Embassy Of Hillsdale Park

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for one of 33 residents reviewed (Resident 5).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included dementia.A nursing note for Resident 5, dated September 7, 2025, revealed that at 1:25 p.m. the resident had a witnessed fall in the hallway resulting in a skin tear to her left ring finger and a reddened area on the left side of her forehead. She was transferred to the hospital and admitted with altered mental status, a head injury, and seizures.Review of Resident 5's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer, or that the ombudsman was notified regarding her hospitalization of September 7, 2025.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documented evidence that Resident 5 and their representative were notified in writing of their transfer to the hospital, or that the ombudsman was notified regarding the hospitalizations.28 Pa. Code 201.29(j) Resident Rights.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 33 residents reviewed (Resident 9). Findings include:The facility's policy regarding care plans, dated April 3, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents medical, nursing, and mental and psychosocial needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 2, 2026, revealed that the resident was cognitively intact, was understood, could understand, and required supervision with care needs.Interview with Resident 9 on February 17, 2026, at 10:42 revealed that she has been having diarrhea for a while, and still has to take medication. A nursing note for Resident 9 dated January 28, 2026, indicated that she had a colonoscopy.Physician's orders for Resident 9, dated October 21, 2025, included an order for the resident to receive 2.5-0.025 milligrams (mg) of Lamotil (an antidiarrheal medication) every six hours as needed for for diarrhea. Physician's orders for Resident 9, dated January 28, 2026, included an order for the resident to receive 2.4 grams (gm) of Mesalamine (an anti-inflammatory medication) twice a day for ulcerative colitis (chronic inflammatory bowel disease).There was no documented evidence that a care plan was developed to address Resident 9's chronic diarrhea and ulcerative colitis.Interview with the Nursing Home Administer on February 19, 2026, at 12:13 p.m. confirmed that Resident 9 did not have a care plan to address her chronic diarrhea and ulcerative colitis with medications.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending March 6, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 20, 2026, identified repeated deficiencies related the development of individualized care plans, providing quality care, ensuring that the resident's environment was free from accident hazards, and preventing issues with the accountability of controlled medications (drugs with the potential to be abused). The facility's plan of correction for a deficiency regarding the development of individualized care plans, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were developed for their individual needs. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 6, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on March 6, 2025, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards. The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.Refer to F656, F684, F689, F75528 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as interviews with staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for three of 33 residents reviewed (Residents 7, 11, and 26). Findings include:The facility policy regarding hand hygiene, dated April 3, 2026, included that hand hygiene is a general term for cleaning your hands with soap and water or the use of an antiseptic hand rub. The use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The facility policy regarding medication administration, dated April 3, 2026, included that medications are administered by licensed nurses or other staff that are licensed to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administering medication per facility policy and product. Remove medication from its source, taking care not to touch medication with bare hands. The facility policy regarding enhanced barrier precautions (EBP), dated April 3, 2026, revealed that the facility would implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of a gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at an increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). The facility was to make gowns and gloves available immediately outside of the resident's room. High contact care activities include wound care: any skin opening requiring dressing. EBP will be used for the duration of the affected resident's stay in the facility or until resolution of the wound heals or the indwelling medical device is removed. Observation of medication administration for Resident 7 on February 20, 2026, at 6:43 a.m. revealed that Licensed Practical Nurse 3 donned gloves and administered eye drops to the resident. Upon completion of the administration of the eye drops, the Licensed Practical Nurse removed her gloves and proceeded to the medication cart and prepared and administered medications to another resident. Licensed Practical Nurse 3 did not complete hand hygiene after removing her gloves or before preparing and administering medication to the next resident. During an interview with Licensed Practical Nurse 3 on February 20, 2026, at 6:55 a.m. she stated I don't think we have to clean our hands between every resident. I am very careful not to touch anything with my bare hands. Observation of medication administration for Resident 11 on February 20, 2026, at 6:35 a.m. revealed that Licensed Practical Nurse 4 dropped a small white pill on the top of the medication cart when preparing the resident's medication then picked the pill up with her bare hands and placed it in a medication cup with other medications. Licensed Practical Nurse 4 proceeded into the resident's room and administered the medication. Interview with Licensed Practical Nurse 4 at the time of the observation confirmed that she should not have touched the resident's medication with her bare hands. An interview with the Nursing Home Administrator on February 20, 2026, at 7:33 a.m. confirmed that pills should not be touched with bare hands, and that hand hygiene should have been performed after glove removal and before providing meds to the next resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated January 22, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had diagnoses that included diabetes and dementia, and had pressure ulcers. Physician's orders for Resident 26 dated June 6, 2025, included an order for the resident to have Enhanced Barrier Precautions in place every shift. Gloves and gowns to be worn when providing wound care: chronic wounds such as pressure ulcers, or diabetic foot ulcers. Physician's orders for Resident 26 dated January 9, 2026, included an order for the resident to have skin prep applied to her left heel every day and evening shift for wound care. Physician's orders for Resident 26 dated January 16, 2026, included an order for the resident to have her right ankle cleansed with 0.125 % Dakin's solution (topical antiseptic to cleanse infected wounds), apply calcium alginate (highly absorbent wound dressing), to the wound bed, an ABD pad (abdominal pad-a thick, highly absorbent medical dressing), and rolled gauze daily and as needed for wound care. Observation of wound care treatment for Resident 26 on February 20, 2026, at 8:51 a.m. revealed that Licensed Practical Nurse 5 donned gloves and removed the soiled dressing from the resident's right ankle. She then removed her gloves, applied clean gloves and cleansed the resident's right ankle with Dakin's solution and applied the calcium alginate, ABD pad, gauze, and tape. She then removed her gloves and went into the bathroom and washed her hands. Licensed Practical Nurse 5 then donned clean gloves, removed the sock on the resident's left foot, removed her gloves, applied clean gloves, applied skin prep to the resident's left heel, and removed her gloves. She then proceeded to clean up her supplies and put items back on the treatment cart. She exited the resident's room without performing hand hygiene.Interview with Licensed Practical Nurse 5 on February 20, 2026, at 9:07 a.m. revealed she should have worn a gown while providing wound care to Resident 26, however she did not because there were no supplies on the unit to use. She revealed that she washed her hands twice during wound care, although handwashing was only observed once, and that she did not wash her hands after completing the resident's wound care and before or immediately after exiting the resident's room and going into another resident's room. An interview with the Nursing Home Administrator on February 20, 2026, at 10:48 a.m. confirmed that a gown should have been worn during Resident 26's wound care, hand hygiene should have been performed each time gloves were removed, and that hand hygiene should have been performed after completion of wound care. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 33 residents reviewed (Resident 68). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated December 20, 2025, revealed that the resident was understood and could understand others, was cognitively intact, and had diagnoses that included hypertension (high blood pressure), and heart failure. A care plan, dated June 14, 2024, revealed that staff were to give all cardiac medications as ordered by the physician.Physician's orders for Resident 68, dated July 15, 2025, included an order for the resident to receive 12.5 milligrams (mg) of Coreg (used to treat high blood pressure) two times a day for hypertension. Staff was to hold the medication for a blood pressure reading of less than 90/60 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm).Review of Resident 68's Medication Administration Record (MAR) for October and November 2025, and February 2026, revealed that the resident's pulse was less than 60 bpm at 7:00 a.m. on October 1, 4, 5, 9, 14, 15, 22-24, and 27-29, November 1, 2, 5-7, 10-12, 16, 19-21, 25-27, 29, and 30, 2025, and February 3, 4, 7, 8, 11-13, 16-18, 2026; however, there was no documented evidence that Coreg was held as ordered by the physician.Interview with the nursing Home Administrator on February 19, 2026, at 11:32 a.m. confirmed that there was no documented evidence that Resident 68's Coreg was held as ordered on the above dates and times.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well observations and staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to the facility's hot water temperatures. Findings include:A facility policy for safe water temperatures, dated April 3, 2025, included that water temperatures will be set to temperatures of no more than 120 degrees Fahrenheit (F), or the state's allowable maximum water temperature. Observation made in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 12:45 p.m. revealed that the water felt hot to the touch and the temperature was 120.3 degrees F. Interview with Licensed Practical Nurse 1 at the time of this observation revealed that the water was hot to touch and that she was unaware of any reported concerns by residents, staff, or visitors that the water was too hot. Observations of the Maintenance Director checking water temperatures in the shared bathroom sink between rooms [ROOM NUMBERS] on February 19, 2026, at 12:54 p.m. revealed a temperature of 115 degrees F.Observations of the Maintenance Director checking water temperatures in the bathroom sink in the shared hallway bathroom across from room [ROOM NUMBER] on February 19, 2026, at 12:56 p.m. revealed a temperature of 131 degrees F. An interview with the Maintenance Director at the time of these observations confirmed that the water temperature was too hot and should be between 100 and 110 degrees F. Observations of the Maintenance Director checking water temperatures in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 1:13 p.m. revealed a temperature of 121.6 degrees F. An interview with the Maintenance Director at the time of the observation confirmed that the water temperature was too hot. Interview with the Maintenance Director on February 19, 2026, at 1:50 p.m. revealed that he has not been notified of any concerns by residents, staff, or visitors that the water was too hot, and that he made adjustments to the mixing valves to correct the hot water temperature. Interview with the Nursing Home Administrator on February 19, 2026, at 2:10 p.m. confirmed that the water temperatures in the residents' room should not have been that high, and that the Maintenance Director had made adjustments to decrease the hot water temperature. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 77).Findings include: The facility's policy for storage of controlled medications dated April 3, 2025, revealed that the destruction/disposal of controlled medications should include a licensed nurse and a licensed pharmacist or authorized nurse supervisor. Documentation on the narcotic record will include the name of the resident, medication, prescription number, amount being destroyed, date of disposition and names and signatures of both the persons disposing of the medication. Physician's orders for Resident 77 dated September 13, 2024, included an order for the resident to receive 0.5 milligrams of Lorazepam (controlled medication for anxiety) one time a day. A nursing note for Resident 77 dated December 23, 2025, revealed that the resident ceased to breath at 4:14 a.m. A controlled narcotic sheet for Resident 77, received on December 1, 2025, revealed that 29 doses of Lorazepam were received. On December 22, 2025, the controlled narcotic sheet revealed that 9 doses of Lorazepam were remaining. There was no documented evidence that the remaining 9 doses of Lorazepam were destroyed and verified by two licensed nurses. Interview with the Nursing Home Administrator on February 20, 2026, at 11:35 a.m. confirmed that there was no documented evidence that Resident 77's Lorazepam was destroyed by two licensed nurses per the facility's policy. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in a medication cart. Findings include:The facility's policy regarding medication storage, dated April 3, 2025, revealed that the facility will maintain and control access to medication carts for licensed and approved personnel. Observations on February 19, 2026, at 2:11 p.m. revealed that Licensed Practical Nurse 2 walked out of the medication room on the ambulatory care unit, leaving the medication cart unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood. Interview with Licensed Practical Nurse 2 on February 19, 2026, at 2:14 p.m. confirmed that the medication cart was unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood, and that both should have been locked. An interview with the Nursing Home Administrator on February 19, 2026, at 2:39 p.m. confirmed that the medication cart should have been locked when unsupervised, and the medication room door should have been closed and locked when the medication room was unsupervised. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 33 residents reviewed (Residents 5).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia. A physician's order and care plan for Resident 5, dated September 12, 2025, indicated that the resident was to use a bed and chair alarm per the family's request.Observations of Resident 5 on February 17, 2026, at 10:32 a.m. revealed that the resident was in the hallway in his chair and had an alarm in place.Review of the Treatment Administration Records (TAR's) and nurse aide documentation for Resident 5, for November and December 2025, and January and February 2026, revealed that there was no documentation by staff that the resident's bed and chair alarms were in place.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documentation in Resident 5's clinical record indicating that the chair and bed alarms were in place.28 Pa. Code 211.5(f) Clinical Records.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment by ensuring that residents' wheelchairs were in good repair for one of 33 residents reviewed (Resident 61). Findings include: The facility's policy for safe and homelike environment dated April 3, 2025, revealed that the facility will provide a safe, clean, comfortable and homelike environment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 1, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, used a scoot and go wheelchair, and had diagnoses that included Paranoid schizophrenia and dementia. Observations of Resident's 61 scoot and go wheelchair on February 17, 2026, at 12:59 p.m. revealed that the leather on both arm rests had black tape wrapped around them. Observation of Resident's 61 scoot and go wheelchair on February 19, 2026, at 2:25 p.m. revealed that the leather on both arm rests had black tape wrapped around them. Interview with the Nursing Home Administrator on February 19, 2026, at 2:25 p.m. confirmed that Resident 61's scoot and go wheelchair had black tape around the leather armrests should have been repaired or replaced. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 33 residents reviewed (Resident 46).
Findings include:
The facility's policy regarding medication administration, dated November 8, 2024, indicated that staff were to document that medication was given on the appropriate line of the resident's Medication Administration Record (MAR).
Physician's orders for Resident 46, dated November 20, 2023, included an order for the resident to receive a 1 milligram (mg) tablet of Ativan (an anti-anxiety medication) every six hours as needed.
Resident 46's controlled drug records for January and February 2025 revealed that a 1 mg dose of Ativan was signed-out on January 21, 2025, at 7:50 a.m. and February 28 2025, at 8:00 a.m.; however, the resident's clinical record, including the MAR, contained no documented evidence that the Ativan was actually administered to the resident.
Interview with the Director of Nursing on March 16, 2025, at 12:44 p.m. confirmed that there was no documented evidence that the doses of Ativan that were signed-out by the nurse on the above dates were actually administered to Resident 46.
28 Pa. Code 211.9(h) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed anti-anxiety medications for one of 33 residents reviewed (Resident 46).
Findings include:
A quarterly Minimum Date Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 1, 2025, indicated that the resident was cognitively impaired, was understood and was able to be understood by others, and had physical behaviors directed toward others. The resident's care plan dated January 14, 2024, revealed that staff were to minimize the potential for disruptive behaviors by offering tasks that divert attention. Physician's orders, dated February 4, 2025, and February 19, 2025, included an order for the resident to receive 1 milligram (mg) of Ativan (an anti-anxiety medication) every six hours as needed for agitation.
Resident 46's Medication Administration Record (MAR) for February 2025 and March 2025 revealed that staff administered as needed Ativan for agitation on February 1, 2025, at 4:05 a.m.; February 3, 2025, at 7:46 a.m.; February 6, 2025, at 11:23 p.m.; February 7, 2025, at 3:23 a.m. and 6:02 a.m.; February 9, 2025, at 5:47 p.m.; February 14, 2025, at 6:09 a.m. and 12:16 p.m.; February 15, 2025, at 7:46 a.m. and 3:00 p.m.; February 16, 2025, at 7:55 a.m. and 3:00 p.m.; February 19, 2025, at 4:00 p.m.; February 20, 2025, at 6:53 a.m. and 2:30 p.m.; February 21, 2025, at 6:33 a.m. and 6:23 p.m.; February 22, 2025, at 4:00 p.m.; February 23 2025, at 6:10 p.m.; February 24, 2025, at 6:14 a.m.; February 25, 2025, at 6:20 a.m.; February 26, 2025, at 5:00 p.m.; February 28, 2025, at 4:00 p.m.; March 1, 2025, at 7:37 a.m. and 5:30 p.m.; March 2, 2025, at 7:10 a.m. and 3:56 p.m.; and March 4, 2025, at 7:21 a.m.
There was no documented evidence in Resident 46's clinical record to indicate that non-pharmalogical interventions were attempted prior to the Ativan being administered on the above dates and times.
Interview with the Nursing Home Administrator on March 5, 2025, at 9:05 a.m. confirmed that there was no documented evidence to indicate that non-pharmacological interventions were attempted prior to the administration of Ativan for Resident 46.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending April 11, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 6, 2025, identified repeated deficiencies related to abuse and neglect, updating/revising care plans, quality of care, and a safe environment that is free of accident hazards.
The facility's plan of correction for a deficiency regarding failure to ensure residents were free from abuse and neglect, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding abuse and neglect.
The facility's plan of correction for a deficiency regarding a failure to update/revise residents' care plans, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating/revising residents' care plans.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending April 11, 2024, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards.
Refer to F600, F657, F684, F689.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.

Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing to ensure that the call bell was within reach for one of 33 residents reviewed (Resident 27).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 13, 2024, indicated that the resident was cognitively impaired and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had recent falls, and staff were to ensure the call bell was within reach.
The facility's call bell policy, dated November 8, 2024, indicated that the call bell would be within easy reach and secured if needed.
Observations of Resident 27 on March 3, 2025, at 10:38 a.m. revealed that the resident was sitting in his wheelchair in the middle of his room with his call bell lying on his bed out of the resident's reach. Interview with Resident 27 at that time revealed that he does not get help when needed because his call bell has been out of reach.
Interview with Nurse Aide 1 at that time revealed that Resident 27 was capable of using his call bell and it should have been placed within her reach.
Interview with the Nursing Home Administrator on March 4, 2025, at 10:25 a.m. confirmed that the call bell should have been within Resident 27's reach.
28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 54).
Findings include:
The facility's policy for abuse, dated November 8, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 11, 2025, revealed that the resident was rarely understood, could rarely understand, and had diagnoses that included Alzheimer's disease and Down's syndrome. A care plan for Resident 54, dated January 29, 2024, revealed that the resident was at high risk for elopement and had impaired cognitive function. Interventions for Resident 54 indicated that if she was wandering in a potentially unsafe area or situation redirect to safer area and offer diversional activities.
A quarterly MDS assessment for Resident 56, dated November 11, 2024, revealed that the resident was understood and could understand others, and had diagnoses that included dementia. A care plan for Resident 56, dated April 15, 2024, revealed that she exhibited behaviors that included physically abusive attacks on staff and/or other residents, scratching, refusal of care and meals, and yelling and screaming. Interventions for Resident 56 included redirecting residents who were attempting to enter her room because this upsets her.
A nursing note for Resident 54, dated August 11, 2024, at 7:23 p.m. revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm.
The facility report, dated August 11, 2024, at 6:50 p.m. indicated that Resident 54 was attempting to get into Resident 56's room. Resident 56 then grabbed Resident 54's arm causing three scratch marks. The nurse aide removed Resident 54 from the room.
A nursing note for Resident 54, dated August 23, 2024, at 1:32 p.m. revealed that the nurse was notified that the resident was witnessed lying in Resident 56's bed. Resident 56 was observed hitting Resident 54 on her waist. No injuries were noted, and staff removed Resident 56 from her room.
A nurse aide witness statement, dated August 23, 2024, revealed that she walked into the room after she heard Resident 54 yelling for help. She observed Resident 56 and another resident standing over top of Resident 54 slapping her and yelling, Get out! The residents were separated, and the registered nurse was notified.
There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering.
A nursing note for Resident 54, dated September 5, 2024, at 3:43 p.m., revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm.
A nursing note for Resident 54, dated September 5, 2024, at 7:55 p.m., revealed that Resident 54's left arm remained slightly pink where fingernail marks occurred from the altercation earlier. The resident was observed staying in her room for a long time after the incident and if you stated her name, she would jump and become very fidgety.
There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering.
Interview with the Nursing Home Administrator on March 6, 2025, at 9:56 a.m. confirmed that Resident 56 had multiple abusive interactions with Resident 54 and that there was no documented evidence that staff was monitoring Resident 54 when wandering.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 33 residents reviewed (Resident 74).
Findings include:
A facility policy for baseline care plans, dated November 8, 2024, indicated that the facility will develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission orders and physician's orders. Interventions shall be initiated that address the resident's current needs including any special needs such as for intravenous therapy (administration of fluids and/or medications directly into a person's vein).
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m., revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time.
Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of Heparin (an anticoagulant medication used to keep intravenous catheters open and flowing freely); for the registered nurse to change the PICC dressing, extension set, and cap every seven days on the day shift and as needed for leakage, blockage and/or soilage; and for staff to measure the external catheter length from insertion site to the end of the injection cap in centimeters (cm) on admission, with each dressing change every seven days on the day shift and as needed.
Review of Resident 74's clinical record revealed no documented evidence that a baseline care plan was developed to address the resident's PICC and related PICC care.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:17 p.m. confirmed that there was no documented evidence that a baseline care plan was developed to address Resident 74's PICC and related PICC care.
28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 33 residents reviewed (Resident 29).
Findings include:
The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 4, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, was receiving hospice services, and had a diagnosis of Alzheimer's disease.
Physician's orders for Resident 29, dated February 6, 2025, revealed that the resident was admitted to 365 Hospice on February 4, 2025.
Review of Resident 29's clinical record revealed that there was no documented evidence that a care plan was developed to address the resident's need for hospice services.
An interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that there was no documented evidence that a care plan was developed to address Resident 29's need for hospice services.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 9, 31).
Findings include:
The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 18, 2025, revealed that the resident was cognitively impaired, was rarely understood, and could rarely understand others. A care plan, dated October 13, 2021, revealed that hospice was to be notified if the resident goes into cardiac arrest.
Physician's orders for Resident 9, dated July 19, 2024, revealed that the resident was discharged from hospice care.
Interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that the resident was no longer on hospice and her care plan should have been updated to reflect that.
A quarterly MDS assessment for Resident 31, dated January 16, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had no pressure ulcers or wounds, and had diagnoses that included diabetes, peripheral vascular disease (a disease causing poor blood circulation to lower limbs), and acquired absence of the left leg below the knee. A skin integrity care plan for Resident 31, dated May 9, 2019, included an intervention for a stump shrinker to be worn to shape the amputation site for a possible prosthesis (an artificial body part) and an intervention for contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) related to Methicillin-resistant Staphylococcus aureus (MRSA) infection (type of staph bacteria resistant to many antibiotics making treatment difficult).
Review of Resident 31's clinical record revealed no documented evidence that the resident continued to wear a stump shrinker and no documented evidence that the resident had a MRSA infection requiring contact precautions.
Interview with the Nursing Home Administrator on March 6, 2025, at 9:55 a.m. confirmed that Resident 31's care plan should have been revised to reflect that the stump shrinker was no longer used and that the resident was no longer on contact precautions for MRSA.
28 Pa. Code 211.12(d)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding wound treatments were followed for one of 33 residents reviewed (Resident 74).
Findings include:
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs).
Physician's orders for Resident 74, dated March 1, 2025, included orders to cleanse the resident's right lateral diabetic foot ulcer with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply betadine (a solution used to treat and prevent infection) to the base of the wound, and secure with abdominal dressing (used for a wound with large amounts of drainage or used as padding for pressure points and cushioning) and rolled gauze (used to hold the dressing in place) daily and as needed.
Observations of Resident 74's wound care on March 5, 2025, at 10:08 a.m. revealed that Licensed Practical Nurse 2, with gloved hands, cleansed the resident's right lateral foot with normal saline, removed her gloves, washed her hands, applied new gloves, applied betadine to the wound, and left the wound open to air.
Interview with Licensed Practical Nurse 2 on March 5, 2025, at 11:52 a.m. revealed that she was not aware that the wound to Resident 74's right lateral foot was to be covered with an abdominal dressing and wrapped with rolled gauze.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:22 p.m. confirmed that the order for Resident 74's wound to her right lateral foot included an order to cover the wound with abdominal dressing and wrap with rolled gauze. She confirmed that the wound should have been covered and wrapped.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide proper positioning in a wheelchair for one of 33 residents reviewed (Resident 38).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated November 29, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included Alzheimer's dementia and depression. Physician's orders for the resident, dated September 17, 2024, included orders for the resident to be seated in a Broda chair (modified wheelchair) at all times when out of bed with bolsters bilaterally to trunk, skil-care back pillow, and leg rests on during transport and off after transport.
Observations on March 3, 2025, at 10:19 a.m. revealed that Resident 38 was sitting in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest.
Observations on March 6, 2025, at 10:40 a.m. revealed that Resident 38 was in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest.
Interview with the Director of Rehabilitation on March 6, 2025, at 10:40 a.m. confirmed that the bilateral bolsters were not in place on Resident 38's Broda chair per physician orders.
Interview with the Nursing Home Administrator on March 6, 2025, at 11:19 a.m. confirmed that Resident 38 did not have the bilateral bolsters to prevent the resident from leaning.
28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 14).
Findings include:
A facility policy for resident alarms, dated November 8, 2024, indicated that the use of alarms does not eliminate the need for adequate supervision of the resident. Wander/elopement alarms alert staff when the resident nears or exits an area or building. When alarms are utilized, additional monitoring shall be provided, including but not limited to verifying alarms are used in accordance with the resident's care plan and verifying alarms are working properly.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 10, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included Alzheimer's dementia. A care plan for the resident, dated March 11, 2024, revealed that the resident was a high risk for elopement due to recent exit-seeking behaviors and wandering. Interventions included a wanderguard to reduce the risk of elopement and to check the device for proper functioning per facility protocol.
Physician's orders for Resident 14, dated December 4, 2024, included an order for the resident to have a wanderguard in place for safety.
A nursing note for Resident 14, dated February 8, 2025, at 9:21 p.m. revealed that the resident had an episode of increased confusion during the first half of the shift and stated she was going home, packing her belongings, and wandering through the hallways.
There was no documented evidence in Resident 14's clinical record to indicate that the wanderguard was checked for proper functioning per the facility policy and the resident's plan of care.
Interview with the Nursing Home Administrator on March 6, 2025, at 11:59 a.m. confirmed that there was no documented evidence that Resident 14's wanderguard was monitored to verify that it was working properly and it should have been.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) as ordered by the physician for one of 33 residents reviewed (Resident 74).
Findings include:
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time.
Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of Heparin (an anticoagulant medication used to keep intravenous catheters open and flowing freely).
Observations of Resident 74's PICC dressing change on March 5, 2025, at 9:50 a.m. revealed that after the PICC dressing was applied, Registered Nurse 3 flushed the resident's PICC with one syringe containing 5 ml of normal saline.
Interview with Registered Nurse 3 on March 5, 2025, at 12:13 p.m. confirmed that she flushed Resident 74's PICC with normal saline and did not flush the PICC with the 5 ml of heparin per the physician's orders. She indicated that she was not aware that the PICC was to be flushed with heparin as well.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:17 p.m. confirmed that Registered Nurse 3 should have flushed Resident 74's PICC with the 5 ml of heparin per the physicians orders and she did not.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending May 11, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 11, 2024, identified repeated deficiencies related to the revision of care plans, failure to ensure that residents remained free of significant medication errors, and medication storage and labeling.
The facility's plan of correction for a deficiency regarding revising care plans, cited during the survey ending May 11, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in correcting deficient practices related to revising care plans.
The facility's plan of correction for a deficiency regarding failure to ensure that residents remained free of significant medication errors, cited during the survey ending May 11, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F760, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding ensuring that residents remained free of significant medication errors.
The facility's plan of correction for a deficiency regarding proper storage and/or labeling of medications, cited during the survey ending May 11, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storing and labeling residents properly.
Refer to F657, F760, F761.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 58).
Findings include:
The facility's policy for abuse, dated March 14, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 117, dated June 8, 2023, revealed that the resident was usually understood, could usually understand, and had diagnoses that included dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A care plan for Resident 117, dated September 21, 2023, revealed that he exhibited behaviors of playing in his food, taking items, wandering (to move around or go to different places usually without having a particular purpose or direction), abusive language, sexually-inappropriate behaviors, and threatening behaviors. Interventions for Resident 117 indicated that if he is wandering in the hallway, attempt to keep him away from other residents, keep him out of reach of other residents when feasible, and when in the dining room for meals and activities attempt to keep the resident out of reach of other resident to prevent future incidents.
A significant change in status MDS assessment for Resident 58, dated August 29, 2023, revealed that the resident was understood, could understand, and had a diagnosis of Alzheimer's disease.
A nursing note for Resident 58, dated September 8, 2023, at 12:50 p.m. revealed that the nurse was called from the dining room by the care aides related to a resident-to-resident altercation. Resident 58 was in her room when Resident 117 was trying to enter. Resident 58 was then observed being kicked by Resident 117. The resident was then found on the floor in her bedroom. Resident 58 stated that Resident 117 was trying to enter her room and she told him that she did not want him in there. Resident 117 then kicked her causing her to fall over. The Registered Nurse Supervisor was called and notified of the incident. The resident's injuries were assessed by supervisor. The resident was assisted by staff back into her recliner at this time.
A nursing note for Resident 58, dated September 8, 2023, revealed that the licensed practical nurse on the floor notified the registered nurse that another resident kicked the resident and she fell to the floor. The nurse aide witnessed the other resident kicking this resident. When the registered nurse arrived on the floor the resident had gotten up and was in her room sitting in her chair. She stated that, he kicked her, and she fell. She denied having any contact with the resident prior to the incident. The resident stated that her right palm hurts. Upon assessment a bruise was noted on her right palm, which measured 3.5 centimeter (cm) by 1.8 cm. There were two bruises noted to her right elbow measuring 0.5 cm by 0.7 cm and 0.7 cm by 0.3 cm. A small abrasion was noted to her left elbow measuring 0.2 cm by 0.3 cm. A small bruise was noted to her right wrist area measuring 0.5 cm by 0.5 cm. The resident had an unmeasurable abrasion to her right buttock. The physician and psychologist were notified.
The facility report, dated September 8, 2023, indicated that an event occurred on September 8, 2023, at approximately 1:00 p.m. when Resident 117 was attempting to get into Resident 58's room. Resident 117 then kicked Resident 58 causing her to fall. Resident 58 was then assessed by the registered nurse and found to have a bruise on her right palm measuring 3.5 cm by 1.8 cm., two bruises on her right elbow measuring 0.5 cm by 0.7 cm and 0.7 cm by 0.3 cm, a small abrasion on her left elbow measuring 0.2 cm by 0.3 cm, a small bruise on her right wrist area measuring 0.5 cm by 0.5 cm, and an unmeasurable abrasion on her right buttock.
A statement completed by Nurse Aide 1, dated September 8, 2023, revealed that she was walking down the hall and saw Resident 117 halfway into Resident 58's room and then saw Resident 117 kick at Resident 58. Nurse Aide 1 ran into her room, and she was on the floor. Nurse Aide 1 then asked the residents what happened. Resident 58 said Resident 117 kicked her, and Resident 117 admitted kicking her.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:24 a.m. confirmed that Resident 117 kicked Resident 58.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for three of 33 residents reviewed (Residents 1, 3, 51).
Findings include:
The facility's policy regarding care plans, dated March 14, 2024, indicated that the care plan revisions would be reviewed, and revised as necessary, when a resident experiences a status change.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, indicated that the resident was moderately cognitively impaired and was not receiving an anticoagulant (blood thinner) medication. Resident 1's care plan, dated February 2, 2024, indicated that the resident had the potential for bleeding or hemorrhage related to the use of anti-coagulant medication.
A review of Resident 1's physician's orders and Medication Administration Record (MAR) for April 2024 revealed that the resident was not receiving an anticoagulant medication.
Resident 1's current care plan was not updated to indicate that the resident was not receiving an anti-coagulant medication.
Interview with the Nursing Home Administrator on April 10, 2024, at 1:28 p.m. confirmed that Resident 1's care plan was not updated to include the discontinuation of the anticoagulant medication.
An admission MDS assessment for Resident 3, dated March 29, 2024, indicated that the resident was cognitively intact, required assistance from staff for his daily care needs, and had diagnoses that included a wound infection of a Stage 3 pressure ulcer (a wound developed from constant pressure extend through the skin into deeper tissue and fat but does not reach muscle, tendon, or bone). A care plan for Resident 3, dated April 10, 2024, revealed that the resident was receiving Cefdinir and Ampicillin for a wound infection.
A review of Resident 3's physician's orders and MAR for March and April 2024 revealed that the resident received 300 mg of Cefdinir Oral Capsule daily and 500 mg of Ampicillin oral capsule every six hours from March 23, 2024, to March 30, 2024.
Resident 3's current care plan was not updated to indicate that the resident was no longer receiving the Cefdinir and Ampicillin.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:57 a.m. confirmed that the care plan was not updated to indicate that Resident 3 was no longer receiving Cefdinir and Ampicillin and should have been.
An annual MDS assessment for Resident 51, dated February 1, 2024, revealed that the resident was cognitively intact, required assistance with care needs, and had diagnoses that included atrial fibrillation. A care plan for Resident 51, dated April 23, 2021, indicated that the resident had the potential for bleeding or hemorrhage related to the use of anti-coagulant medication.
Review of Resident 51's current physician's orders revealed that the resident was not receiving an anti-coagulant medication.
Interview with Regional Registered Nurse 2 on April 9, 2024, at 12:01 p.m. confirmed that Resident 51's care plan should have been revised when her anti-coagulant was discontinued in August 2023 and it was not.
28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for blood sugar checks were obtained by a professional (registered) nurse for one of 33 residents reviewed (Resident 24).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
Physician's orders for Resident 24, dated October 4, 2024, included an order for the resident to receive one 500 milligram (mg) tablet of Metformin (helps to control the amount of glucose (sugar) in your blood) in the morning at 7:00 a.m.
Resident 24's Medication Administration Record (MAR), dated March and April 2024, revealed that staff were obtaining the resident's blood sugar level prior to the administration of the 500 mg tablet of Metformin in the morning at 7:00 a.m. However, there was no documented evidence that an order was obtained from the resident's physician for staff to obtain the resident's blood sugar level prior to the administration of the Metformin.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no documented evidence that an order was obtained from Resident 24's physician for staff to obtain the resident's blood sugar level prior to the administration of the Metformin, and that staff should have obtained an order.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for four of 33 residents reviewed (Residents 12, 14, 22, 24).
Findings include:
The facility's policy regarding medication administration, dated March 14, 2024, indicated that staff were to obtain and record vital signs when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.
An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated February 22, 2024, revealed that the resident was understood and could understand others, was cognitively intact, and required minimal assistance with care.
A nursing note for Resident 12, dated March 16, 2024, revealed that the nurse aide noticed that the resident's left eye was red and swollen. The physician was notified and orders were received for polymyxin/trimethoprim ophthalmic solution (an eye drop used to treat eye infections) to be administered every three hours for seven days.
A review of Resident 12's Medication Administration Record (MAR) for March 2024 revealed that the eye drops were not available for administration for the first five doses. There was no documented evidence that the physician was made aware that the drops were unavailable or that the treatment would need to be extended to ensure the resident would receive the entire seven-day treatment as ordered.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:27 a.m. confirmed that Resident 12 did not complete the entire treatment as ordered and the treatment should have been completed.
A quarterly MDS assessment for Resident 14, dated December 15, 2023, revealed that the resident was understood, could understand, and had diagnoses that included high blood pressure. A care plan for the resident, dated September 8, 2023, revealed that the resident was at risk for coronary artery disease (a condition that affects the heart). Staff were to administer medications for hypertension and document the response to the medication and any side effects. Staff were to monitor the blood pressure and notify the physician of any abnormal readings.
Physician's orders for Resident 14, dated September 2, 2023, included an order for the resident to receive one 2.5 milligram (mg) of Amlodipine (used to treat high blood pressure) one time a day for hypertension. Staff was to hold the medication for a blood pressure less than 90/60 millimeters of mercury (mm Hg) (a normal blood pressure for most adults is defined as a systolic pressure (top number) of less than 120 mm Hg and a diastolic pressure (bottom number) of less than 80 mm Hg).
Resident 14's Medication Administration Record (MAR), dated March and April 2024, revealed that there was no documented evidence that the resident's blood pressure was obtained prior to the administration of the 2.5 mg tablet of Amlodipine to determine if the medication should be withheld.
Interview with the Nursing Home Administrator on April 10, 2024, at 3:05 p.m. confirmed that there was no documented evidence that Resident 14's blood pressure was obtained prior to the administration of the Amlodipine to determine if the medication should be withheld.
A quarterly MDS assessment for Resident 22, dated December 12, 2023, revealed that the resident was understood, could understood others, was cognitively intact, independent for daily care needs, and received insulin (medication that lowers blood sugar levels).
Physician's orders for Resident 22, dated March 17, 2022, included an order for the resident to have her blood sugar checked four times a day and for the physician to be contacted if the blood sugar is less than 60 or greater than 350.
Resident 22's MAR, dated March, 2024 revealed that on March 3 at 9:00 p.m. the resident's blood sugar was 360 mg/dL; on March 10 at 11:45 a.m. it was 358; and on March 17 at 5:15 p.m. it was 376. There was no documented evidence that the physician was notified about the resident's blood sugar being above 350 mg/dL on these dates and times.
Interview with the Nursing Home Administrator on April 9, 2024, at 11:55 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 22's elevated blood sugars as ordered.
A quarterly MDS assessment for Resident 24, dated January 10, 2024, revealed that the resident was understood, could understand, and had a diagnosis that included high blood pressure. A care plan for the resident, dated October 9, 2023, revealed that the resident was at risk for coronary artery disease. Staff were to administer medications for hypertension and document the response to the medication and any side effects. Staff were to monitor the blood pressure and notify the physician of any abnormal readings.
Physician's orders for Resident 24, dated January 16, 2024, included an order for the resident to receive one 0.1 mg tablet of Clonidine (used to treat high blood pressure) two times a day for hypertension at 7:00 a.m. and 7:00 p.m. Staff were to hold the medication for a blood pressure less than 90/60 mm Hg.
Resident 24's MARS, dated March and April 2024, revealed that there was no documented evidence that the resident's blood pressure was obtained prior to the 7:00 p.m. administration of the 0.1 mg tablet of Clonidine to determine if the medication should be withheld.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no documented evidence that Resident 24's blood pressure was obtained prior to the administration of the Clonidine to determine if the medication should be withheld.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of 33 residents reviewed (Residents 3, 30).
Findings include:
The facility's policy regarding pressure ulcers, dated March 14, 2024, indicated that the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.
An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 29, 2024, indicated that she was cognitively intact, had no history of rejecting care, required extensive assistance from staff for daily care needs, and had an unhealed Stage 3 pressure ulcer.
A physician's progress note, dated March 29, 2024, revealed that Resident 3 was to be assessed for an air mattress to assist with pressure distribution.
Observations of Resident 3 on April 8, 2024, at 11:35 a.m. revealed that the resident did not have an air mattress. There was no documented evidence in the clinical record that Resident 3 had been assessed for an air mattress as requested by the physician.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:33 a.m. confirmed that the resident did not have an air mattress, was never assessed for an air mattress, and that he should have been per the physician's request.
A quarterly MDS assessment for Resident 30, dated March 14, 2024, indicated that the resident was cognitively intact and had pressure ulcers (skin breakdown caused by pressure).
A wound clinic note, dated March 22, 2024, revealed that Resident 30 had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the coccyx (lower part of spine) that measured 5.0 x 4.5 x 5.0 centimeters (cm) with undermining (tissue breakdown beneath the skin), and it was recommended that the wound be cleansed with 0.125 percent Dakins (used to prevent infection) solution and collagen (used to stimulate wound healing) and silver alginate (dressing used to prevent infection) be applied to the coccyx twice a day.
A wound clinic note, dated March 29, 2024, revealed that Resident 30 continued to have a Stage IV pressure ulcer to the coccyx, and it was recommended that the wound be cleansed with 0.125 percent Dakin's solution, and collagen and silver alginate be applied to the coccyx twice a day.
The Treatment Administration Record for Resident 30 for March 2024 revealed that the application of collagen and silver alginate to the resident's coccyx twice a day was not started until March 30, 2024.
There was no documented evidence that the application of collagen and silver alginate to Resident 30's coccyx twice a day was started following the recommendations of the wound clinic on March 22, 2024.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:34 a.m. confirmed that the treatments to Resident 30's coccyx were not completed as recommended by the wound clinic on March 22, 2024.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards caused by residents with aggressive behaviors for four of 33 residents reviewed (Residents 44, 58, 61, 63).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 15, 2023, revealed that she was understood, could understand, and had a diagnosis of dementia. A care plan for the resident, dated September 8, 2023, revealed that the resident had an alteration in behavior related to abusive attacks on staff and/or other residents; verbally abusive, threatening behaviors; argumentative with staff; yells at staff and other residents, and a history of resident-to-resident altercations. Staff were to intervene as needed to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to another location as needed.
A nursing note for Resident 14, dated December 25, 2023, at 5:30 p.m. revealed that the resident was hollering at the residents in the dining room and singled one resident out, threatening to hit her with her hands clenched in fists. Residents were separated and Resident 14 was in her room at this time. A nursing note at 7:10 p.m. revealed that the resident went into Resident 58's room hollering at the resident. This licensed practical nurse went down the hall to see what was going on. Resident 14 was shaking Resident 58 and hit the resident in the stomach with a closed fist several times. The licensed practical nurse told the resident to stop, and she pushed Resident 58 and made the resident stumble out of her room. The licensed practical nurse told the resident that she cannot hit or push other residents and the resident insisted that this is her house and that Resident 58 was burning it down.
A nursing note for Resident 14, dated January 5, 2024, revealed that during breakfast another resident began speaking inappropriately to this resident, and she in turn, began verbally making comments that she would punch the other resident.
A nursing note for Resident 14, dated March 20, 2024, revealed that the writer was called to the unit at 8:30 p.m. by the licensed practical nurse reporting that the resident had slapped Resident 63's arm while in the hallway. The incident was witnessed by the hospitality aide who had reported it to the licensed practical nurse. The licensed practical nurse immediately separated the two residents. Upon entry to the unit both residents were away from one another and resting in their wheelchairs with staff nearby. Neither resident could give a description of what had occurred.
A significant change in status MDS assessment for Resident 117, dated June 8, 2023, revealed that the resident was usually understood, usually understands, and had diagnoses that included dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A care plan for the resident, dated September 21, 2023, revealed that the resident had exhibited behaviors of playing in his food, taking items, wandering (to move around or go to different places usually without having a particular purpose or direction), abusive language, sexually-inappropriate behaviors, and threatening behaviors. If the resident was wandering in the hallway, attempt to keep him away from other residents, keep the resident out of reach of other residents when feasible, and when in the dining room for meals and activities attempt to keep the resident out of reach of other resident to prevent future incidents.
A nursing note for Resident 44, dated July 16, 2023, revealed that the nurse aide hollered for the licensed practical nurse to come help her. The nurse aide stated, Resident 117 hit Resident 44 on the back. Resident 44 was standing in room [ROOM NUMBER] behind the nurse aide. The registered nurse was notified after Resident 117 was taken to his room.
A nursing note for Resident 117, dated September 8, 2023, at 1:22 p.m. revealed that the licensed practical nurse on the floor notified the registered nurse that this resident kicked Resident 58 in the leg and caused her to fall to the floor with minor injuries noted. Upon arrival to the unit the resident was in the hallway in his wheelchair. When asked what happened he refused to say anything. The licensed practical nurse stated that he told her he kicked Resident 58 after she kicked him. Resident 58 denied kicking him. The resident continues to self-propel in the hallway currently. A nursing note at 1:28 p.m. revealed that the licensed practical nurse notified the registered nurse that the resident punched Resident 44 in the buttocks as she walked away from him. Upon arrival, the resident was seen sitting in his room. The resident refused to explain what happened.
A statement Social Worker 3, dated September 8, 2023, revealed that he was completing MDS's in his office around 1:00 p.m. to 1:15 p.m. when a nurse aide called him into the hallway to help keep Resident 117 away from Resident 58. He brought Resident 117 to his office and spoke about what happened. Resident 117 said, I was going into her room, she told me to get out, she turned around and I kicked her in the butt. Resident 117 was in the office for about 15 to 20 minutes when the phone rang. Social Worker 3 answered and spoke on the phone and when he hung up, Resident 117 was no longer in his office.
A quarterly MDS assessment for Resident 58, dated February 29, 2024, revealed that the resident was understood, understands, and had a diagnosis of Alzheimer's disease. A care plan for the resident, dated February 23, 2023, revealed that the resident is/has a potential to be physically aggressive.
A nursing note for Resident 58, dated March 19, 2024, revealed that the licensed practical nurse notified the registered nurse at 6:30 p.m. that the resident had hit Resident 61 once in the back and another time in the left breast.
Following the above incidents, there was no documented evidence that the facility analyzed the key times, places, circumstances, and triggers that caused the multiple episodes of resident-to-resident altercations.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:24 a.m. confirmed that Resident 117 had an altercation with Resident 58 and after the altercation then went and had an altercation with Resident 44. She indicated that Social Worker 3 should have gotten someone else to watch Resident 117 when he received the phone call.
28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 33 residents reviewed (Resident 1) who had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated March 14, 2024, revealed that care would be taken to follow infection control guidelines when providing catheter care and emptying the drainage bag.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, revealed that the resident was moderately cognitively impaired, required assistance from staff for daily care activities, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (lack of bladder control).
Physician's orders, dated December 28, 2023, included an order for the resident to have a urinary catheter, 18 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place).
Observations of Resident 1 on April 8, at 12:40 p.m. and April 10, 2024, at 8:18 a.m. revealed that the resident was in a wheelchair in his room and in the hallway, and his catheter tubing was in contact with the floor.
Interview with Registered Nurse 4 on April 10, 2024, at 8:21 a.m. confirmed that Resident 1's catheter tubing was on the floor and should not have been.
Interview with the Nursing Home Administrator on April 10, 2024, at 12:51 p.m. confirmed that Resident 1's catheter tubing should not have been in contact with the floor.
28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 33 residents reviewed (Resident 22).
Findings include:
The facility's policy regarding medication administration, dated March 14, 2024, indicated that the facility was to administer medication in accordance with the physician orders.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated March 14, 2024, revealed that the resident had diagnoses that included diabetes (a disease that interferes with blood sugar control) and received insulin.
Physician's orders for Resident 22, dated December 15, 2022, included an order for the resident to receive 6 units of Lispro insulin subcutaneously (injected just under the skin) one time a day in the morning, 6 units one time a day at the lunch meal, and 6 units one time a day at the supper meal, and to hold the insulin if the resident's blood sugar was less than or equal to 100 mg/dL.
Resident 22's Medication Administration Records for March and April 2024 revealed that on March 4, 2024, at 7:00 a.m. the resident's blood sugar was 93 mg/dL; on March 6, 2024, at 11:45 a.m. the resident's blood sugar was 98 mg/dL; on March 19, 2024, at 7:15 a.m. the resident's blood sugar was 88 mg/dL; on March 18, 2024, at 7:15 a.m. the resident's blood sugar was 80 mg/dL; and on April 1, 2024, at 11:45 a.m. the resident's blood sugar was 81 mg/dL.
There was no documented evidence that the resident's insulin was held on the above dates as ordered by the physician.
Interview with Regional Registered Nurse 2 on April 9, 2024, at 11:55 a.m. confirmed that Resident 22's insulin was not held when the resident's blood sugar was less than 100 mg/dL on the dates mentioned above and should have been held.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, medication manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled/dated for three of 33 residents reviewed (Residents 10, 11, 45).
Findings include:
The facility's policy for labeling medications, dated March 14, 2024, indicated that all pre-filled pens and multi-dose vials of medication maintained in the facility shall be labeled with date opened and the initials of the healthcare professional, and are to be discarded within 28 days unless otherwise specified by the manufacturer.
The most current manufacturer's instructions for insulin Humalog Kwikpen Pen-injector 100 unit/ml (milliliter) solution (a fast acting insulin) indicated that prefilled pens that are in use should be kept at room temperature and must be used within 28 days or be discarded.
Physician's orders for Resident 10, dated July 9, 2023, included an order for Keppra solution (medication used to treat seizures) 100 mg/mL 5 ml by mouth two times a day.
Physician's orders for Resident 11, dated March 20, 2023, included an order for Humalog KwikPen Pen-injector 100 unit/ml solution subcutaneously (directly under the skin) before meals and at bedtime per sliding scale.
Physician's orders for Resident 45, dated August 28, 2023, included an order for Humalog KwikPen Pen-injector 100 unit/ml solution subcutaneously (directly under the skin) before meals and at bedtime per sliding scale.
Observations on April 11, 2024, at 10:57 a.m. of the medication cart on the 200 unit revealed a multi-dose bottle of Keppra for Resident 10 that was in use and not dated when opened, and a Humalog KwikPen Solution Pen-injector for Resident 11 that was in use and not dated when it was opened.
Interview with Registered Nurse 4 at that time indicated that the multi-dose bottle of Keppra and insulin pen should have been dated when first opened.
Observations on April 9, 2024, at 8:59 a.m. of the medication cart on the ACU unit revealed that there was a Humalog KwikPen Solution Pen-injector for Resident 45 that was in use and it was not dated when it was opened. Interview with Licensed Practical Nurse 5 at that time indicated that the insulin pen should have been dated when first opened.
Interview with the Nursing Home Administrator April 11, 2024, at 10:55 a.m. confirmed that the medications should have been dated when opened.
28 Pa. Code 211.9(a) Pharmacy Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 24).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated January 10, 2024, revealed that the resident was understood and understands. Physician's orders, dated January 4, 2024, included an order to obtain a urine culture (a test that looks for and identifies bacteria in urine) and sensitivity (a test that helps find out which antibiotic will be most effective in treating a bacterial infection).
A progress note for Resident 24, dated January 5, 2024, revealed that the resident was straight cathed (an invasive procedure in which a plastic tube is inserted into the bladder) for a dark amber urine and the sample was sent to the lab.
There was no documented evidence that staff obtained a physician's order to obtain Resident 24's urine specimen via catheterization.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no evidence that a physician's order was obtained for Resident 24 to be catheterized to obtain the urine specimen.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of five residents reviewed (Resident 3).
Findings include:
A facility policy for resident showers dated March 14, 2024, indicated that residents will be provided showers as per request or as per facility schedule protocols.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2024, indicated that the resident was cognitively impaired, was dependent on staff for showers and bathing, and had diagnoses that included peripheral vascular disease.
A care plan for Resident 3, dated December 12, 2023, indicated that the resident required two staff members to provide care. A care plan, dated January 1, 2024, indicated that the resident was to be assisted with showering as per facility policy weekly.
A review of the facility shower schedule indicated that Resident 3 was to have a shower every Wednesday and Saturday on day shift.
Review of bathing documentation for Resident 3, dated February 20, 2024, through March 19, 2024, indicated that the resident only received two showers during that time. There was no documented evidence that the resident was offered or refused showers weekly as per his care plan.
Observations of Resident 3 on March 20, 2024, at 11:00 a.m. revealed that the resident lying in bed with his eyes closed. Observations on March 20, 2024, at 3:45 p.m. revealed that the resident was lying in bed with several visitors in his room.
Interview with Nurse Aide 3 on March 20, 2024, at 11:05 a.m. revealed that she was the only nurse aide providing care on the North Shore unit and that she was not able to complete her scheduled resident showers. She reported this as a common occurrence and sometimes was unable to get residents out of bed if she could not find help from other staff.
Interview with Licensed Practical Nurse 1 on March 20, 2024, at 11:30 a.m. revealed that only one nurse aide was working on the [NAME] Shore unit; therefore, Resident 3 was not able to be provided his scheduled shower that day.
Interview with Nurse Aide 2 on March 20, 2024, at 11:45 a.m. revealed that she was the only nurse aide providing care on the [NAME] Shore unit and that she was not able to provide the scheduled resident showers on that unit that day.
Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that there was no documented evidence that Resident 3 was offered or refused showers weekly from February 20, 2024, through March 19, 2024, per the resident's care plan.
28 Pa. Code 211.12(d)(5) Nursing Services.