Every finding on record at Zerbe Sisters Nursing Center,

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, sanitary environment for three out of four residents (Residents R1, R2, and R3). Findings include: Observation on August 5, 2026, at approximately 10:00 a.m., in the Hearth Room common area finds an air conditioning window unit containing spots of a black, organic appearing substance within the air vent and on the plastic fins.Observation on August 5, 2026, at 10:40 a.m., in the room of Resident R1, reveals an air conditioning window unit with a moderate amount of spots of a black, organic appearing substance within the air vent and on the plastic fins.Observation on August 5, 2026, at 10:45 a.m., in the room of Resident R2, reveals an air conditioning window unit with a moderate to large accumulation of black, organic appearing substance within the air vent and on the plastic fins. Observation on August 5, 2026, at 10:50 a.m., in the room of Resident R3, reveals an air conditioning window unit with a large amount of black, organic appearing substance within the air vent. The plastic fins of the air conditioning window unit are encrusted with a black, organic appearing substance, with a white and green fuzzy growth.Interview with the facility Maintenance Manager on August 5, 2026, at 10:59 a.m., reveals that air conditioning window units are used in resident rooms in the Mountain Vista and [NAME] View units, which are serviced once a month or every two months. Further interview with the Maintenance Manager reveals that there is no policy regarding care of air conditioning window units, and no log or record is kept for maintenance or care performed on the air conditioning window units. Further interview with facility Maintenance Manager on August 5, 2026, at 12:11 p.m., confirms might be mildew in the air vent of the air conditioning window unit in the Hearth Room. Further interview with facility Maintenance Manager on August 5, 2026, at 12:13 p.m., confirms buildup within the air vents of the air conditioning window unit of Resident R2. Further interview with facility Maintenance Manager on August 5, 2026, at 12:15 p.m., confirms large amount of black, white, and green growth within the air vents and on the plastic fins of the air conditioning window unit in Resident R3's room. stating, looks like that one got missed.Interview with facility Housekeeping Supervisor on August 5, 2026, at 12:27 p.m., reveals that every time housekeeping cleans a room, they are to clean the air conditioners and place a work order if they need help from maintenance. Further interview with the facility Housekeeping Supervisor in Resident R3's room, confirms that they should've put work order in for this, regarding the air conditioning window unit. Further interview confirms that there is no written policy or procedure in place regarding the care or cleaning of the air conditioning window units. Review of facility work orders provided by the Nursing Home Administrator on August 5, 2026, at 1:17 p.m., does not reveal a work order placed for air conditioning window units in the Hearth Room, or the rooms of Resident R1, R2, or R3. Interview with the Nursing Home Administrator on August 5, 2026, at 1:30 p.m., confirmed the above information.The facility failed to maintain a safe and sanitary environment for residents, in regard to the care and maintenance of window air conditioning units. 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, facility investigation review, and staff interview, it was determined the facility failed to ensure adequate supervision was provided during toileting transfer resulting in a fall of one of 20 residents reviewed (Resident 55). Findings include: A review of Resident 55's diagnosis list includes repeated falls, generalized weakness, abnormalities with gait and mobility, and Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 55's Quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents), dated December 11, 2024, revealed that the resident was cognitively intact. The same MDS revealed that the resident required extensive two-person assistance for both transferring and toileting. A review of Resident 55's care plan, developed on November 18, 2024, revealed an ADL (activities of daily living) care plan for self-performance deficit due to recent falls and left shoulder injury, impaired mobility, muscle weakness, and overall decline. Interventions/tasks included two (person) assists with rolling walker with transfers and two (person) assists with toileting-bathroom grab bars. A review of the nursing progress notes dated December 16, 2024, revealed that at 8:13 p.m., the nurse was notified by an NA (nurse aide) that Resident 55 was lowered to the floor during the transfer from the toilet to a wheelchair. The resident was observed sitting on her bottom with their back against the wheelchair. The resident stated, I just couldn't move. A review of the facility's investigation report revealed a statement from NA Employee E3, dated December 16, 2024, stating: She/he was transferring from the toilet and her knees started to buckle. I did my best to lower her slowly to the ground. A review of the facility's investigation report revealed a statement from NA Employee E4, dated December 18, 2024, stating I had [name of NA- Employee E3] for orientation, I told her/him to get [resident's name] ready to toilet and wait for me to transfer. She/he did not wait and lowered her to the floor. She did not use a gait belt (Also known as a transfer belt. A device put on a patient who has mobility issues, by a caregiver before that caregiver moving the patient) An interview conducted with the Director of Nursing on December 27, 2025, at 10:00 a.m., confirmed that Resident 55 required two-person assistance with toileting and transfers. The DON confirmed that the resident was provided with one person's assistance with transfers despite needing two as indicated in the resident's plan of care. The facility failed to ensure Resident 55 was provided with adequate supervision during toileting transfers resulting in a fall. 28 Pa Code 211.12 (c)(d)(1)(3) Nursing Service Previously cited 3/8/24

Based on review of facility policy, observations, and interviews, it was determined the facility failed to document medication disposition for two of three discharged residents. (Resident 7 and Resident 76) Findings include: Review of facility policy titled Discarding and Destroying Medications, documents disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by resident. Disposal must be documented on the medication disposition record, with the signature of at least two witnesses. The medication disposition record will contain the resident's name, date medication disposed, name and strength of medication, name of dispensing pharmacy, quantity disposed, reason for disposition and signature of witnesses. Review of resident 76's clinical records revealed physician orders that included Buspirone (for anxiety) 5mg, Gabapentin (for nerve pain) 900mg, and Zoloft (for depression) 12.5 mg. Review of Resident 76's clinical records revealed a discharge summary date [DATE], documenting the resident expired while hospitalized at Tower Heath Reading Hospital. Resident 76 was transferred to the hospital on [DATE], due to change of mental status and shortness of breath, she was admitted with Congestive Heart Failure exacerbation (impairment in the heart's ability to fill with and pump blood) on [DATE], the facility was notified that Resident 76 ceased to breath while hospitalized . Review of Resident 76's clinical records failed to reveal a medication disposition form. Review of Resident 7's clinical records revealed physician orders that include Duloxetine (for depression) HCI 60mg, Apixaban (for irregular heartbeat) 5mg, and Digoxin (for chronic heart failure) 125mcg. Review of Resident 7's clinical records revealed a discharge summary dated February 21, 2025, documenting the resident discharged to home on February 21, 2025. The discharge summary documents medication reconciliation of all pre-discharge medications with post discharge medications was completed. Review of Resident 7's clinical records revealed a medication list that did not include the quantity of each medication dispensed. Interview on February 27, 2025, at 1:30 p.m., with Director of Nursing (DON) when the above information was presented, The DON confirmed there was no medication disposition sheet for Resident 76, and Resident 7's medication disposition sheet did not document the quantity of medications disposed. 28 Pa. Code 211.9(j) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, facility documentation, clinical records and staff interviews, it was determined that the facility failed to protect residents from neglect for one of eighteen residents reviewed (Resident 47). Resulting in actual harm of skin tear and bruising to Resident 47. Findings include: The facility's policy Preventing Resident abuse revised April 2019, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Additional review of same policy defines neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident 47's clinical record indicated Resident 47 was admitted to the facility on [DATE]. Review of Resident 47's Minimum Data Set (MDS - periodic assessment of care needs) dated January 31, 2024, indicated Resident 26's diagnoses include but not limited to Alzheimer's disease (decline in memory, thinking, learning and organizing skills over time.), Peripheral Artery Disease (condition of narrowed arteries reducing blood flow to the arms or legs), Depression (persistent feeling of sadness and loss of interest), and Anxiety Further review of Resident 47's MDS dated [DATE] Section C; revealed a completed Brief Interview for Mental Status (BIMS -tool used to measure a person's cognition) with score of 3 (indicating severe impairment). Review of Resident 47's ADL (Activities of Daily Living) care plan dated December 27, 2023, revealed the following interventions for Resident 47: requires an assist for two for bed mobility (initiated on July 11, 2019), requires an assist of two for transfers (initiated on July 11, 2019), requires an assist of one for dressing (initiated July 11, 2019), and requires an assist of one with personal hygiene (initiated on July 11, 2019). Review of Resident 47's clinical record revealed Resident 47 was administered the following medications: Eliquis (blood thinner used to prevent blood clots), Remeron (used to treat depression), Ativan (used to treat anxiety). Review of information dated September 4, 2023 submitted by the facility submitted on September 4, 2023 revealed Resident 47 experienced neglect during afternoon care on September 4, 2023, at 11:30 a.m. from Certified Nursing Assistant (CNA) Employee E1. Further review of the information dated September 4, 2023 submitted on September 4, 2023 summarized; E1 entered Resident 47's room to get resident up and dressed, per E1 [he/she] told Resident 47 it was time to get ready for lunch, informing [resident] [he/she] was going to wash and dress [resident]. Resident 47 responded get the hell out of here. E1 went and gathered [his/her] supplies and reapproached the Resident 47, Resident 47 did not respond, so E1 initiated care, Resident 47 was calm until E1 began providing incontinence care when Resident 47 began to yell and tried to swing back and hit E1. E1 placed Resident 47 on [resident] back and calmly asked what is wrong, Resident 47 continued to yell Get the hell away from me. E1 waited a minute until Resident 47 calmed and explained once again, we have to get dressed. E1 then continued to wash Resident 47's bottom, Resident 47 pushed back and began to hit, at that time the E1 folded Resident 47's arms on her chest and tried to get a brief on her. E1 let [resident] arms go to roll Resident 47 back to the right side, as E1 did the Resident 47 started swinging [his/her] arms and trying to bite E1. When E1 sat Resident 47 on the side of the bed, E1 saw a skin tear. Resident 47 was calmed and assisted with transferring [resident] to the recliner with walker to chair, Resident 47 then began to yell get the hell out of here and E1 immediately reported skin tear. Review of Nurse Aide, Employee E2 witness statement dated September 4, 2023, indicated there was bruising on Resident 47's left arm and bruising and a skin tear on Resident 47's right arm. E2 also indicated, I went to check on Resident 47 at 2:15 p.m. and Resident 47 said she held both of my arms and there was nothing I could do. Review of Nurse Aide, Employee E1's witness statement revealed, Nurse Aide, Employee E1 folded Resident 47's arms against her chest which resulted in Resident 47 sustaining multiple bruises and skin tears. Review of facility investigative documentation including the PB-22 (form that is utilized to report instances of abuse, neglect, or exploitation of vulnerable adults) completed by the facility dated September 6, 2023, at 3:18 p.m. substantiated the information indicated above and concluded that Resident 47 experienced neglect from E1 resulting in bruising and skin tears to bilateral (right and left) lower arms. Additional review facility investigative document PB-22 revealed E1 was removed from the facility and placed on the do not return list, [Nursing Agency] employer notified via phone call of events and staff member status. Review of Resident 47's clinical record revealed a progress note by psychiatric-mental health nurse practitioner (PMHNP) dated September 5, 2023, at 7:00 p.m. indicating, contacted by SW (social worker). Resident 47 with recent increase in aggression. Hit and bit staff. Aggressive with care. DVT (Deep vein thrombosis, a blood clot forms in one or more of the deep veins in the body) currently being treated. Increased pain. Probable increase in anxiety r/t (related to) care. Recommend Ativan .25 mg (milligrams) q (every) 12 hours for anxiety x 14 days. Hold of sedation. Resident 47 was unavailable for an interview due to being admitted to the hospital on March 3, 2024. Interview conducted with the Nursing Home Administrator (NHA) on March 8, 2024, at 10:30 a.m. confirmed that the facility failed to protect residents from abuse for one of eighteen residents reviewed resulting in actual harm to the resident (Resident 47). 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies 28 Pa Code 211.12 (d)(3) Nursing services

Based upon review of facility policy and procedure, clinical records and documentation provided by the facility, it was determined that the facility failed to ensure residents were free from significant medication errors causing harm of hospitaization to one of eighteen residents reviewed (Resident 230). Findings include: Review of facility policy and procedure titled Medication Administration revealed The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical records and if necessary, verifying resident identification with other facility personnel. Additional review of the Medication Administration policy revealed The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review of the Medication Administration policy revealed the following information is checked/verified for each resident prior to administering medications: a) allergies to medications; and (b) vital signs if necessary. Review of Resident 230's diagnosis list revealed diagnoses including acute respiratory failure with hypoxia, Chronic Kidney Disease (failure of the kidneys to function properly), and Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 230's allergy list included allergies to Baclofen (muscle relaxant) and Gabapentin (anti-seizure and nerve pain medication). Review of Resident 230's clinical progress notes dated December 7, 2022, revealed [nurse practitioner] made aware of med error, patient was given another patient's medication. Gabapentin which causes patient to hallucinate and Baclofen which causes restless leg syndrome and insomnia in patient. New verbal order received and noted. RP [representative] needs to be made aware 12/8/2022. Neuro checks time 72 hours. Further review of Resident 230's clinical progress notes dated December 8, 2022, revealed This RN [Registered Nurse] and DON [Director Of Nursing] assessed [resident] this morning. [resident] was laying in her bed appeared to be sleeping, attempts made to arouse her via verbal and tactile stimuli. She was unresponsive, blood sugar 108, BP [blood pressure] 111/59, HR [heart rate] 68, pulse ox [oxygen saturation in blood] 94% with periods of apnea. [nurse practitioner] notified order to start oxygen at 2 liters and transport to ED [emergency department] for further evaluation. Review of hospital documentation dated December 8, 2022, revealed resident presented to the hospital with altered mental status after being administered Gabapentin 400 mg [milligram], Baclofen 20 mg and Melatonin 9 mg and found to be unresponsive this morning and had to be intubated for airway protection. Review of hospital history and physical documentation dated December 8, 2022, revealed given wrong medications at SNF [skilled nursing facility], became obtunded [reduced level of alertness or consciousness], intubated December 8, 2022, extubated December 9, 2022. Review of hospital admitting diagnosis dated December 8, 2022, revealed acute hypoxemic respiratory failure. Review of Resident 230's clinical record revealed that Resident 230 was readmitted to the facility on [DATE]. Review of facility documentation dated December 7, 2022, revealed [nurse] gave [resident] another resident's medication. [Resident] has allergy to baclofen and gabapentin. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2022, revealed that Resident 230 was administered another resident's medication on December 7, 2022, which resulted in Resident 230 becoming unresponsive and being transferred to an acute care facility. The facility failed to ensure residents were free from significant medication errors causing hospitalization , intubation and harm to Resident 230. 28 Pa. Code 211.12(c)(d)(1)(3) Nursing Services Previously cited 5/12/2022

Based on facility policy review, clinical record review, and staff interview it was determined the facility failed to provide care for a Foley catheter for one of one resdient reviewed. (Resident 67) Findings Include: Review of facility policy titled Catheter Care, Urinary, dated April 2021, revealed the following information should be documented in the residents clinical record: The date and time that catheter care was given. The name and titles of the individual giving the catheter care. All assessment date obtained when giving catheter care. Review of Resident 67's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 67's care plan revealed no interventions for the care of the Foley catheter. Review of Resident 67's entire clinical record revealed no documentation that catheter care had been completed since the insertion of the Foley catheter on April 28, 2022. Interview with the nursing assistant Employee E3 assigned to Resident 67 on May 12, 2022, at 9:45 a.m. revealed she was only responsible for emptying the collection bag of Resident 67's Foley catheter. Interview with the Licensed Nurse Employee E4 assigned to Resident 67 on May 12, 2022, at 9:50 a.m. revealed she was only responsible to make sure Resident 67's Foley catheter was in place and working. Interview with the Director of Nursing on May 12, 2022 at 11:15 a.m. confirmed there was no documented evidence Resident 67, received foley care since the insertion of the Foley catheter on April 28, 2022. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on observation, record review and documentation provided by the facility, it was determined that the facility failed to provide appropriate interventions to ensure resident safety, failed to put current interventions in place to ensure resident safety and failed to update interventions to ensure resident safety for one of five residents reviewed (Resident #17). Findings include: Clinical record review revealed Resident #17's diagnosis list revealed a diagnosis of Huntingdon's Disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [an abnormal involuntary movement disorder, one of a group of neurological disorders called dyskinesias, which are caused by overactivity of the neurotransmitter [MEDICATION(S)] in the areas of the brain that control movement. and progressive dementia.]). Observation of Resident #17 on all days of the survey revealed Resident #17 sitting in a Broda [type of reclining chair] chair in the common area of the nursing unit. Further observations on all days of the survey revealed staff members sitting in the nurses' station with the door closed and other staff members passing through the common area. Review of Resident #17's clinical progress notes dated March 26, 2021, at 10:09 p.m. revealed Called to common area to assess resident post fall. Found in common area lying on left side. Resident with severe chorea. Pillow placed beneath his head to prevent injury. Able to move all extremities. Denied pain. Slipper socks with good grip and all preventive limb guards in place. LPN charge nurse initiated neuro checks. PERRLA [pupils equal and reactive to light and accomodation, a neurological test]. Resident transferred back to chair with staff assist of four, then transferred to bed for assessment. Bruise measuring 5cm x 2cm noted to left hip with reddened area measuring 12cm x 10cm surrounding bruise. MD made aware. Review of documentation provided by the facility dated March 26, 2021, revealed the following employee statement Resident was sitting in chair while I was charting. Un-witnessed fall out of chair onto floor. I didn't see only heard. Further review of this documentation revealed interventions including staff education to place resident in the common area when in chair. Interview with Director of Nursing on April 15, 2021, at approximately 10:00 a.m. revealed that the intention of the above intervention was to keep resident in the common area in view of nursing staff to monitor resident for safety. Review of Resident #17's clinical progress notes dated April 12, 2021, revealed Resident was sitting in cube [reclining] chair in common area outside of nurses' station 1. A sound was heard from common area and staff had already responded to find resident on floor. Resident was lying on his left side to the front/left side of cube chair. All protective equipment in place. Wearing slipper socks with good grip. No environmental hazards noted. Resident denies pain. Able to move all extremities. Lower extremities equal in length. No apparent injury noted. Resident was transferred to cube chair with staff assist of 3. Neuro checks initiated. [physician] office notified. Review of documentation provided by the facility dated April 12, 2021, revealed the following employee statement I was in with another resident at the time of the fall. Further review of this documentation revealed another employee statement All I know is I was on B hall cart by room 30 turned my head to look at something and he was in midair and then hit the floor on his left hip. He smelled like he may have been incontinent of BM. Further review of this documentation revealed an intervention to place resident on a [MEDICATION(S)] two times per day to decrease loose stools. Review of Resident #17's care plan revealed an intervention to place resident in common area when in chair, in view of nursing staff. Interview with Director of Nursing on April 15, 2021, at approximately 10:00 a.m. confirmed that the facility failed to keep Resident #17 in view of nursing staff while in the common area and failed to ensure resident's safety. The facility failed to provide appropriate interventions to ensure resident safety, failed to put current interventions in place to ensure resident safety and failed to update interventions to ensure resident safety. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to follow physicians' orders for one of eight residents reviewed (Resident #44). Findings include: Review of Resident #44's clinical documentation revealed an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #44's Quarterly Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated October 23, 2020, revealed that the resident was always incontinent of bowel and required extensive assistance for toilet use. Review of Resident #44's clinical documentation failed to reveal a bowel movement documented from November 2, 2020, on evening shift until November 10, 2020, on evening shift. Further review of Resident #44's clinical documentation on November 9, 2020, revealed resident was on day seven with no bowel movement and physician was notified at that time. Interview with Director of Nursing on April 15, 2020, at 11:30 a.m. confirmed the facility failed to notify the physician until day seven with no bowel movement for one reviewed (Resident #44). 28 Pa Code: 211.5(f) Clinical records. 28 Pa Code: 211.12(d)(1) Nursing services.

Based upon observation, the facility failed to ensure the dignity of residents by allowing a physician to perform services in a common area with other residents and staff in attendance in one of two common areas observed (Mountain Vista). Findings include: Observation on April 15, 2021, at approximately 9:50 a.m. revealed Resident #5 sitting in a wheelchair against the wall in the Mountain Vista common area. Further observation revealed Resident #5 was having his toe nails clipped by the facility podiatrist while sitting in the wheelchair in the Mountain Vista common area. Further observation revealed four residents sitting in the same common area. Further observation also revealed multiple staff members walking through the common area while Resident #5 was being administered to by the facility podiatrist. The facility failed to ensure the dignity and privacy of a resident while sitting in a common area by allowing a physician to administer care to the resident. 28 Pa. Code 201.29(d) Resident Rights Previously cited 12/1/2020

Based on a review of facility policy, review of facility documentation, and staff interview it was determined that the facility failed to report an allegation of abuse to the appropriate State agencies for two of three residents reviewed (Resident R1 and R2). Findings include: Review of facility policy, Abuse Investigations, revised April, 2018, revealed that the Administrator or designee will submit an electronic report of the results of all abuse investigations to the state survey and certification agency, as required by current regulations. Review of Resident R1's concern form, undated, revealed resident reported that on March 31, 2020, the aide (Employee E3) grabbed her arm and threw her into bed and that the aide was rough with her. Review of facility documentation revealed that on June 30, 2020, Employee E4 reported hearing Employee E3 yelling at Resident R2. Employee E4 also reported witnessing Employee E3 grabbing Resident R2's hand and and placing it on the armrest forcefully. Interview with the Nursing Home Administrator on December 1, 2020, at 10:15 a.m. confirmed that these incidents had been investigated, but not reported to the state agency as allegations of abuse. Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 210.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to serve food under sanitary conditions on one of two dining rooms. (Meadow View dining room) Findings include: Review of facility policy, Food Preparation and Service, policy revised date (MONTH) 14, 2014, revealed that dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, policy revised (MONTH) 2008, revealed employees must wash their hands after handling soiled equipment or utensils. Observation on (MONTH) 22, (YEAR), at 10:50 a.m. during the tour in the kitchen off the Meadow View dining room revealed dietary staff, Employee E3 not wearing a beard guard. Further observation of the Meadow View dining room revealed dietary staff, Employee E4 cleaning dirty dishes at the sink and then going to unload the clean dishes off the clean rack. Employee E4 did not wash hands or change gloves between handling soiled and clean dishes. Observation on (MONTH) 22, (YEAR), at 12:15 p.m. on the Meadow View dining room dietary staff, Employee E3 was observed serving food. Employee E3 was not wearing a beard guard. Observation on (MONTH) 25, (YEAR), at 9:55 a.m. during the tour in the kitchen off the Meadow View dining room revealed dietary staff, Employee E3 not wearing a beard guard. Interview with the dietary staff, Employee E3 on (MONTH) 25, (YEAR) at 10:10 a.m. indicated that beard guards should be worn for facial hair. The Food Service Director also revealed that employees should wash their hands after handling soiled utensils. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.6(f) Dietary Services

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide necessary services to maintain personal hygiene for residents unable to carry out activities of daily living for two of two residents reviewed (Resident #14 and #36). Findings include: Review of Resident 14's clinical record revealed a [DIAGNOSES REDACTED]. Further review revealed a Minimum Data Set (MDS- periodic assessment of resident care needs) completed on (MONTH) 2, (YEAR), revealed Resident 14 was an extensive assist of two for personal hygiene. Observation on (MONTH) 23, (YEAR) at approximately 11:20 a.m. revealed the resident seated in the common area with fingernails that were visibly soiled. Further observation on (MONTH) 25, (YEAR) at approximately 10:55 a.m. revealed the resident in the common areas with fingernails that were visibly soiled. Review of documentation for nursing assistants and the personal hygiene tasks for Resident 14, revealed that the resident was given a bed bath on (MONTH) 20, (YEAR) and nail care was not completed at this time. There was no further documentation that the resident had refused this task. Review of Resident 36's significant change MDS assessment, dated (MONTH) 17, (YEAR) revealed that the resident had [DIAGNOSES REDACTED]. Observation on (MONTH) 22, (YEAR) at approximately 1:45 p.m. revealed the Resident 36 seated in the common area with fingernails which were long and unclean. Observation on (MONTH) 24, (YEAR) at approximately 10:16 a.m. revealed the resident in his bed with one hand out of the bedding, hand curled so that only the thumb could be seen and that thumbnail was long and unclean. Observation on (MONTH) 25, (YEAR) at approximately 11:23 a.m. revealed the resident with fingernails which were long and unclean. Review of Resident 36's active care plans for both skin integrity and activities of daily living revealed interventions for trimming the resident's nails and cleanliness of nails on shower days. Review of documentation for nursing assistants and the personal hygiene tasks revealed that the resident was showered on (MONTH) 23, (YEAR) but that fingernail care was not provided on (MONTH) 23, (YEAR) with no documentation that the resident had refused this task. Interview with the director of nursing on (MONTH) 25, (YEAR) at approximately 11:25 a.m. confirmed that Resident 14 and Resident 36 fingernails should have been clipped and cleaned on each shower/bath day. 28 PA Code 211.5(f) Clinical records Previously cited 2/1/2018; 11/1/2017; 4/26/2017 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 2/1/2018; 11/1/2017; 4/26/2017

Based on clinical record review and staff interview, it was determined that the facility failed to accurately identify target behaviors for monitoring the use of antipsychotic medication for one of five residents reviewed (Resident #53). Findings include: Review of Resident 53's quarterly assessment, dated (MONTH) 29, (YEAR), revealed [DIAGNOSES REDACTED]. anxiety (a condition characterized by feelings of tension, worried thoughts and physical changes) and [MEDICAL CONDITION] (severe mental disorder that causes abnormal thinking and perceptions). Review of the resident's Behavior Monthly Flow Sheets for May, (MONTH) and (MONTH) (YEAR) revealed that behaviors were being monitored for [MEDICATION NAME] 0.25 milligrams (antipsychotic medication) and [MEDICATION NAME] 0.5 milligrams (antipsychotic medication). The behaviors listed as being monitored were anxiety, restlessness and wandering, none of which were appropriate for a resident with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing on (MONTH) 25, (YEAR) at approximately 11:35 a.m. confirmed that the facility was not monitoring for appropriate targeted behaviors for the administration of an antipsychotic medication for a resident diagnosed with [REDACTED]. 28 PA Code 211.5(f) Clinical records Previously cited 2/1/2018; 11/1/2017; 4/26/2017 28 PA Code 211.12(d)(3)(5) Nursing services Previously cited 2/1/2018; 11/1/2017; 4/26/2017

Based on observation and review of manufacturer's guidelines, it was determined that the facility failed to ensure that medications were labeled in accordance with currently accepted professional principles for two of three medication carts observed. (Mansion View East Medication Cart and Mountain Vista North Medication Cart). Findings include: Review of manufacturer's guidelines for [MEDICATION NAME] Insulin (medication used to treat high blood sugar levels) revealed that [MEDICATION NAME] Insulin should be stored in the refrigerator until opened. Further review of manufacturer's guidelines revealed that [MEDICATION NAME] Insulin should be discarded 28 days after opening or removal from the refrigerator. Review of manufacturer's guidelines for Latanoprost eye drops (medication used to treat [MEDICAL CONDITION]) revealed that Latanoprost eye drops must be discarded 6 weeks (42 days) after opening. Observation on (MONTH) 22, (YEAR) at approximately 11:10 a.m. of the Mansion View East Medication Cart revealed one open vial of [MEDICATION NAME] Insulin with an open date of (MONTH) 13, (YEAR) and an expiration date of (MONTH) 11, (YEAR). Further observation of the Mansion View East Medication Cart revealed one open and undated bottle of Latanoprost eye drops with a pharmacy label stating, bottle expires 42 days after opening. Observation on (MONTH) 22, (YEAR) at approximately 11:15 a.m. of the Mountain Vista North Medication Cart revealed one unopened and undated vial of [MEDICATION NAME] Insulin. Interview with the Director of Nursing on (MONTH) 25. (YEAR) at approximately 10:30 a.m. confirmed that the above-mentioned medications should have been labeled with open dates and/or discarded upon expiration. 28 Pa. Code 211.9(a)(1) Pharmacy Services Previously cited 4/26/17 28 Pa. Code 211.10(a) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 4/26/17, 11/1/17, 2/1/18

Based on clinical record reviews and staff interviews, it was determined that the facility failed to schedule a recommended specialist appointment for a rash of unknown origin in a timely manner for one of three residents reviewed (Resident CL1). Findings include: Review of Resident CL1 (MONTH) (YEAR) physcian's orders revealed that an order was obtained on (MONTH) 4, (YEAR) for [MEDICATION NAME] (cream used for the treatment of [REDACTED]. Further review of Resident CL1's nursing notes revealed that a rash was found on the resident on (MONTH) 5, (YEAR) on the left side of the back and an order for [REDACTED]. The TMC ointment continued to be used. Further investigation showed on (MONTH) 6, (YEAR), it is noted to have a mild redness to the back and abdomen and a treatment for [REDACTED]. On the week of (MONTH) 27, (YEAR), the rash was reported to be over the entire body and was thought to be plaque psoriasis. An order was obtained for the anti [MEDICAL CONDITION] medication [MEDICATION NAME] 40 milligrams (mg) or 5 days and 10 mg for 7 days was ordered (51 days since the reappearance of the rash). Clinical record review revealed that Resident CL1 was seen on (MONTH) 1, (YEAR), by the Nurse Practitioner from the wound clinic and recommended the facility to consult the dermatologist. Further review of the clinical record revealed that the physician was notified in a MD/Communication form by the unit nurse, Employee E2. The form dated (MONTH) 1, (YEAR) stated Wound Healing Solution CRNP (Certified Registered Nurse Practitioner) visit suggests consult Dermatology. Physician response dated (MONTH) 1, (YEAR), continue with LAC-hydrin (a cream indicated for the treatment of [REDACTED]. Review of the entire clinical record revealed no documented evidence that an appointment was scheduled at this time. Review of the clinical record revealed a nursing note dated (MONTH) 11, (YEAR) (10 days after the recommendation 65 days after initial treatment for [REDACTED]. An interview was conducted on (MONTH) 1, (YEAR) at approximately 3:06 p.m. revealed that the dermatology appointment was not scheduled until (MONTH) 11, (YEAR). Registered Nurse Employee E2 agreed that the order should have been clarified and 65 days was a long time to have a rash that would not go away. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/26/17, 11/1/2017 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/1/2017 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 4/26/17, 11/1/2017

Based on clinical record review, it was determined that the facility failed to properly administer pain medication in accordance with physician's orders for one of two residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident R1's physician's orders revealed an order dated October 10, 2017 for [MEDICATION NAME] (narcotic pain medication) 5 milligrams (mg) 1 tablet by mouth every 4 hours as needed for severe pain (7-10 on a scale of 1-10); [MEDICATION NAME] (narcotic-like pain medication) 50 mg 1 tablet by mouth every 6 hours as needed for moderate pain (4-6 on a scale of 1-10) and Tylenol 325 mg 2 tablets by mouth every 6 hours as needed for mild to moderate pain. Review of Resident R1's October 2017 Medication Administration Record [REDACTED]. Resident R1 also received [MEDICATION NAME] on October 17, 2017 with no pain scale documented. Further review of Ocotber 2017 MAR indicated [REDACTED]. The resident received Tylenol nine times from October 12, 2017 to October 23, 2017 for pain rated anywhere from 8-10. The physcian's orders indicated that a pain of 7-10 was identified as a severe pain and [MEDICATION NAME] ordered to manage the resident's pain. Review of Resident R1's physician's orders revealed an order dated October 17, 2017 for [MEDICATION NAME] (narcotic pain medication) 5 mg by mouth every 4 hours as needed for pain. Review of Resident R1's clinical record failed to reveal any physician clarification as to what level of pain the [MEDICATION NAME] should have been given for. Review of Resident R1's October 2017 MAR indicated [REDACTED]. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/26/17 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing servicesPreviously cited 4/26/17

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to properly store and safeguard medications and failed to ensure that effective safeguards for the disposal of controlled medications were implemented to prevent inadvertent administration or diversion on two of two nursing units (Station I and Station II/III). Findings include: Review of facility policy titled, Discontinued Medications Disposition and Documentation, revision date December 2012, indicated that medications discontinued by physician order, resident's death, or discharge to hospital are returned to pharmacy for destruction or storage. Narcotics and controlled substances are handled per the respective policies. Procedure step 1 indicated that medications awaiting disposal or return are stored in a locked, secure area designated for that purpose until disposed of or picked up by pharmacy. Procedure step 2 indicated that discontinued medications are counted or the the volume of liquid estimated, and the quantity destroyed or returned is entered into the electronic Medication Administration Record [REDACTED] Review of facility policy titled, Discarding and Destroying Medications, dated March 2017, indicated that all narcotic medication wasted will be placed in a disposable cup and mixed with hand sanitizer. Place the cup and the contents in a hazardous waste bag. Place this bag in a hazardous waste freezer located in the soiled utility room at Station I. Review of facility policy titled, Controlled Substances, dated July 23, 2013, indicated that the facility shall comply with all laws, regulations and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. Implementation step 1 indicated that only authorized licensed nursing and/or pharmacy personal shall have access to controlled drugs maintained on premises. Step 6 indicated that the medication nurse on duty would maintain keys to controlled substance containers. The Director of Nursing services would maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Observation of nursing Station I soiled utility room, accompanied by licensed nurse, Employee E7, on April 23, 2017 at 9:40 a.m. revealed the storage location for the facility's secured biohazard freezer. Further observation revealed that the key used to access this secured freezer was being stored on the wall. Licensed nurse, Employee E7 confirmed that all facility staff have access to the soiled utility room. Licensed nurse, Employee E7 further confirmed that the biohazard freezer was utilized by both licensed and direct care nursing staff for disposal of controlled medications and any biohazard materials (biohazardous waste, also called infectious waste, any waste containing infectious materials or potentially infectious substances such as blood. Of special concern are sharp wastes such as needles and other wastes that can cause injury during handling). Observation of the contents of the biohazard freezer, accompanied by licensed nurse, Employee E7, on April 23, 2017 at 9:45 a.m. confirmed the presence of three small biohazard bags which contained controlled medications that were previously disposed, as confirmed by licensed nurse, Employee E7; and three large biohazard bags which were identified by licesed nurse, Employee E7 as containing biohazard waste materials. Observation of Station I nursing office, accompanied by Employee E10, on April 25, 2017 at 1:40 p.m. confirmed the medication refrigerator was being stored in this nursing office. The medication refrigerator was equipped with a pad lock key entry. Employee E10 confirmed that a back-up key for the medication refrigerator was being stored in an unsecured drawer in nursing office of Station I and could not ensure that the nursing office was always secured or supervised by medication nurse on duty. Further observation of the Station I nursing office, accompanied by Employee E10, on April 25, 2017 at 1:45 p.m. confirmed that an unsecured, plastic red bin being stored on the floor, was the designated container utilized for the storage and safeguarding of any medications or treatments that were to be returned to pharmacy. Observation of the contents of the storage bin revealed an 8 ounce bottle of Glycol powder (a laxative medications to treat constipation). Subsequent observation of Station II/III nursing office, accompanied by licensed nurse, Employee E9, on April 25, 2017 at 2:00 p.m. confirmed that the designator plastic, red bin utilized for the storage of those medications or treatments that were to be returned to pharmacy was not secured to prevent inadvertent administration or diversion. Observation of the contents of the bin, confirmed by licensed nurse, Employee E9, revealed one pill identified as Tylenol/codeine number 4 (combination of acetaminophen and a narcotic pain medicine used to relieve mild to moderate pain) and 26 tabs of Lactaid (enzyme that aides with digestion of milk sugar). Further observation of Station II/III electrical closet revealed the storage of an unsecured, medication refrigerator. Licensed nurse, Employee E9 confirmed that maintenance and pharmacy staff had access to this electrical closet; and that the medication refrigerator contents was not secured and would be accessible by anyone who gained access to the electrical closet. Interview with Administrator and Director of Nursing, on April 26, 2017 at approximately 1:00 p.m. confirmed that facility failed to ensure effective safeguards for the storage and disposal of regular and controlled medications to prevent inadvertent administration or diversion. 483.60(b)(d)(e) Drug Records, Label/Store Drugs and Biologicals 28 Pa. Code: 211.9(a)(1) Pharmacy services Previously cited 3/23/2016 28 Pa. Code: 211.10(d) Resident care policies Previously cited 3/23/2016 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 3/23/2016

Based on clinical record review, observation and interview with staff, it was determined that the facility failed to follow physician's orders during an observation of the medication pass in the administration of an insulin medication and the proper consistency of a dietary supplement for two of five residents observed (Residents B9 and G2). Findings include: Review of Resident B9's current physician's orders revealed an order for [REDACTED]. Further review of physician's orders, revealed an order for [REDACTED]. Observation of Resident B9's medication administration on April 24, 2017 at 8:45 a.m. revealed that a licensed nurse Employee E9, administered medication crushed in applesauce to the resident and provided a thin liquid Health Shake which she drank through a straw. Interview with licensed nurse Employee E9 on April 24, 2017 at 11:00 a.m. confirmed that she felt the Health Shake was thick enough. However, stated the facility does provided pre-packaged honey thick liquid Health Shakes. Interview with the Director of Nursing on April 24, 2017 at 11:20 a.m. confirmed that the facility does not provide pre-thickened, ready to serve liquid Health Shakes of a honey thick consistency. The Director of Nursing confirmed that licensed nurse, Employee E9 should have mixed the health shake with thickener to a honey thick consistency before administering to Resident B9. Review of Resident G2's [DIAGNOSES REDACTED]. cells), Hypertension (elevated/high blood pressure), [DIAGNOSES REDACTED] (deficiency of potassium in the bloodstream), [MEDICAL CONDITION] ([MEDICAL CONDITION] - Stroke; brain hemorrhage), Depression (Major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine) and Anxiety (a feeling of worry, nervousness or unease). Review of Resident G2's physician's orders dated April 10, 2017 revealed an order for [REDACTED]. Hold for blood sugar less than 120. Observation of Resident G2's medication administration on April 24, 2017 at 8:58 a.m. revealed that the licensed nurse Employee E9 administered the injection of [MEDICATION NAME] 10 units after Resident G2 had eaten her breakfast an d not with a meal as ordered by the physician. Interview with licensed nurse Employee E9 on April 24, 2017 at 11:00 a.m. confirmed that the [MEDICATION NAME] injection was administered to the resident after Resident G2 came back from eating her breakfast in the main dining room. The facility failed to ensure that licensed staff follow physician's orders in the administration of an insulin medication for Resident G2 and in providing a dietary supplement at the fluid consistency order by the physician for Resident B9. F309 483.25 Quality of Care Previously cited 3/23/16 28 Pa. Code 211.5 (f) Clinical records Previously cited 3/23/16 28 Pa. Code 211.12 (d)(3)(5) Nursing services Previously cited 3/23/16

Based on observations, it was determined that the facility failed to assure visual privacy and promote dignity for one out of 17 residents reviewed (Resident D6). Findings include: Review of Resident D6's current [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weaknesses and unsteady gait). Review of Resident D6's April 2017 physician's orders [REDACTED]. Resident D6's was observed lying in bed with her foley catheter bag attached to the bed frame, that could be seen from the hallway on April 23, 2017 at approximately 9:15 a.m. On April 24, 2017 at 1:45 p.m. Resident D6's again was observed lying in bed with her foley catheter bag attached to the bed frame, that could be seen from the hallway. Resident D6's was observed lying in bed with her foley catheter bag attached to the bed frame and could be seen from the hallway on April 25, 2017 at 9:17 a.m., 10:55 a.m. and then again at 1:50 p.m. Further observation made on April 26, 2016 at 9:45 a.m. revealed Resident D6 lying in bed with her foley catheter bag attached to the bed frame, that could be seen from the hallway. The facility failed to ensure that Resident D6 was provided a privacy bag for her foley catheter bag to safeguard the resident's visual privacy. 28 Pa. code 201.9 (j) Resident rights

Based on a review of facility policy, personnel records, and staff interviews, it was determined that the facility failed to implement their abuse policy by completing a criminal background check upon hire for two of five employees reviewed (Employees E11 and E12). Findings include: Review of the facility policy titled, Abuse Prevention Program, reviewed date August 2006, facility documented that a criminal background would be done and the facility would not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Review of Employee E11's personnel record revealed a hiring date of March 20, 2017 and no evidence of that the state police criminal background check was completed for Employee E11. Review of Employee E12's personnel record revealed a hiring date of January 9, 2017 and no evidence that a state police criminal background check was completed for Employeee E12. On April 26, 2017 at approximately 10:00 a.m., this information was presented to the Director of Nursing and Nursing Administrator. The Administrator and Director of Nursing both confirmed that facility failed to completed a state police criminal background checks upon hire for both Employees E11 and E12. The facility failed to implement their abuse prevention policy by not completing state police criminal background checks upon hire for Employees E11 and E12. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies

Based on review of clinical records and interviews with residents and facility staff, it was determined that the facility failed to identify, assess, provide treatment and implement preventative measures for new pressure ulcers for three of 15 residents reviewed (Resident G1, G4, and CL1, resulting in actual harm to G1. Findings include: Review of Resident G4 ' s clinical record revealed that the resident had the following (but not limited to) Diagnosis: [REDACTED]. Review of Resident G4 ' s Annual Minimum Data Set (MDS) dated [DATE], the resident required extensive assist of two for bathing (meaning the resident need a lot of help by two individuals for bathing and hygiene. Review of Resident G4 ' s clinical record revealed a nursing note dated February 9, 2016, that an open area (no stage documented or idientified) was found by a nursing assistant on the resident ' s buttocks measuring 1 cm x 1 cm. On the same nursing note it was also stated that the resident had an open area to his scrotum. A nursing note on February 12, 2016 noted the Registered Nurse looked at the wound on the resident ' s bottom and labeled it incontinence [MEDICAL CONDITION]. Further review of Resident G4 ' s clinical record revealed a nursing note on February 25, 2016 that the resident ' s laboratory study came back indicating a low [MEDICATION NAME] and Protein level and requested a diet review noting that the dietician was notified. On February 26, 2016 the Nurse Practitioner requested dietary to review protein preferences with the resident. Review of the dietician notes revealed that the dietician note was not completed until noted on March 7, 2016, eleven days after the initial results of the blood work. Further review of Resident G4 ' s clinical record revealed a nursing note dated March 8, 2016, that the Resident continues with incontinence [MEDICAL CONDITION] to the right buttocks which appears to be worsening. Area is not 2 cm x 1 cm, noted bleeding around edges and an area which appears to be black in color. Surrounding surface area is blanchable with no noted redness. Resident is currently getting [MEDICATION NAME] Cream to buttocks BID (twice a day). Further review of Resident G4 ' s clinical record revealed a physician's order [REDACTED]. There is no documentation indicating the resident ' s open area on his scrotum was being addressed. Further review of Resident G4 ' s clinical record revealed that on March 21, 2016 the care plan states that there is a stage 2 pressure ulcer on the right buttocks. An interview was conducted with the Director of Nursing on March 22, 2016 at approximately 9:55 a.m., which revealed that the stage of the pressure ulcer pressure area was not conveyed correctly to the Nurse Practitioner or the physician therefore it was treated incorrectly since the first nursing note dated February 9, 2016. Further interview revealed that the Dietician did not respond quickly to the request for a dietary review in a timely matter, and may have led to the deterioration of the wound. The facility failed to identified, stage and accurately assessed Resident G4's pressure ulcer to the resident's right buttock which resulted in actual harm to Resident G4 with a deterioration of the right buttocks presssure ulcer. Review of Resident G1's [DIAGNOSES REDACTED]. Review of Resident G1's nurisng notes revealed that on January 31, 2016 the resident had right ankle fusion surgery and returned to the facility with a cast in place on the right leg which extended from below the right knee to the base of the toes on the right foot. Further review Resident G1's progress notes revealed that on March 11, 2016 the resident's surgeon removed the cast from the right leg. Further review of Resident G1's progress notes revealed that on March 17, 2016 the resident removed an ace wrap from the right leg that had been in place since the cast was removed on March 11, 2016. After removal of the ace wrap by the resident, a 1.5 cm x 2.0 cm open area with no stage documented or identified was noted on the dorsal (top) surface at the base of the right great toe. Review of Resident G1's clinical record failed to reveal that any skin observations of the right foot/toe area were completed during the time the cast was in place from January 31, 2016 through and including March 17, 2016. Review of Resident G1's clinical record revealed that skin prep was applied to the open area on March 17, 2016 and the physician was notified of the open area. A physician's orders [REDACTED]. Further review of Resident G1's clinical record revealed a letter, dated March 11, 2016, from the resident's surgeon, which identified the open area at the base of the resident's right great toe and that the surgeon applied Xeroform gauze to the wound. An interview with the Director of Nursing, Nursing Home Administrator and Licensed Employee E7 on March 23, 2016 at approximately 9:30 a.m. confirmed that Resident G1 had no skin assessments completed for the cast area from January 31, 2016 through and including March 17, 2016. This interview also confirmed that no skin assessment was completed when the resident returned to the facility after the cast was removed; that there was no awareness of the Xeroform gauze dressing that was applied by the surgeon; that the ace wrap was not removed until one week after the cast was removed and that the skin prep treatment was applied to the open area prior to the order being received by the physician. Review of residents CL1 ' s clinical record it was revealed that an admitted [DATE] from another facility, with the following (but not limited) Diagnoses: [REDACTED]. Upon arrival at the facility the facility found no skin issues. Further review of the transfer records from the previous facility for the month of January 2016, the resident was receiving a Remedy Nutrishield (a protective barrier used to protect the skin for breakdown) to the sacrum every shift and as needed three times per day. The admission orders [REDACTED]. Further review of the clinical record revealed a nursing note dated February 5, 2016 the resident has an opening on his lower back. A nursing note was added to the initial assessment on February 5, 2016 stating that an open stage 2 pressure related area on the resident lower middle back by the boney prominence measuring .1 cm x .2 cm was noted. Physician notified and signed order on February 7, 2016. Interview with Licensed Employee E10 occurred on March 23, 2017 at approximately 12:26 p.m. verified that the orders were not transferred on the date of admission for the Remedy Nutrishield (a protective barrier) which may have prevented the open area discovered on February 5, 2015. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited: 04/10/2015 28 Pa. Code 211.5(f) Clinical records. Previously cited: 12/3/15, 6/15/15, 4/10/2015 28 PA Code: 211.10(d) Resident care policies Previously cited 4/10/15, 6/15/15, 7/13/15 28 Pa. Code: 211.12 (c) and (d)(1)(5) Nursing services. Previously cited: 12/3/15, 6/15/15, 4/28/15, 4/10/2015

Based on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to monitor that sufficient fluid intake was maintained to ensure proper hydration for one of three residents reviewed, resulting in actual harm (Resident R1). Findings include: Review of facility policy Hydration - Clinical Protocol, revised April 2013 indicated that as part of the initial assessment, the physician and staff will help define the individual's current hydration status. The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte balance; for example, those who are not eating or drinking well. Review of Resident R1's admission comprehensive minimum data set (MDS - assessment of resident care needs and status) dated May 12, 2015, included [DIAGNOSES REDACTED]. The resident was also identified as having severe cognitive impairments and requiring supervision with one person physical assistance for eating and drinking. The care area assessment summary identified dehydration/fluid maintenance as an area of concern and indicated that the area would be addressed in the care plan. Review of the care plan revealed no care plan addressing dehydration/fluid maintenance. Review of Resident R1's nutritional risk assessment dated [DATE], estimated fluid needs of 2400 milliliter (mL) per day. The assessment noted a fair appetite with 42-56% meal completion and fluid intakes ranging from [PHONE NUMBER] mL daily. Review of nurse aide documentation revealed average meal fluid intake for May 9- 15, 2015 of 763 ml, May 16-22, 2015 of 566 ml, and May 23 - 29, 2015, of 247 ml. Review of meal intakes for May 23- 29, 2015, revealed that of 18 meals recorded, Resident R1 refused meals five times and ate 0-25% on nine occasions. Review of progress note of May 28, 2015, revealed that crisis intervention was contacted due to resident physically abusing a staff member. Nurses note dated May 28, 2015 at 4:47 p.m. revealed 911 was called for transport to the hospital for observation. Progress note of May 28, 2015, revealed that the resident's son was informed that the resident's fluid intake had been poor over the past week. Resident returned from the hospital on May 29, 2015 at 2:36 a.m. Progress note of May 29, 2015, revealed resident was an extensive assist of one when feeding breakfast, noted to be chewing, pocketing food inside upper right denture. After five minutes of chewing resident was able to swallow, but noted facial grimacing when swallowing. Resident then closed his mouth and would not eat. Certified registered nurse practitioner (CRNP) note of May 29, 2015, indicated resident choking with fluids and pocketing, suspected possible aspiration pneumonia. Note also indicated possible urinary tract infection versus dehydration. Progress note of May 29, 2015, revealed 911 called and resident to be sent to the hospital for evaluation and treatment. Review of emergency room note of May 29, 2015, revealed that facility staff reported that Resident R1 had been more somnolent (sleepy) and less responsive the past few days. The patient has decreased oral intake. Staff states that the patient has been pocketing his food, after which he occasionally chokes. Staff stated that the patient has had generalized weakness and probably has dehydration. The patient was seen in the emergency room yesterday and lab evaluation revealed sodium 148 millimole/Liter (mmol/L) (normal range 136-145 mmol/L) and blood urea nitrogen (BUN) of 60 milligrams/deciliter (normal 7-26 milligrams/deciliter). Review of hospital history and physical of May 29, 2015, revealed patient appeared dehydrated due to poor appetite. Resident did try punching some emergency room staff, but also appeared to be very weak and dehydrated with poor skin turgor. Lab value revealed sodium of 149 mmol/L, BUN of 60 milligrams/deciliter, and creatinine of 1.22 milligrams/deciliter (normal 0.70-1.30 milligrams/deciliter). Impressions indicated dehydration. Hospital transfer form dated June 5, 2015, indicated a discharge [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on June 15, 2015, at 2:30 p.m. revealed that aides only record fluids that are consumed with meals. Licensed staff and activities staff do not record fluids provided. It was also confirmed that no care plan was developed to address dehydration/fluid maintenance. The DON also confirmed that staff, including speech therapy and the dietitian were aware of the resident's decrease in intakes, but there were no documented assessments of the resident's hydration status. There was no evidence that the resident's fluid intake had been monitored or that interventions had been implemented to prevent dehydration when the resident was determined to be at risk. The resident was hospitalized for [REDACTED]. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited 4/10/15 28 Pa. Code: 211.10(c) Resident care policies Previously cited 4/10/15 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 4/10/15

Based clinical record review and staff and resident interview, it was determined that the facility failed to provide needed care, timely assessment and/or failed to timely notify the physician ; failed to follow policies for neurochecks, and /or failed to follow physician orders for five of 17 residents reviewed. The failure to timely assess and monitor a resident ' s pain after a fall resulted in actual harm to one resident (Resident F8). (Residents: F8, H8, C3, E2 and C8). Findings include: A review of the facility policy for falls it is stated to assess the resident for pain as needed and to conduct neurological checks as per their policy. Resident F8 ' s nurses notes dated March 22, 2015 at 6:35 p.m. stated that CNA helped resident to bathroom using her walker and left to get a wheelchair because CNA felt resident tired. Resident got up and started walking without her walker and fell on left side. Resident was able to move extremities. Denied pain. Message left for family. Nurses ' note dated March 22, 2015 at 8:53 p.m. stated resident crying and yelling out in pain when attempts made to transfer into bed. Pain not relieved by repositioning or relaxation techniques. [MEDICATION NAME] sul sol 20 mg/ml 0.25 ml orally was given orally for pain at this time. The order stated [MEDICATION NAME] sul sol 20 mg/ml. Give 0.25 ml orally every 4 hours as needed for pain/shortness of breath. The Medication Administration Record [REDACTED]. PRN administration was effective. This was approximately 1 ½ hours after the initial dose. There was no documentation in Resident F8 ' s nurses ' notes that the physician was contacted to report the onset of pain March 22, 2015 at 8:53 p.m. or the second administration of [MEDICATION NAME] before the prescribed 4 hour interval on March 22, 2015 to Resident F8. There was no indication that the family was informed of Resident F8 ' s pain when they returned the call March 23, 2015 at 10:35 a.m. There was no indication that Resident F8 was fully assessed after the fall March 22, 2015 and after she cried out and yelled in pain when attempts to transfer to bed at 8:53 p.m. Nurses ' note dated March 25, 2015 at 0:35 a.m. stated resident given [MEDICATION NAME] sul sol 20 mg/ml 0.25 ml given for signs of pain with care to left hip. Nurses ' note March 25, 2015 at 0:48 a.m. state resident has extreme pain during repositioning in her left hip. No redness or leg shortening observed. Resident F8's nurses ' note dated March 25, 2015 at 9:14 a.m. stated resident left leg/hip examined. Presents with limited ROM and verbalizing severe pain to left hip and thigh. X-ray ordered and PRN [MEDICATION NAME] for pain. RNC (certified RN Practioner ' s) note dated March 25, 2015 at 9:31 a.m. stated resident seen today for increasing pain in left hip/leg and pelvis. Nurses ' note dated March 25, 2015 at 2:24 p.m. states x-ray results received. There is a minimally displaced left femoral neck fracture. 911 called for transport to ER. Nurses ' note at 2:40 p.m. stated transported to ER. Resident F8 was not timely assessed for injury or pain and the physician was not notified timely of the change in resident status. The fall resulted in actual harm and pain to Resident F8. Interview with DON on April 8, 2015 at approximately 3:15 p.m. revealed that Resident F8 ' s first dose of [MEDICATION NAME] Sul Sol 20mg/ml .25ml indicated a reassessment of injury that was not conducted. The DON also stated that the second dose of [MEDICATION NAME] Sul Sol 20mg/ml .25ml was given and was considered a medication error and this in itself indicated a call to the physician that was not done, and at this time the physician and family should have been alerted to Resident F8 ' s increase in pain exhibited by the resident and an additional assessment should have been performed. The facility failed to follow their policy for falls and reassessment for injury, the facility failed to inform the physician of a medication administration and error, and failed to alert the physician and family of increased pain, which resulted to actual harm to Resident F8 who sustained injuries requiring hospitalization and surgery. Review of facility's policy title Glucose Monitoring- Management of [DIAGNOSES REDACTED] revealed that for asymptomatic and responsive residents with [DIAGNOSES REDACTED] (<70 mg/dl or less that the physician ordered parameters) give the resident an oral form of rapidly absorbed glucose (4 ounces juice or 5-6 ounces of soda) and recheck blood glucose in 15 minutes. For a symptomatic (lethargic, drowsy) but responsive (conscious) resident with [DIAGNOSES REDACTED] if the resident was able to swallow, immediately give the resident an oral form of rapidly absorbed glucose and recheck blood glucose in 15 minutes. Review of Resident H8's March 2015 physician's orders revealed the [DIAGNOSES REDACTED]. Review of the (Minimum Date Set (MDS-periodic assessment of care needs and status) dated January 2, 2015 identified the resident with no cognitive impairments. The resident had a physician's order for accuchecks (blood sugar test) four times daily for [DIAGNOSES REDACTED]. The resident was ordered to be administered [MEDICATION NAME] 100 units/ml 10 units to be injected subcutaneously every morning and at bedtime, [MEDICATION NAME] solution 100 units/ml 15 units to injected subcutaneously two times a day at 8:00 a.m. and 4:00 p.m. and [MEDICATION NAME] emergency injection kit 1 milliliter to inject 1 milliliter intramuscularly as needed if accuchecks less than 60 for sign and symptoms of [DIAGNOSES REDACTED] and unable to take glucose by mouth. Review of Resident H8 ' s nursing notes dated March 19, 2015 indicated that at 10:30 a.m. the resident stated that she was not feeling well and that her blood sugar was low in the morning. The resident stated that her vision did not seem right. The resident was given 240 milliliter of the nutritional supplement Healthshake and milk along with 120 cc of orange juice. It was documented that the resident blood sugar level was re-check approximately one hour after and had risen to 61. The facility failed to re check the resident blood sugar level 15 minutes after administration of a rapidly absorbed glucose as indicated in the facility's policy. Further review of Resident H8 ' s nurses ' note on March 20, 2015 at 5:57 a.m. it was noted that the resident blood sugar was 44, the resident was moaning "please help me, come on" Glucogon was administered and the resident blood sugar was re-check (no time was noted) and it was 35. Instant glucose was administered at the time and the resident was answering questions appropriately and correctly. There was no documented evidence that the resident blood sugar level was re-checked 15 minutes after the instant glucose was administered. Nursing documentation on March 20, 2015 6:30 a.m. ( ½ hour after that the instant glucose was administered) indicated that resident blood sugar level was re-checked at that time and it was 71. The facility failed to properly monitor Resident H8 blood sugar levels after two hypoglycemic episodes on March 19 and 20, 2015 as indicated in the facility's policy. Review of the policy for neurochecks post fall revealed the following schedule for neurochecks: Every 15 minutes x1 hour Every 30 minutes x 1 hour Every hour x 4 hours Every 4 hours x 24 hours; then every shift for the remainder of 72 hours. Review of Resident C3's December 2014 physician's orders revealed the [DIAGNOSES REDACTED]. Review of nursing documentation dated March 17, 2014 at 3:51 p.m. noted that the resident was observed ambulation at quick pace with weight on her toes, leaning forward. Resident fell forward landing in prone position, striking her face on the floor. The resident was noted to have blood from left nares, a superficial abrasion at the bridge of her nose and slightly redness below the left eye. Neurological checks were initiated at 5:00 p.m. Nursing documentation dated December 17, 2014 at 5:50 p.m., indicated that the resident left via ambulance to the hospital for evaluation. Review of Resident C3 ' s neurological evaluation record revealed that neurological checks were documented on December 17, 2014 at 5:00 p.m. and again at 10:50 p.m. although the resident was transferred out of the facility at 5:50 p.m. The facility failed to complete neurological assessment as indicated on the facility's policy after Resident C3 sustained a fall sustaining face injuries. Review of Resident E2's clinical medical record revealed that the resident had a fall on March 26, 2015. Review of the medical chart revealed that nursing neurological checks were only completed twice on March 26, 2015. Interview with resident C8 during the group interview April 9, 2015 at 10:00 a.m. related concerns with her medication [MEDICATION NAME]. Review of the physician ' s order dated March 26, 2015 listed [MEDICATION NAME] 40 mg. today and taper down by 5 mg every day till off. Review of the Medication Administration Record [REDACTED]. on March 26, 2015 and received [MEDICATION NAME] 35 mg on March 27, 2015; 30 mg. [MEDICATION NAME] March 28, 2015; 25 mg [MEDICATION NAME] March 29, 2015; 20 mg on March 30, 2015 and 15 mg on March 31, 2015 and then the [MEDICATION NAME] was discontinued. An interview was conducted with the DON on April 10, 2015 at 10:00 a.m. and admitted the medication error that occurred and the proper treatment was not administered. The facility failed to follow the physician order for [REDACTED]. 28 Pa Code: 201.18(b)(1)(3) Management Previously cited: 1/7/2015 28 Pa Code: 211.5(f) Clinical records Previously cited: 5/23/14, 2/13/15 28 Pa Code: 211.10(d) Resident care policies Previously cited: 5/23/14, 2/13/15 28 Pa Code: 211.12(c)(d)(10(5) Nursing services Previously cited: 5/23/14, 2/13/15