of progress notes revealed on April 30th, 2025, documented measurement of sacrum, and on May 6th, 2025, documented measurements of sacrum and right great toe; however, the notes lacked the visual description of the wounds. During an interview with the Director of Nursing (DON) on May 8, 2025, at 12:56 PM, it was revealed that open areas should be monitor weekly to include documentation wound measurement, observed characteristics of the wound, and evaluation of treatment orders. The DON further stated that she would expect wound treatment and services to be consistent with professional standards of practice. Review of Resident 122's clinical record revealed diagnoses that included pressure ulcer of sacral region (wound that occurs when the skin and tissue are damaged by prolonged pressure) and muscle weakness. During an email correspondence with the DON on May 6, 2025, at 10:07 AM, she revealed Resident 122 had a stage II pressure ulcer on his right buttock, and a stage III pressure ulcer on his left buttock. Review of Resident 122's clinical record failed to reveal weekly wound assessments for his aforementioned wounds on April 22 and 29, 2025. Review of select facility documentation provided failed to reveal wound measurements were taken on Resident 122's wounds on April 22, 2025, and failed to reveal a wound measurement on Resident 122's stage II wound on April 29, 2025. Interview with the DON on May 7, 2025, at 10:56 AM, revealed they are currently in the process of hiring a new wound nurse for the facility, and that Employee 7 (Registered Nurse) and Employee 8 (Licensed Practical Nurse) have been designated to assist with wound rounds since the previous wound nurse since April 22, 2025. Follow-up interview with the DON on May 8, 2025, at 10:54 AM, she revealed she has no additional information to provide about Resident 122's missing wound measurements and wound assessments, and that she would expect wound treatment and services to be consistent with professional standards of practice. Review of Resident 238's clinical record revealed diagnoses that included pressure ulcers to the left and right heel (wound that can extend into the deep tissue and bone that is caused by pressure over a bony prominence), atrial fibrillation (irregular heartbeat), and history of gangrene infection (infection that results in the death of tissue) of the right second toe, which resulted in the partial amputation of the second right toe. Review of Resident 238's pre-admission hospital referral documentation revealed that upon discharge from the hospital and admission to the facility, Resident 238 was documented as having a pressure ulcer to the left heel, a pressure ulcer to the right heel, and a surgical wound post partial amputation of the right second toe. Review of Resident 238's admission assessment conducted at the facility, dated May 1, 2025, revealed that section, Skin, did not have Resident 238 marked for the following concerns: Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion); Other open lesions of the foot,; nor, Surgical wound(s). However, staff did include a Skin Note in the assessment section that stated, Left heel DTI [deep tissue injury] Scabbed Left outer leg Right bunion scab Right scabbed area in between 1st and 2nd toes on Right foot. The admission assessment did not include the pressure ulcer to Resident 238's right heel, nor did it identify that Resident 238 had surgical wound after partial amputation to the right second toe. Review of Resident 238's clinical record revealed no orders for treatment to Resident 238's left heel pressure ulcer until May 7, 2025 (six days after admission), and no orders for treatment for Resident 238's right heel pressure ulcer until May 6, 2025 (five days after admission). Review of available information revealed no assessment of the pressure injuries to Resident 238's left or right heels until May 6, 2025 (five days after admission). Review of the progress note revealed it stated, Resident seen during wound rounds this am. Area on left heel measures 0.1 x 0.1 [centimeters] with eschar present. Area on right heel measures 2.0 x 1.5 [centimeters] and is dry .New treatments recommended. During a staff interview on May 8, 2025, at approximately 1:30 PM, the DON confirmed there was not further information at that time to provide. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised for three of 31 reviewed (Residents 39, 51, and 55). Findings include: Review of facility policy, titled Person-Centered Care Plan last revised October 24, 2022, read, in part, The care plan will be prepared by the interdisciplinary team. The care plan must be customized to each individual patient's preferences and needs. Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 39's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Review of Resident 39's care plan revealed a care plan with a focus are of: Pressure Ulcer, Left great toe, with a date initiated of August 11, 2024. Review of Resident 39's physician's orders revealed a physician order for a dressing change to Resident 39's left great toe, discontinued April 17, 2025, with discontinue reason of, resolved. Interview with the Director of Nursing (DON) on May 8, 2025, at 10:40 AM, Resident 39's pressure ulcer was resolved on April 17, 2024, and the care plan should have been resolved also. A review of Resident 51's clinical record on May 6, 2025, at 11:00 AM, revealed diagnoses that included atrial fibrillation (irregular and rapid heart rate) and convulsions (seizures). A review of Resident 51's physician orders on May 2025, reveals an order for Eliquis (anticoagulant medication that prevents clot formation) 5 milligrams by mouth twice a day for atrial fibrillation. A review of Resident 51's care plan on May 6, 2025, revealed the facility never revised the care plan to reveal Resident 51 was receiving an anticoagulant medication. During an interview with the DON on May 7, 2025, the DON confirmed the care plan should have been revised to include the usage of an anticoagulant with appropriate interventions. Review of Resident 55's clinical record revealed diagnoses that included repeated falls, diabetes, and muscle weakness. Review of Resident 55's comprehensive care plan on May 6, 2025, revealed a focus area that he is at nutritional risk last revised on October 29, 2024, with an intervention for 1-1 Feeding assistance required to promote adequate oral intake, last revised on October 29, 2024. Observation on May 5, 2025, at 12:06 PM, revealed he was sitting up in bed feeding himself lunch. Review of Resident 55's nurse aid tasks for eating ability revealed he was documented as being independent with feeding after set-up help for the 14 days of look back documentation April 26, 2025-May 8, 2025. During an interview with Employee 12 (Director of Rehabilitation) on May 8, 2025, at 1:22 PM, revealed the intervention for feeding assistance was implemented when Resident 55 was first admitted to the facility last fall, and was related to a nutritional intervention to remain alert during meals, rather than a functional recommendation from therapy, she further revealed this intervention should have been revised at least since therapy has been working with him since April 2025, as he is noted to be independent with eating after set-up help. Review of Resident 55's fall report from February 27, 2025, revealed he had sustained a fall that morning, and under Immediate Action Taken it was noted Intervention of perimeter mattress to be added. Review of Resident 55's care plan on May 6, 2025, revealed a comprehensive fall care plan but failed to reveal an intervention for a perimeter mattress. Review of Resident 55's care plan on May 8, 2025, at 9:40 AM, revealed an intervention for a perimeter mattress had been added to his care plan on May 7, 2025. Interview with the DON on May 8, 2025, at 1:40 PM, revealed she would expect care plans to be reviewed and revised as needed to reflect the response to care and changing needs. 28 Pa. Code 211.12(d)(1)Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 31 residents reviewed (Residents 48, 86, and 101). Findings include: Review of the clinical record for Resident 48 on May 5, 2025, revealed diagnoses that include bilateral trochanter (hip bone) decubitus ulcers (pressure wounds over bony prominences) and End Stage Renal Disease (kidney function is severely impaired requiring dialysis or transplant). A review of Resident 48's care plan dated May 2025 revealed a focus for Documented Pressure Ulcer: bilateral hips. Date Initiated: 04/23/2025 Created on: 04/23/2025. A review of Resident 48's physician orders on May 6, 2025, revealed the following orders: Cleanse wounds on bilateral hips with Vashe (wound cleanser); soak 2-5 minutes; scrub 30 seconds; apply skin prep to peri wound; apply Medihoney (aids in removal of necrotic tissue and wound healing); cover with border foam. Every day shift every other day for decubitus ulcers. A review of Resident 48's Admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated April 29, 2025, failed to reflect the bilateral trochanter decubitus ulcers on admission to the facility in Section M: Skin Conditions. During an interview with the Director of Nursing (DON) on May 8, 2025, at 11:04 AM, the DON confirmed that the MDS should be marked based on the data in the clinical record and that the trochanter wounds were marked as other wounds on the MDS. Review of Resident 86's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets) and muscle weakness. Review of Resident 86's clinical record revealed he had a 5.1% weight loss from January 1 to 17, 2025, and that his diagnosis of protein calorie malnutrition was added on February 14, 2025. Review of Resident 86's Quarterly MDS, State MDS, and Modification of Quarterly MDS, all with ARD of January 23, 2025, under Section K: Swallowing / Nutritional Status, subsection K0300. Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months, revealed Resident 86 was marked no or unknown. Review of Resident 86's Significant Change MDS with ARD of February 14, 2025, under Section I: Active Diagnoses, subsection I5600, revealed Resident 86 was marked no for risk of malnutrition or having an active diagnosis of malnutrition. During an interview with the DON on May 8, 2025, at 10:56 AM, she revealed the aforementioned MDS assessments had been modified for accuracy, and she would expect MDS assessments to be coded accurately. Review of Resident 101's clinical record revealed diagnoses that included Alzheimer's Disease (irreversible, progressive degenerative brain disease that results in decreased ability to perform activities of daily living and decreased contact with reality) and hypertension (elevated/high blood pressure). Review of Resident 101's clinical record revealed that Resident 101 was admitted to hospice services on December 13, 2024. Review of Resident 101's Quarterly MDS revealed that Section O0100, Special Treatments, Procedures, and Programs, subsection K1, Hospice, was coded to reflect that Resident 101 was not receiving hospice services at the time of the assessment. During a staff interview on May 7, 2025, at approximately 10:30 AM, the DON confirmed that Resident 101 was receiving hospice services at the time of the Quarterly MDS assessment and that the Quarterly MDS assessment should have been coded to reflect Resident 101's hospice status. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on observations, record review, policy review, and staff interview, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call bell was in reach for three of 31 residents reviewed (Residents 31, 59, and 67). Findings include: Review of facility policy, Call lights, with a revision date of June 1, 2021, revealed, All Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times. Review of Resident 31's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Review of Resident 31's current care plan revealead a focus area of, at risk for falls due to history of cardiovascular accident, and an intervention of, Reinforce need to call for assistance. Observation of Resident 31 on May 5, 2025, at 9:42 AM, revealed Resident 31 lying in bed and his call bell was lying on the floor under the center of the Resident's bed. Observation of Resident 31 on May 6, 2025, at 9:40 AM, revealed Resident 31 lying in bed and his call bell was still lying on the floor under the center of the Resident's bed. Review of Resident 59's clinical record revealed diagnoses that included protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and peripheral vascular disease (a progressive circulation disorder). Observation of Resident 59 on May 6, 2025, at 8:51 AM, revealed Resident 59 lying in bed and her call bell was lying on the floor under the center of the Resident's bed. Review of Resident 67's clinical record revealed diagnoses of sepsis (a serious condition in which the body responds improperly to an infection) and urinary tract infection (an infection of any part of the urinary system). Observation of Resident 67 on May 5, 2025, at 9:54 AM, revealed Resident 67 lying in bed and his call bell was in the top drawer of his bedside stand, behind the head of his bed, where Resident 67 could not access it. Interview with the Director of Nursing on May 8, 2025, at 10:30 AM, revealed that all residents should have their call bells within their reach, and they have reeducated their staff. Pa. Code 211.12(d)(1) Nursing Services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of six residents reviewed for hospitalization (Resident 86). Findings Include: Review of facility policy, titled Bed Holds last revised January 16, 2023, read, in part, Bed hold notification is required per Federal Regulation. The resident/resident representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax, or hard copy via mail. Purpose: To properly secure a private payer source, if applicable, to ensure a bed is reserved and available upon the resident's return. Review of Resident 86's clinical record revealed diagnoses that included protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets) and muscle weakness. Review of Resident 86's clinical record revealed that he was transferred and admitted to the hospital on February 18, 2025, and March 6, 2025. Further review of Resident 86's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. During an interview with the Director of Nursing on May 8, 2025, at 10:54 AM, she revealed she would expect that Resident 86 and/or his Representative were provided with a written notice of the facility's bed hold notice at the time of either hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours for one of six residents reviewed that were admitted during the prior 30 days (Resident 238). Findings include: Review of Resident 238's clinical record revealed diagnoses that included pressure ulcers to the left and right heel (wound that can extend into the deep tissue and bone that is caused by pressure over a bony prominence) and atrial fibrillation (irregular heartbeat). Review of Resident 238's clinical record revealed that Resident 238 was discharged from the hospital to the facility on [DATE]. Review of Resident 238's clinical record revealed that at the time of admission to the facility Resident 238 had pressure ulcers to the left and right heel and an unhealed surgical wound as a result of a partial amputation of the right toe. Review of Resident 238's baseline care plan revealed that Resident 238 did not have a care plan that addressed Resident 238's wound/skin concerns. Further review of Resident 238's clinical record revealed that Resident 238 had experienced ongoing lower extremity pain. Upon admission to the facility, Resident 238 was ordered multiple medication for pain. These medications included: Acetaminophen 650 milligrams (mg - metric unit of measure) every four hours as-needed for mild pain (discontinued on May 2, 2025); acetaminophen 1,000 mg every four hours as-needed for pain; gabapentin 100 mg three times a day for pain control; and tramadol 25 mg every four hours as-need for pain that was not relieved by acetaminophen. Review of Resident 238's medication administration record revealed that Resident 238 was experiencing pain after admission and was administered the as-needed acetaminophen (1,000 mg) on three occasions and the as-needed tramadol on five separate occasions. Review of Resident 238's baseline care plan revealed Resident 238 had no care plan that addressed Resident 238's pain. Review of Resident 238's clinical record revealed that upon admission, Resident 238 had been ordered an anticoagulant medication (medication used to decrease the ability of the blood to clot) which requires the monitoring of possible serious side effects, such as unintended bleeding. Review of Resident 238's baseline care plan revealed that Resident 238's care plan did not include a care plan for the use of an anticoagulant medication. During a staff interview on May 8, 2025, at approximately 11:25 AM, Resident 238's facility admission assessment was reviewed. During the interview, the Director of Nursing (DON) revealed that the baseline care plan is generated from the admission assessment; however, the DON revealed that it appeared that the assessment was not completed correctly, which resulted in the baseline care plan not including areas of concern as identified above. During the interview, the DON revealed that Resident 238's skin conditions, pain, and use of an anticoagulant should have been included on Resident 238's baseline care plan. 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of 31 residents reviewed (Resident 95). Findings Include: Review of the facility's policy, titled Restorative Nursing, recently revised August 7, 2023, defined its purpose To promote the patient's ability to adapt and adjust to living as independently and safely as possible. Also, To help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient-specific based on individual patient needs. Review of Resident 95's physician's orders revealed diagnoses that included muscle weakness (a decrease in muscle strength, where the muscles may not contract or move as easily as usual) and reduced mobility (a partial or total loss of the ability to move around freely, whether due to physical limitations, age, or other factors). Review of Resident 95's interdisciplinary plan of care, revised on October 12, 2023, revealed an identified problem area that read At risk for loss of range of motion r/t [related to] physical limitations, Will exhibit no decline in ROM [range of motion] within confines of disease processes. The interventions included Restorative Active ROM: upper extremities during ADLs [ activities of daily living - a term used in healthcare to refer to an individual's daily self-care activities], 15 minutes, 10 reps each (shoulders, elbows, wrists, fingers). Review of the facility's documentation for Resident 95's restorative nursing program revealed that staff documented not applicable for 21 of the 30 days reviewed. An interview with the Staff Educator (Employee 1) on May 8, 2025, at 9:46 AM, revealed that staff were documenting not applicable when Resident 95 refused the program and were educated on documenting resident refused instead. The interview also revealed that Resident 95 refuses when she has pain, and staff are educated to inform Employee 1 to determine the appropriateness of the restorative nursing program for any resident. An interview with the Director of Nursing on May 7, 2025, at 10:06 AM, also revealed that staff should document resident refused instead of not applicable. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation, facility policy review, clinical record review, wound assesment review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing of a pressure ulcer for two of two residents reviewed for pressure ulcers (Residents 24 and 71); resulting in the deterioration of a pressure ulcer for one of two residents reviewed (Resident 24). Findings include: Review of facility policy, titled NSG 236 Skin Integrity and Wound Management with a revision date of February 1, 2023, and a last review date of May 24, 2023, revealed under the section titled Policy that A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Review of the aforementioned policy, under section titled Practice Standards the following was noted: Identify patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information. The nursing assistant will observe skin daily and report any changes or concerns to the nurse. Further review states that the licensed nurse will document newly identified skin/wound impairments as a change in condition. Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Perform daily monitoring of ulcer/wound site with or without dressing. The policy also states that staff should monitor the status of tissue surrounding the wound; adequate control of wound associated pain; and signs of decline in wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound associated pain, complete a wound re-evaluation, change in condition; and implement wound care treatments/techniques as indicated and ordered. Review of Resident 24's clinical record revealed diagnoses that included dementia and chronic pain. Review of Resident 24's progress notes revealed a note dated November 18, 2022, at 3:24 PM, by Wound Care Certified Registered Nurse Practitioner (CRNP) that indicated they had seen Resident 24 for moisture associated skin damage (MASD - an injury to the skin characterized by the inflammation and erosion of the outer layer of the skin from prolonged exposure to various sources of moisture) with skin breakdown to the sacrum that was found the same week and treatment recommendations given. The Wound Care CRNP continued to see Resident 24 every one to two weeks from November 18, 2022, through February 24, 2023. Review of progress note dated February 20, 2023, at 11:25 AM, by a Registered Nurse (RN), indicated that Resident 24 had an open area on their sacrum measuring 1 centimeters (cm) long x 0.8 cm wide x 0.2 cm deep; the area was noted to be on a bony prominence with 50% slough (necrotic or dead tissue) and 50 % red granulation tissue; that the peri-wound was intact; and that the CRNP was notified. Resident 24's weekly wound round assessments for the pressure ulcer were initiated on March 3, 2023. Review of facility documentation form, titled Wound Rounds revealed a list of residents with wounds noting the location, measurement, description, and treatment. Further review of the form revealed that the weekly assessments were not performed for Resident 24 on the week of April 14 and 28, 2023, and May 26, 2023. The wound was assessed on June 2, 2023, and was noted to be 1.4 cm by 1.0 cm by 0.5 cm, red granulation 100%, peri-wound intact. There was no weekly skin assessment since June 2, 2023, until requested by the surveyor on August 3, 2023. At that time of request, the pressure ulcer increased in size and now measured 2.6 cm by 1.0 cm by 0.8 cm and was classified as a Stage III. Review of Resident 24's physician services progress notes revealed that she was seen by a CRNP on February 22, 2023; April 11, 2023; and June 15, 2023, with no mention of the pressure ulcer in the notes. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 2, 2023, at 11:36 AM, the DON indicated that the area started as a MASD (Moisture Associated Skin Damage), and then was noted to be a pressure area in February 2023. When asked about the Wound Rounds document and lack of documentation in the Resident's clinical record of measurements and assessment of the wound from June 2, 2023, through present; she confirmed that there was no documentation and further indicated that their Wound Practitioner had left around March 2023, which resulted in the lack of assessment/documentation. She stated that the Unit Managers on each unit were responsible for the weekly assessment of the wound in the absence of the Wound Practitioner. During an interview with the DON on August 3, 2023, at 10:55 AM, the DON confirmed that she could not provide any wound measurements or assessments for Resident 24's pressure ulcer for the month of July 2023. Review of Resident 24's current physician orders revealed the following order: Sacrum: Cleanse with normal saline solution, pat dry, apply slightly moist silver collagen (advanced, topically applied wound dressings that transform into cool, soothing gel upon contact with drainage), and cover with bordered foam dressing (an adhesive padded dressing). Change daily and PRN (as needed) for soiling for a pressure area. During a wound care observation on August 2, 2023, at 1:29 PM, with Employee 14 (RN) and Employee 15 (Licensed Practical Nurse), it was observed that there was no dressing present on the wound. Employee 14 confirmed that no dressing was present on sacral wound, and Employee 15 indicated they had performed the wound care and applied a dressing yesterday. During an interview during this observation, Employee 14 indicated that the wound started as a MASD and then presented with slough, was noted to be on a bony prominence, and, therefore, the area was reclassified an unstageable pressure ulcer. Employee 14 further indicated that when the slough was no longer present, the pressure injury was reclassified as a Stage III. During an interview with the NHA and DON on August 2, 2023, at 2:05 PM, the surveyor shared the observation of no dressing being present on wound at time of wound care observation. The DON indicated that she would expect nurse aides to report to the nurse if a dressing becomes dislodged during care so wound care could be provided at that time. On August 3, 2023, at approximately 10:30 AM, the DON provided a statement from Employee 16 (Nurse Aide) that indicated they had provided incontinence care just before lunch and had removed the dressing because it was soiled and coming off. The statement further indicated that she planned to tell the nurse when they saw them. Review of Resident 24's March 2023 Treatment Administration Record for their sacral pressure ulcer treatment revealed that the dressing change was not performed, per order, on March 6, 10, 12, 16, 18, 20, 22, 28, and 30, 2023. Review of Resident 24's April 2023 Treatment Administration Record for their sacral pressure ulcer treatment revealed that the dressing change was not performed, per order, on April 1, 7, 9, 13, 17, 19, 23, and 27, 2023. Review of Resident 24's May 2023 Treatment Administration Record for their sacral pressure ulcer treatment revealed that the dressing change was not performed, per order, on May 1, 3, and 5, 2023. Review of Resident 24's June 2023 Treatment Administration Record for their sacral pressure ulcer treatment revealed that the dressing change was not performed, per order, on June 17, 2023. Review of Resident 24's July 2023 Treatment Administration Record for their sacral pressure ulcer treatment revealed that the dressing change was not performed, per order, on July 10, 16, and 29, 2023. During a follow-up wound care observation completed on August 3, 2023, at 10:06 AM, Employee 14 (RN) revealed that Resident 24's pressure ulcer increased in size and now measured 2.6 cm by 1.0 cm by 0.8 cm and was classified as a Stage III. During a follow-up interview with the NHA and DON on August 3, 2023, at 11:50 AM, the surveyor again reviewed all concerns with the pressure ulcer: treatments not being documented as provided, as ordered; the absence of a dressing on the wound upon first observation; no wound certified nurse/physician follow-up; lack of routine assessment/evaluation of the wound from June 2, 2023, through August 3, 2023; and the wound had increased in size (length and depth). The DON confirmed that she would expect their policy to have been followed, that the wound would have been assessed/monitored per policy and documented, and that ordered treatments be provided. Per policy, the licensed nurse will document newly identified skin/wound impairments as a change in condition, complete weekly assessments, and will perform daily monitoring of ulcer/wound site with or without dressing. The policy also states that staff should monitor the status of tissue surrounding the wound; adequate control of wound associated pain; and signs of decline in wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound associated pain, complete a wound re-evaluation, change in condition; and implement wound care treatments/techniques as indicated and ordered. The facility did not follow their policy to complete thorough assessments and documentation of Resident 24's pressure ulcer. Treatments and assessments were missed and there was no evidence that the physician was aware of the pressure ulcer or monitoring it. There was no assessment with measurements of the pressure ulcer since June 2, 2023, and, upon request of an assessment with measurement on August 3, 2023, the pressure ulcer was noted to increase in size. Review of Resident 71's clinical record on July 31, 2023, at approximately 10:45 AM, revealed diagnoses that included congestive heart failure (CHF - disease process of the heart that results in decreased ability of the heart to pump blood through the body) and peripheral vascular disease (disease of the vascular system that results in decreased blood flow to the extremities). Review of Resident 71's physician orders on August 3, 2023, at approximately 9:30 AM, revealed an active order dated April 29, 2023, electronically signed by the physician on May 1, 2023, for, Cleanse coccyx with [normal saline solution], apply skin prep, apply comfort foam. Review of Resident 71's Treatment Administration Record (TAR - clinical document utilized to record when treatments are provided) revealed that licensed nursing staff continued to, Cleanse coccyx with [normal saline solution], apply skin prep, apply comfort foam, every three days for wound care in May, June and July, 2023. Review of Resident 71's August 2023 TAR revealed the last treatment provided was documented on August 1, 2023. Review of Resident 71's progress notes revealed that on May 3, 2023, at 2:12 PM, Employee 2 documented, .open [stage III pressure ulcer] area on coccyx 0.4 x 0.5 pink granulation tissue, [treatment] of comfort foam remains appropriate . Further review of Resident 71's clinical record revealed no further assessments, including assessments of size, condition of wound bed, condition of surrounding skin, of the stage III pressure ulcer to Resident 71's coccyx between May 3, 2023, and August 2, 2023. During a staff interview on August 3, 2023 at approximately 11:30 AM, DON revealed that an interview with Employee 2 confirmed that there was a stage III pressure ulcer on Resident 71's coccyx on May 3, 2023. DON further revealed that it was the facility's expectation that Resident 71's pressure ulcer be assessed per the facility's policy on wound management. During a staff interview on August 2, 2023, at approximately 1:30 PM, it was requested by the surveyor that facility assess Resident 71's coccyx to determine if the Resident continued to have a wound to the coccyx. During a staff interview on August 3, 2023, at approximately 11:30 AM, the DON revealed that an interview with Employee 2 confirmed that there was a stage III pressure ulcer on Resident 71's coccyx on May 3, 2023. During the staff interview, the DON revealed that an assessment conducted on August 2, 2023, revealed that Resident 71's coccyx pressure ulcer had healed. The DON further revealed that it was the facility's expectation that Resident 71's pressure ulcer be assessed per the facility's policy on wound management. The facility was unable to determine when the pressure ulcer resolved. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, select facility documents, clinical and hospital record review, and staff interviews, it was determined that the facility failed to ensure that a licensed agency nurse had the specific competencies and skills necessary to perform catheter care irrigation resulting in irrigation into the wrong port causing harm, as evidenced by pain, hematuria, (blood in urine), transfer to the hospital, and prophylactic administration of antibiotics for 10 days to one of 7 residents reviewed with urinary catheters (Resident 1). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing, and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. A review of the facility policy, titled Catheter Indwelling Urinary-Irrigation, last revised February 1, 2023, states to place the resident in supine position (lying horizontally with the face and torso facing up) before starting the irrigation. The policy further states that irrigations are performed via catheter aspiration port or manually via catheter drainage port. For irrigation through the aspiration port staff are to attach the syringe to the aspiration port. For manual irrigation, staff are to attach the syringe to the drainage port. Policy also states if resistance is encountered during instillation, do not force solution into bladder. Stop procedure and notify physician. A review of Resident 1's clinical record revealed diagnoses that included obstructive and reflux uropathy (when your urine can't flow either partially of completely through your ureter, bladder, or urethra due to some type of obstruction, instead of flowing from the kidneys to the bladder, urine flows backward, or refluxes, into the kidneys) and benign prostatic hyperplasia infection (age associated prostate gland enlargement that can cause urination difficulty). Review of Resident 1's current physician orders revealed an order that was initiated July 7, 2022, for a 14 French bladder catheter (tube placed into the bladder to drain urine) in place with 10 milliliters of fluid inserted in the balloon to maintain placement in the bladder. A physician order dated December 10, 2022, noted staff were to flush (irrigate) the bladder catheter with 60 milliliters of sterile water every shift to maintain patency. Review of facility reported event report, dated March 31, 2022, revealed that Resident 1 was transported to the Emergency Department on March 30, 2023, for urinary catheter dysfunction and gross hematuria after the balloon of the catheter ruptured during routine catheter flush. Employee 1 (Agency Licensed Practical Nurse) in a written statement dated March 30, 2023, documented that on March 30, 2023, at approximately 7:20 AM, Employee 1 administered Resident 1's AM medications without concerns. Employee 1 then obtained sterile water and a piston syringe (a large barrel syringe used for irrigation) from the supply room to flush Resident 1's bladder catheter per physician order. Resident 1 was seated in a chair in his room. 30 milliliters of sterile water pulled into the syringe and attached it to the balloon port unknowingly (10 milliliters is the amount of fluid that should be in the catheter balloon to maintain placement in the bladder). Employee 1 pushed the 30 cc's (milliliters) into the balloon port. Employee 1 documented that not all of the 30 cc's went in, and then Employee 1 heard a pop. The Resident expressed discomfort. Employee 1 immediately stopped and asked another nurse to assist, Employee 2 (Registered Nurse). A written statement from Employee 2 dated March 30, 2023, revealed the catheter fell to the floor when Resident 1 was assisted back to bed. Employee 2 stated that she was unaware that the balloon port was utilized for irrigation until Employee 1 informed Employee 2 during replacement of the catheter. Resident 1 was assisted back to bed and upon standing the catheter fell on the floor. There was a small amount of mucous blood-tinged drainage that was on the catheter. Resident 1 still appeared to be in pain. The Resident's abdomen was firm and Resident 1 demonstrated some pain while palpated (lower abdomen). Employee 1 re-inserted another catheter with Employee 2's assistance. Resident did not tolerate procedure well. Employee 2 took over when Resident 1 was observed in pain. The catheter went in, and there was urinary return along with blood and clots. Employee 2 inflated the balloon. This was around 9:00 AM. Employee 1 did not check vital signs up until this point. Employee 3 (Unit Manager) arrived on the unit at approximately 9:00 AM, and Employee 1 notified her of the event. Employee 3 took over and notified the Certified Registered Nurse Practitioner (CRNP) around 10:41 AM. The CRNP gave recommendations for Resident 1 to be sent to the hospital. Employee 3 notified the physician who gave a verbal order to send the Resident to the hospital. Employee 3 obtained a blood pressure of 190/130, which is elevated from baseline. Resident 1 left the facility for evaluation at the hospital on March 30, 2023, at 12:08 PM. Based on hospital record review, Resident 1 arrived at the hospital emergency department on March 30, 2023, at 12:17 PM. Hospital documents revealed bladder catheter drainage bag with approximately 150 milliliters of fruit punch colored urine on arrival. Blood pressure was 145/85 and Resident was afebrile (98.2 degrees Fahrenheit). At 6:00 PM, a Urology consult was performed. The Urology physician evaluated Resident 1 and documented that the Foley catheter was actually located in the urethra, and was not in the bladder. The catheter was removed by the Urologist and replaced appropriately without difficulty. Based on hospital record review on March 31, 2023, at 7:15 AM, the hospital form, titled After Visit Summary, stated that Resident 1 had a discharge diagnosis of chronic urinary retention, with minor urethra trauma. Resident 1 was discharged and returned to the facility at that time with orders to receive an antibiotic three times a day for the next 10 days. The Urologist also documented during his consult that a 16 French Foley catheter was inserted, and not to be changed for one month, to allow the urethra to heal. As a result of administering the irrigation into the balloon port and placing the replacement catheter in the urethra, it resulted in harm to the Resident who suffered with pain, hematuria (blood in the urine), and required antibiotic medication for 10 days following the emergency room visit. On April 6, 2023, the facility requested Employee 1's competency documentation. The Director of Nursing (DON) revealed that agency staff are hired with the expectation that they are competent in skills that are basic to the nurse practice act. The DON did contact the contracted agency that Employee 1 was hired and requested the competency for Employee 1. The agency sent a form titled, Clinical Competency Testing, and it showed 90% pass rate overall, but was marked as limited experience in male and female bladder catheter equipment and procedures. During an interview with the DON on April 6, 2023, at approximately 2:15 PM, the DON stated that Employee 1 no longer works at the facility, and all licensed staff are currently being re-educated to ensure competency with bladder catheter irrigation/flushes. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based on clinical record review, staff interviews, policy review, and hospital record review, it was determined that the facility failed to ensure that residents with foley catheters received appropriate treatment and services consistent with professional standards during catheter care by irrigating into the wrong port causing the catheter balloon to break, resulting in actual harm as evidenced by pain, hematuria (blood in the urine), transfer to the hospital, and administration of antibiotics for 10 days for one of seven residents reviewed with urinary catheters (Resident 1). Findings include: A review of the facility policy, titled Catheter Indwelling Urinary-Irrigation, last revised February 1, 2023, states irrigation's are performed via catheter aspiration port or manually via catheter drainage port. Policy also states if resistance is encountered during instillation, do not force solution into bladder. Stop procedure and notify physician. A review of the clinical record for Resident 1 on April 6, 2023, revealed clinical diagnoses that included obstructive and reflux uropathy (when your urine can't flow either partially or completely through your ureter, bladder, or urethra due to some type of obstruction; instead of flowing from the kidneys to the bladder, urine flows backward, or refluxes, into the kidneys) and benign prostatic hyperplasia infection (age associated prostate gland enlargement that can cause urination difficulty). A physician order dated July 7, 2022, noted Resident 1 had a 14 French bladder [foley] catheter in place with 10 milliliters of fluid inserted in the balloon to maintain placement in the bladder. A physician order dated December 10, 2022, noted staff were to flush (irrigate) the bladder catheter with 60 milliliters of sterile water every shift to maintain patency. A review of Resident 1's progress notes dated March 29, 2023, at 10:24 AM, revealed Resident 1's bladder catheter was changed by Employee 5 (Registered Nurse) due to blockage/leakage. A 14 French catheter with 10 milliliters of sterile water was inserted into the balloon to maintain placement. During removal of the previous placed catheter, 45 milliliters of water was removed from the balloon instead of the 10 milliliters that was ordered. Further review of the progress note revealed the nurse documented the previous foley balloon was incorrectly inflated 45 milliliters. A urine sample was collected at that time for urinalysis with a culture and sensitivity (UA C&S - to determine type of antibiotic effective against any bacteria found with culture) to be performed. Urine was noted to be cloudy yellow with a strong odor. A written statement via email from the facility, regarding the March 29th incident, was obtained from Employee 3 on April 7, 2023, at 11:21 AM, that states the following: I replaced the Foley catheter on the Resident 1 due to leakage into his brief and low urine output into urine drainage bag. Resident 1 was asymptomatic at the time, no pain, discomfort, no bladder distention. During the replacement when I deflated the balloon to remove the old catheter (supposed to be 14 F /10 mL), I removed 45 mL from the balloon, the foley was then removed without difficulty and new catheter was replaced. Immediate yellow urine return, at that time I collected a urine sample to be sent to the lab because he was scheduled to have UA C&S collected due to urinary symptoms. Resident 1 tolerated insertion well with no signs or symptoms of pain or discomfort. Foley was draining yellow urine when I completed my shift at 11pm with no ill effects. Review of facility reported event report, dated March 31, 2022 revealed that Resident 1 was transported to the Emergency Department on March 30, 2023, for urinary catheter dysfunction and gross hematuria after the balloon of the catheter ruptured during routine catheter flush. In a written statement dated March 30, 2023, Employee 1 (Licensed Practical Nurse) documented that on March 30, 2023, at approximately 7:20 AM, the following events took place while providing care to Resident 1. Employee 1 administered Resident 1's AM medications without concerns and obtained sterile water and a piston syringe (syringe used for irrigation) from the supply room to flush Resident 1's bladder catheter. Resident 1 was seated in a wheelchair in his room. 30 milliliters of sterile water was pulled into the syringe and attached it to the balloon port unknowingly. Not all of the 30 milliliters went in when a pop was heard, Resident 1 expressed discomfort and irrigation was stopped. Employee 2 (Registered Nurse) was called to the room for assistance. Resident 1 was assisted back to bed and upon standing the catheter fell on the floor. There was no drainage around the meatus (catheter insertion site). There was a small amount of mucous blood-tinged drainage that was on the catheter. Resident 1 still appeared to be in pain. The Resident's abdomen was firm and Resident 1 demonstrated some pain while palpated (lower abdomen). Employee 1 re-inserted another catheter with Employee 2's assistance. Resident did not tolerate that well. Employee 2 took over when Resident 1 was observed in pain. The catheter went in, and there was urinary return along with blood and clots. Employee 2 inflated the balloon.This was around 9:00 AM. Employee 1 did not check vital signs up until this point. Employee 3 (Unit Manager) arrived on the unit at approximately 9:00 AM, and Employee 1 notified her of the event. Employee 3 took over and notified the Certified Registered Nurse Practitioner (CRNP) around 10:41 AM. The CRNP gave recommendations for Resident 1 to be sent to the hospital. Employee 3 notified the physician who gave a verbal order to send the resident to the hospital. Employee 3 obtained a blood pressure of 190/130, which is elevated from baseline. Resident 1 left the facility for evaluation at the hospital on March 30, 2023, at 12:08 PM. A written statement from Employee 2 dated March 30, 2023, revealed the catheter fell to the floor when Resident 1 was assisted back to bed. Employee 2 stated that she was unaware that the balloon port was utilized for irrigation until Employee 1 informed Employee 2 during replacement of the catheter. Based on hospital record review, Resident 1 arrived at the hospital emergency department on March 30, 2023, at 12:17 PM. Hospital documents revealed bladder catheter drainage bag with approximately 150 milliliters of fruit punch colored urine on arrival. Blood pressure was 145/85 and Resident was afebrile (98.2 degrees Fahrenheit). At 6:00 PM, a Urology consult was performed. The Urology physician evaluated Resident 1 and documented that the Foley catheter was actually located in the urethra, and was not in the bladder. The catheter was removed by the Urologist and replaced appropriately without difficulty. Based on hospital record review on March 31, 2023, at 7:15 AM, the hospital form, titled After Visit Summary, stated that Resident 1 had a discharge diagnosis of chronic urinary retention, with minor urethra trauma. Resident 1 was discharged and returned to the facility at that time with orders to receive an antibiotic three times a day for the next 10 days. The Urologist also documented during his consult that a 16 French Foley catheter was inserted, and not to be changed for one month, to allow the urethra to heal. On April 6, 2023, the facility requested Employee 1's competency documentation. The Director of Nursing (DON) revealed that agency staff are hired with the expectation that they are competent in skills that are basic to the nurse practice act. The DON did contact the contracted agency that Employee 1 was hired and requested the competency for Employee 1. The agency sent a form titled, Clinical Competency Testing, and it showed 90% pass rate overall, but was marked as limited experience in male and female bladder catheter equipment and procedures. As a result of administering the irrigation into the balloon port and placing the replacement catheter in the urethra, it resulted in harm to the Resident who suffered with pain, hematuria (blood in the urine), and required antibiotic medication for 10 days following the emergency room visit. During an interview with the DON on April 6, 2023, at approximately 2:15 PM, the DON stated that Employee 1 no longer works at the facility, and all licensed staff are currently being re-educated to ensure competency with bladder catheter irrigation/flushes. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based on observations, facility document and policy review, Center for Disease Control recommendations review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each staff person correctly wears personal protection equipment for two of two staff persons (Employees 17 and 18), failed to ensure infection prevention practices during medication administration for one of three residents observed (Resident 89), and failed to ensure appropriate isolation of COVID-19 positive residents in one of six nursing units (Arcadia), resulting in actual harm from symptoms of contracting COVID-19 for one of 37 residents residing on the Arcadia unit (Resident 281). Findings include: Review of the Center for Disease Control (CDC) policy, titled Wearing a Mask stated, mask must cover your nose and mouth. Observations of Employee 17, on [DATE], at 12:53 PM, and on [DATE], at 11:04 AM, revealed the Employee providing Resident care without the surgical mask covering the nose. An observation on [DATE], at 12:53 PM, revealed of Employee 18, in a Resident's room without the N-95 respirator mask covering her mouth and nose. An interview with the Nursing Home Administrator (NHA), on [DATE], at 11:06 AM, revealed staff should wear masks properly while performing duties. Review of the facility's current Medication Policy revealed in Step 17, Medications should be administered as follows: a. Do not touch medication. Review of Resident 89's medical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication preparation on [DATE], at 7:55 AM, revealed Employee 3 (Licensed Practical Nurse) preparing medication to administer. She removed two tablets of Acetaminophen (medication used to treat minor aches and pains) 325 mg out of a medication bottle by dispensing them out of the bottle, into her bare hand, and then placing them into a medication cup. She then administered the medication to Resident 89. Interview with the Director of Nursing (DON) on [DATE], at 10:50 AM, DON revealed that she would expect the nurse to follow the facility policy and not touch the medication to be administered with her bare hand. Review of facility policy regarding cohorting for positive COVID-19 residents, revealed a process flow diagram for COVID-19 Admission Criteria dated [DATE], which reads, in part, a patient with confirmed COVID-19 infection and has not met criteria to discontinue transmission-based precautions should be admitted into isolation in a transmission-based precaution unit until recovery criteria is met. Interview with NHA on [DATE], at approximately 2:00 PM, revealed that the facility follows CDC guidance related to cohorting of COVID-19 positive residents. Review of CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic updated February 2, 2022, stated source control and physical distancing are recommended for everyone in a healthcare setting when: have suspected or confirmed COVID-19 infection or other respiratory infection; and/or had close contact or higher-risk exposure with COVID-19 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing an outbreak. Review of the facility reported diseases, including COVID-19, from [DATE] through [DATE], revealed that the facility had a COVID-19 outbreak that initiated on [DATE]. Eight Residents on the Arcadia unit (locked dementia unit) were moved to the Bethany unit (COVID-19 isolation unit). Further review of facility reported diseases for positive COVID-19 cases revealed that on [DATE], four Residents tested positive from the Arcadia unit, and those residents were also moved to the Bethany unit for isolation. Review of facility action summary report revealed that on [DATE], the aforementioned 12 Residents from the Bethany isolation unit were moved back into the Arcadia unit, into the rooms they previously resided in. This isolation period would only account for up to three full days of isolation. Further review revealed [DATE], through [DATE], an additional 15 total Residents from Arcadia Unit tested positive for COVID-19, and remained within the room they resided in. Four of the 15 aforementioned Residents had roommates who tested positive on [DATE], and one Resident's Roommate tested positive on [DATE]. Observations on the Arcadia unit throughout the survey on [DATE], through [DATE], revealed that most Residents were actively moving throughout the unit and in common areas for activities and dining. Interview with the NHA on [DATE], at approximately 12:40 PM, revealed that there weren't enough beds on the Bethany unit to accommodate all of the COVID-19 positive residents from the Arcadia unit. The following are examples of COVID-19 positive residents who moved back into their room on [DATE], cohorted with their roommate who was COVID-19 negative at that time, and the roommate subsequently became COVID-19 positive: Resident 41 resided in a room with Resident 30. Resident 30 became COVID-19 positive [DATE], Resident 30 was moved to the Bethany unit on [DATE], and moved back into the aforementioned room with Resident 41 on [DATE]. Progress notes for Resident 30 revealed Resident 30 was symptomatic beginning [DATE], including cough and increased fatigue. Resident 41 became COVID-19 positive [DATE]. Resident 41 was on hospice services at that time. Respiratory note dated [DATE], at 10:27 AM, read, in part, COVID-19 positive, out of bed ambulating around unit per baseline. Respiratory note dated [DATE], at 12:46 PM, read, in part, out of bed for lunch and ate in the dining room, roamed the unit the rest of the shift. Resident 293 resided in a room with Resident 1. Resident 1 tested positive for COVID-19 on [DATE]. Resident 1 was moved to the Bethany unit on [DATE], and moved back into the aforementioned room with Resident 293 on [DATE]. Review of progress notes for Resident 1 revealed Resident 1 to be symptomatic beginning [DATE], including cough and lethargy. Resident 293 became COVID-19 positive [DATE]. Respiratory note dated [DATE], read, in part, still fatigued and attends meals in the dining room. Medical Practitioner note dated [DATE], read, in part, Resident reported having increased fatigue, encouraged Resident to remain in room for isolation. Resident 24 resided in a room with Resident 29 and tested positive for COVID-19 [DATE]. Resident 24 was moved to the Bethany unit on [DATE], and moved back into the aforementioned room with Resident 29 on [DATE]. Review of progress notes revealed Resident 24 to be symptomatic beginning [DATE], including chronic cough, general discomfort, extra fatigued, decreased appetite, and cold chills. Resident 29 resided in a room with Resident 24 and tested positive for COVID-19 on [DATE]. Resident 101 resided in a room with Resident 282, and tested positive for COVID-19 on [DATE]. Resident 101 was transferred to the hospital due to a fall, and returned to the facility on [DATE], back into a room with Resident 282. Review of Progress notes revealed Resident 101 was symptomatic beginning [DATE], including low oxygen, poor appetite, low heart rate, cough, and fatigue. Resident 282 resided in a room with Resident 101 and tested positive for COVID-19 on [DATE]. Review of Resident 281's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 281's clinical record revealed that the Resident tested positive for COVID-19 on [DATE]. Nursing progress note on [DATE], stated Resident 281 is fatigued and had a poor appetite. Medical Practitioner note dated [DATE], stated, spoke with Resident's Daughter, Resident in bed non-verbal, increased fatigue, and poor appetite since COVID-19 positive. Medical Practitioner note [DATE], stated that a voicemail was left for Daughter, explained Resident has significantly declined since testing positive for COVID-19, very poor appetite, has not been able to be out of bed since [DATE], today Resident minimally responsive, encouraged to call the facility. Respiratory note dated [DATE], at 1:32 PM, lung sounds diminished, right and left upper and lower lobes. Nursing note dated [DATE], at approximately 2:49 PM, in part, read, Resident 281 continues to have an overall decline, speaks a few whispered words at times, appetite continues to be poor, noted to be pocking food at times, needs frequent reminders to swallow. Nursing note dated [DATE], in part, read, call from Physician services, Resident's Daughter phoned the on-call serves; new orders for stat (urgent/immediate) labs including a complete blood count (CBC) w/differential and basic metabolic panel (BMP), D-dimer (use to check for blood clotting problems), chest x-ray, IV (intravenous- administered int a vein) dextrose Sodium Chloride (for hydration) solution at 70 milliters (unit of measure) per hour for one liter. There was also a hospice order for consult per family request after labs are obtained. Review of Resident 281's laboratory results dated [DATE], documented the following were elevated above the reference range: White Blood Cell Count (help to protect us against bacteria, viruses, and parasites - a high count is usually a sign of infection), Red Blood Cell Count (measures how many red blood cells - a high count can be a sign of dehydration, heart disease, or a bone marrow disease), hematocrit (the ration of the volume of red blood cells to the total volume of blood - high levels can indicate dehydration or lung, heart disease, and/or bone marrow disease), hemoglobin (a red protein responsible for transporting oxygen in the blood - elevated when your body requires an increased oxygen-carrying capacity, the blood is thicker and can lead to blood clots), mean corpuscular volume (MCV - measures the average size of red blood cells - high level means that red blood cells are too large and can be caused by low folate or vitamin B12), neutrophils (a type of white blood cell that is an important part of the immune system and helps fight infection), sodium (may be a sign of dehydration), chloride (may be a sign of dehydration), anion gap (your blood is more acidic than normal - may mean that you are dehydrated), blood urea nitrogen (BUN- high levels means your kidneys aren't working well, or dehydration), creatinine (high levels indicate that the kidneys aren't working correctly). Further review revealed that the D-dimer was significantly elevated at 10.7 (reference range 0.0 - 0.52 mg/L [unit of measure, milligram per liter]), and the glomerular filtration rate was low (indicating that the kidneys are not functioning as they should). Review of Resident 281's laboratory results dated [DATE], documented that hemoglobin, hematocrit, MCV, sodium, chloride, BUN, and creatinine remained elevated; glucose level was elevated (elevated blood sugar not related to disease or medication use is indicative of having an illness or infection); and the GFR remained low. Review of urinalysis results: turbid (unclear or cloudy), moderate leukocytes (white blood cells), and the presence of nitrites, protein, WBC, and bacteria; indicative of an infection. Respiratory note dated [DATE], approximately 1:45 AM, stated left and right lower lobes (lung) diminished. Nursing note dated [DATE], urinalysis collected at approximately 6:22 AM, received order for [MEDICATION(S)] (used to prevent serious blood clots from forming); at approximately 4:00 PM, labs reviewed with Medical Practitioner, waiting for urine culture, no new orders, Resident having difficulty swallowing meds, refused breakfast and lunch. Medical practitioner note dated [DATE], stated Resident 281 was positive for right femoral deep vein [CONDITION(S)], family agreed to comfort care, discontinue all routine oral medications. Electronic medication administration note dated [DATE], at 3:47 PM, read, in part, Resident at end of life, facial grimacing and periods of labored breathing, occasional moaning, [MEDICATION(S)] (pain medicine) administered. Progress note dated [DATE], at approximately 12:42 PM, Resident ceased to breathe, family at beside, support provided. Review of Physician discharge summary dated [DATE], revealed that Resident 281 expired. Medical history included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility provided visitation log for Resident 281 for [DATE], revealed Resident 281 had outside visitation on [DATE], and then again on [DATE] (after COVID-19 positive testing); therefore, the only physical interaction Resident 281 had for the three weeks prior to documented COVID-19 symptom onset would have been facility staff and/or fell ow Residents. The facility failed to quarantine and appropriately cohort COVID-19 positive Residents, which resulted in continued spread of the COVID-19 virus throughout one unit and exacerbated the death of one Resident. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 201.18 (e)(1) Managment

Based on observation, review of clinical records, facility documentation, and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure residents were free from neglect, which resulted in harm and required a resident to be sent to the emergency room and 6 sutures applied to the right hand for one of three residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Resident 1's care plan, initiated on (MONTH) 14, (YEAR), and reviewed on (MONTH) 15, (YEAR) (after the incident on (MONTH) 1, (YEAR)), revealed a focus area related to a self-care deficit due to physical limitations. Staff were to transfer the resident to and from bed and wheelchair with the assist of two people. The care plan focus area for alteration in skin integrity indicated that staff should provide frequent reminders for resident to keep her hands inside the sling during transfers with the lift. Review of the facility's incident report dated (MONTH) 1, (YEAR), revealed that Nurse Aide (NA) 1 was transferring Resident 1 independently, with a sit to stand lift, when her right hand got stuck in between the bathroom grab bar and the lift creating a skin tear and a laceration on her right hand. A nursing assessment was done, the CRNP (Certified Registered Nurse Practitioner) was notified and the resident was sent to the emergency room and required 6 sutures (a row of stitches holding together the edges of a wound) to the right hand. Further review of the facility's incident report dated (MONTH) 1, (YEAR), revealed that at the conclusion of the investigation, NA 1 received education. A form attached to the incident report listed the following: facts that require improvement - CNA transferred resident using mechanical lift without assistance from a second nursing staff; expectations that have not been met - did not follow mechanical lift policy; solutions that NA 1 is willing to do to meet the expectations - complete training and adhere to policy; and actions that the facility will take when NA 1 meets the expectation or follow up should you not meet the expectation - progressive discipline. Review of the Notification and Use of Lifts policy, review dated (MONTH) (YEAR) stated that, should the use of a mechanical lift or sit-to-stand be needed there must be two (2) trained staff members to assist. During an interview with the Director of Nursing on (MONTH) 14, (YEAR), at 3:00 p.m. she confirmed that the assistance of two staff should have been in place. The facility staff failed to ensure residents were free from staff neglect by not following the plan of care, resulting in harm to Resident 1 which required the resident to be sent to the emergency room and 6 sutures applied to the right hand. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/28/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 211.12(c) Nursing services. Previously cited 9/28/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/28/17, 8/26/16.

Based on clinical record review, facility incident report review and staff interview, it was determined that the facility failed to implement interventions to prevent accidents for one of three residents (Resident 1) reviewed, resulting in harm to the resident. Findings include: Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Resident 1's care plan, initiated on (MONTH) 14, (YEAR) and reviewed on (MONTH) 15, (YEAR) (after the incident on (MONTH) 1, (YEAR)), revealed a focus area related to a self-care deficit due to physical limitations. Staff were to transfer the resident to and from bed and wheelchair with the assist of two people. The care plan focus area for alteration in skin integrity indicated that staff should provide frequent reminders for resident to keep her hands inside the sling during transfers with the lift. Review of the facility's incident report dated (MONTH) 1, (YEAR), revealed that Nurse Aide (NA) 1 was transferring Resident 1 independently, with a sit to stand lift, when her right hand got stuck in between the bathroom grab bar and the lift creating a skin tear and a laceration on her right hand. A nursing assessment was done, the CRNP was notified and the resident was sent to the emergency room and required 6 sutures (a row of stitches holding together the edges of a wound). Further review of the facility's incident report dated (MONTH) 1, (YEAR), revealed that at the conclusion of the investigation, NA 1 received education. A form attached to the incident report lists the following: facts that require improvement - CNA transferred resident using mechanical lift without assistance from a second nursing staff; expectations that have not been met - did not follow mechanical lift policy; solutions that NA 1 is willing to do to meet the expectations - complete training and adhere to policy; and actions that the facility will take when NA 1 meets the expectation or follow up should you not meet the expectation - progressive discipline. Review of the Notification and Use of Lifts policy, review dated (MONTH) (YEAR), stated that, should the use of a mechanical lift or sit-to-stand be needed there must be two (2) trained staff members to assist. During an interview with the Director of Nursing on (MONTH) 14, (YEAR), at 3:00 p.m. she confirmed that the assistance of two staff should have been in place. The facility failed to implement interventions to prevent accidents for one of three residents (Resident 1) reviewed resulting in harm, which required the resident to be sent to the emergency room for six sutures in the right hand. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/28/17. 28 Pa. Code 211.5(f) Clinical record. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 9/28/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/28/17, 8/26/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/28/17.

Based on observations, facility policy reviews and staff interviews, it was determined that the facility failed to provide an environment that remained free of accident hazards, related to the storage of compressed oxygen tanks, for two of eight halls observed (400 hall and 700 hall), placing the health and safety of the residents in Immediate Jeopardy. Findings include: Observations on July 27, 2015, at 5:11 p.m., revealed that a portable oxygen tank was unsecured in room 405. The portable oxygen tank was observed at the end of the bed, approximately 2 feet away from the back wall that contained the heating/air conditioning unit. The oxygen tank was observed from the hallway. Inspection of the portable oxygen tank gauge revealed that the tank had approximately 1,250 pounds per square inch (psi) of pressure. During an interview on July 27, 2015, at 5:13 p.m., Registered Nurse 1 (RN 1), revealed that the oxygen tank should be secured. RN 1 immediately removed the oxygen tank and secured it in an oxygen tank rack, located in the medication room of the 200 hall. As of July 28, 2015, the Nursing Home Administrator (NHA) was unable to provide an explanation as to why the oxygen tank was located in the resident's room. The NHA also indicated that when residents require oxygen it is frequently delivered via the oxygen concentrator (a device which concentrates the oxygen from a gas supply (typically ambient air) to supply an oxygen enriched gas mixture) in the room. Observations on July 27, 2015, at 5:20 p.m., revealed that a portable oxygen tank was unsecured in room 709. The oxygen tank was observed to be free standing on the floor at approximately 1 foot from the outer wall and approximately four to five feet from the foot of the bed. The oxygen tank was observed from the hallway. Inspection of the portable oxygen tank gauge revealed that the tank had approximately 1,500 psi of pressure. During an interview on July 27, 2015, at 7:20 p.m., the NHA revealed that Resident 15, of Room 709, returned from the hospital with a respiratory infection and required oxygen. A review of Resident 15's clinical record on July 29, 2015 at approximately 12:30 p.m., revealed that Resident 15 received supplemental oxygen (oxygen delivered by any means other than natural respiration - oxygen tank, oxygen concentrator) on July 13, 2015, at 10:03 p.m. Review of Resident 15's clinical record revealed no physician's order for supplemental oxygen therapy. The NHA was unable to provide the manner in which the oxygen tank became stored and unsecured in room 709. On July 27, 2015, observations from 5:25 p.m. through 5:40 p.m., of every resident room in the facility, revealed no further unsecured oxygen tanks. On July 27, 2015, at 5:42 p.m., a review of the facility's policy titled, Respiratory: Oxygen Administration dated January 2011, with a review date of June 1, 2015, revealed that oxygen cylinders (tanks) should be secured in a stand or a cart. On July 27, 2015, at 6:27 p.m., the NHA and the Director of Nursing (DON) were notified that Immediate Jeopardy had been identified related to the storage of oxygen tanks. The NHA and the DON were asked to provide a corrective action plan. An interview on July 27, 2015, at 6:29 p.m., with the NHA revealed that it is the facility's expectation that oxygen tanks should be stored in a secured manner. The NHA revealed that by the oxygen tanks not being secured, they may present an accident hazard if they were to tip over. On July 27, 2015, at 7:19 p.m., the NHA submitted a corrective action plan. At 7:26 p.m., the corrective action plan was rejected because it failed to address how the facility would identify unsecured oxygen tanks in the building. On July 27, 2015, at 7:28 p.m., the NHA submitted a revised corrective action plan. At 7:36 p.m., the facility was informed that the corrective action plan was accepted. The corrective action plan stated all oxygen tanks would be identified and secured, the nursing staff would be educated on securing oxygen tanks, the Medical Director would be notified of the IJ situation, the Director of Care Delivery would conduct weekly audits of the oxygen storage and the results of the audits would be taken to the monthly QA and A (Quality Assessment and Assurance) committee for review and recommendations. On July 28, 2015, at 8:58 a.m., the NHA submitted staff education and staff signature sheets to the State Survey Team. At 9:00 a.m., observation of the facility revealed that there were no unsecured oxygen tanks. On July 28, 2015, at 9:29 a.m., an interview was conducted with a representative from Airgas Medical, the manufacturer of the two oxygen tanks that had been found to be unsecured. During the interview with the Airgas Medical Representative 1, it was revealed that it is Airgas Medical's expectation and requirement that all oxygen tanks are to be stored securely in a rack, cart, or other Occupational Safety and Health Administration (OSHA), NSF International (product testing, inspection, and certification organization that help develop national and international safety standards and certification programs), Federal, and/or State approved apparatus. The Immediate Jeopardy for the storage and securing of oxygen tanks was lifted on July 28, 2015 at 9:38 a.m., when it was evident that the corrective action plan had been implemented. On July 29, 2015, at 9:35 a.m., the NHA submitted further evidence of staff education. 42 CFR 483.25(h) Free of Accidents Hazards/Supervision/Devices.Previously cited 7/25/13. 28 Pa. Code 211.12(c) Nursing services.Previously cited 7/25/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/14/14, 7/25/13.