Wallingford Skilled Nursing And Rehabilitation Cen

Based on clinical records review and staff interview, it was determined that the facility failed to follow the wound care physician's order for one of two residents reviewed (Resident CL1). Findings: A review of Resident CL1's wound physician's notes dated January 15, 2026, revealed residents had a right heel DTI (Tissue Pressure Injury- Persistent non-blanchable deep red, maroon or purple discoloration) measuring 2.5 x 3.5 cm (centimeters), and a left heel DTI measuring 2.5 x 2.3 cm. An order was made to cleanse both heels with soap and water, apply skin prep, and leave them open to air daily. A review of Resident CL1's January 2026 Treatment Administration Record (TAR) revealed that the skin prep order for both heels was followed. A review of Resident CL1's wound physician's notes dated January 22, 2026, revealed that the right heel DTI had worsened with a measurement of 3.7 x 6.0 cm. The left-heel DTI had a measurement of 0.3 x 0.3 cm. A new wound treatment was made to apply Betadine (brownish solution used to prevent infections)-soaked gauze to the right heel and cover with a dressing. A new order was also made to apply the left heel with Betadine and leave it open to air. A review of Resident CL1's January 2026 TAR revealed that the right heel treatment was followed. However, further TAR review reveal that left heel DTI treatment was not done from January 23, 2026, until February 8, 2026. An interview was conducted with the Director of Nursing (DON) on March 31, 2026, at 1:00 p.m. The DON confirmed that the left heel DTI order from the wound physician was missed and was therefore not followed. The facility failed to ensure Resident CL1's left heel DTI treatment order was followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of two medication rooms (Two South and Two North) and two of four medication carts (Two South Long Hall and Two South Short Hall). Review the facility policy, Storage of Medications dated, indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. Review of the U.S. FDA approved prescribing information for Lantus (a type of insulin, an injectable medication to treat diabetes) dated 05/2019, indicated that in-use injection pens must be used within 28 days. Review of the U.S. FDA approved prescribing information for insulin lispro (a type of insulin) dated 05/2015, indicated that in-use injection pens must be used within 28 days. During an observation of the Two South nursing unit medication room on [DATE], at approximately 3:30 p.m., the following was observed: (1) Debridement tray [DATE].(1) Package oxygen tubing, [DATE](3) Safety needles, 03/2019.(1) Extension tubing with connector [DATE].(5) Transport swabs [DATE].(3) Urinary catheter securement devices 02/2020.(4) Urinary catheter securement devices [DATE].(1) Urinary catheter securement device [DATE].(1) Urinary catheter securement device [DATE].(1) Urinary catheter [DATE].(1) Urinary catheter [DATE].(2) Urinary catheter insertion kits [DATE].(1) Pair sterile gloves [DATE].(6) Pair sterile gloves 07/2024.(1) Needleless connector [DATE].(1) Luer access device [DATE].(2) Dressing change trays [DATE].(1) Dressing change tray [DATE].(6) Pair sterile gloves 07/2024.(1) Bottle ostomy lubricating deodorant 05/2024. During an interview on [DATE], at approximately 4:00 p.m., the DON and Registered Nurse (RN) Employee E1 confirmed the above medical supplies were expired. During an observation of the Two North nursing unit medication room on [DATE] at approximately 5:20 p.m., the following was observed: (6) Luer lock access devices [DATE](1) Package oxygen tubing, [DATE](5) Safety needles, 09/2018(1) Transfer straw kit 09/2020(1) Tuberculin syringe [DATE](1) IV catheter 04/2009(1) Syringe with connector [DATE].(5) Blood collection needles [DATE].(1) Tissue infusion sets [DATE].(1) Tissue infusion sets [DATE].(1) Dressing change tray [DATE].(1) Luer access device 08/2017.(1) Luer access device [DATE].(2) 2023-2024 season Fluzone High Dose influenza vaccines.(1) Vial tuberculin solution (Tubersol) with an open date of 12/2(3) Transdermal scopolamine patches Feb/25. During an interview on [DATE], at 5:35 p.m., Licensed Practical Nurse (LPN) Employee E2 confirmed the above medications and medical supplies were expired. During an observation of the Two South Long Hall medication cart on [DATE], at 5:45 p.m., the following was observed:One partially used Lantus injection pen with a written open date of [DATE], and a written expiration date of [DATE]. One partially used Lantus injection pen, undated. One partially used lispro injection pen, with [DATE], written on the pen lid, and [DATE], written on the dating sticker. During an interview on [DATE], at 5:48 p.m. LPN Employee E3 confirmed the above injection pens were undated and/or expired. During an observation of the Two South Short Hall medication cart on [DATE], at 5:50 p.m., the following was observed:Two partially used Lantus injection pens, undated. During an interview on [DATE], at 5:53 p.m., RN Employee E4 confirmed the above injection pens were undated. During an interview on [DATE], at approximate 12:00 p.m., the DON and the Administrator in Training confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.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 facility policies, clinical record review, and staff interviews, it was determined that the facility failed to obtain the required dental services for three of five residents. (Resident R1, R2, and R3)Findings include: Review of the facility policy, titled Dental Services dated May 21, 2025, revealed the facility will provide, or obtain from an outside resource, routine and emergency dental services to meet the needs of each patient. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated June 4, 2025, included diagnoses of Anemia (too little iron in the body causing fatigue) and Dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Section L: Oral/Dental Status revealed Resident R1 had experienced, Mouth or facial pain, discomfort or difficulty with chewing within the lookback period (5/28/25 through 6/4/25). Review of Resident R1's plan of care failed to reveal goals and interventions related to dental services or mouth pain until June 2, 2025. Review of a nurse practitioner progress note created on April 15, 2025, at 7:18 p.m., indicated She is being seen today at [resident] request due to complaint of tooth pain. Upon exam, no obvious tooth abnormality or deformity noted, but patient reports pain in right upper back tooth. No increased redness or edema noted. [Resident] denies any other pain or discomfort at this time. The progress further noted: Assessment & Plan:#Tooth pain-acute-new order given to consult dentist.-new order given for Tylenol (acetaminophen, non-narcotic pain medication) 650 mg PO TID (by mouth, three times daily) x5 days. Review of Resident R1's physician note dated April 21, 2025, at 1:03 p.m., revealed Resident R1 C/o (complains of) tooth pain which [he/she] has 2 weeks, relieved by Tylenol. No abscess seen. Dental to see at facility. The progress further noted: Plan:*Tooth Pain-Dental referral placed-d/w (discussed with) nursing-Tylenol for pain prn (as needed). Review of a nurse practitioner progress note dated May 27, 2025, at 3:34 p.m., revealed, No dental consult completed, order placed on 4/21, d/w nursing to schedule. The progress further noted:*Tooth Pain--still pending consult---Dental referral placed-d/w nursing,-Tylenol for pain prn, Review of a change in condition progress note dated June 2, 2025, at 3:30 pm., revealed Resident R1 was experiencing pain and required a dental consult related to pain and tooth cracked. Review of a nurse practitioner progress note dated June 2, 2025, at 3:26 p.m., revealed Resident R1 was seen related to a toothache. Pt (patient) is reporting severe pain L (left) upper side of mouth. On exam, there are no abscesses noted. R (right) upper quadrant tooth 5 or 6 appears chipped/cracked. The progress further noted:#Toothache, acute, labile-Pt c/o R upper quadrant toothache-Order APAP (acetaminophen) 1 gm q 8 x 7 days then PRN (1 gram every 8 hours for seven days, then as needed).-Order Anbesol (topical anesthetic that numbs the skin or mouth for pain relief) qid (four times daily) as prn.-Refer to dentist. Review of Resident R1's progress note dated June 10, 2025, at 4:36 p.m., revealed Resident R1 returned from his/her dental appointment, with temporarily Bridge 2-3-4-5 that is broken in 2 places. Recommendation: needs permanent bridge 2 thru 5. New order Amoxicillin (antibiotic medication). Review of a follow-up note dated June 11, 2025, at 2:08 p.m., revealed Pt initially referred to dentist for L[eft] sided toothache. Reviewed paperwork from appt. Pt with broken temporary bridge 2-5. Recommendations to f/u for permanent bridge as well as course of Amoxicillin. Pt examined today post visit. [Resident] reports [he/she] continues to have pain in L upper quadrant of mouth thought it has improved with APAP. Review of Resident R1's progress note dated June 18, 2025, at 3:06 p.m., revealed Resident R1 was transferred to the hospital for tooth pain/swollen jaw. Review of Resident R1's nurse practitioner progress note dated June 18, 2025, at 3:59 p.m., revealed Pt seen today by request of unit manager for evaluation of swollen face and pt crying in pain. Pt was examined while sitting up in chair. Pt is in obvious distress. [Resident] is crying reporting pain in [his/her] mouth. [Resident] is unable to provide further details only repeating [he/she] needs to see a doctor. On exam, pt with flat red, blotchy area on skin from chin on R side of face. Upper and bottom lips are swollen. Unable to examine inside of pt's mouth as [he/she] is unable to open mouth wide enough presumably due to pain. Review of hospital documentation dated June 18, 2025, revealed Resident R1 was treated in the emergency room for dental pain and a dental infection. Review of Resident R1's progress note dated June 19, 2025, at 2:38 a.m., indicated Resident returned to the facility at 0230 (2:30 a.m.). N/O (new order) to start Augmentin (antibiotic medication) and to schedule a dental appointment ASAP (As Soon As Possible). Review of a follow-up progress note dated June 19, 2025, at 6:31 p.m., revealed, Pt seen today for f/u (follow up) of facial swelling and tooth pain. Pt transferred to ED yesterday after crying in pain and noted with swelling redness on face and lips. Pt was transferred back to facility with Rx (prescription) for Augmentin and recs (recommendations) to f/u with dentist ASAP. Pt examined today while sitting up in chair. [Resident] is a poor historian. [He/she] continues to report pain in tooth. Currently on scheduled APAP with no relief. Was also previously on IBU (ibuprofen, non-narcotic pain medication) with no relief. Review of a progress note dated June 20, 2025, at 2:45 p.m., indicted, Pt seen today in hallway after [he/she] was noted to be at the nurse station crying in pain. Pt is unreliable historian and cannot elaborate on the pain. [He/she] is holding [his/her] face on the R side crying and repeatedly saying [he/she] needs to see a doctor. Pt returned from ED on June 18, 2025 and returned with recs to complete abx and f/u with dentist. The progress further noted:Assessment & Plan:#Dental infection, acute, labile#Broken temporary bridge#Facial swelling- Pt returned from ED with Rx for Augmentin x 10 days- Pt recently completed course of amoxicillin on 6/16, was noted to have facial/lip swelling on 6/18- Augmentin switched to doxycycline (antibiotic medication) 100mg bid x 10 days through 6/29- Ordered tramadol 25mg q8 prn for severe pain- Pt again at nurses station crying in pain. Nurse reports pt just recently received tramadol. Instructed nurse to notify provider if tramadol ineffective for pain control- Continue APAP 1gm q(every) 8 hours. Review of Resident R2's clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses Dementia and gastroesophageal reflux disease (GERD, condition where stomach contents flow back up into the esophagus, causing irritation and other symptoms). Review of a physician's progress note dated April 2, 2025, at 7:01 p.m., indicated, [Resident] is requesting for eye glasses and also to get dental check. The progress note further noted:New order:refer to Opto (optometry)Refer to Dental Review of Resident R2's physician's order dated April 2, 2025, revealed, consult Optometry and dental for Eye glasses and poor dentation. One time only for dentation and poor eye sight for 60 Days. Review of the order details revealed that completion of this order was to be documented on the MAR (medication administration record). Review of Resident R2's MAR from April 2, 2025, through the order completion date of June 1, 2025, revealed this order was completed on April 2, 2025, at 8:57 p.m. Further review of Resident R2's clinical record failed to reveal a dental visit had been scheduled or completed. Review of Resident R3's clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses Dementia and history of a stroke. Review of Resident R3's nurse practitioner note created April 15, 2025, at 1:23 p.m., revealed, Pt was seen by dentist on February 11 at facility. Uploaded consult note reviewed however difficult to read. It appears pt is recommended to follow up in office for extraction of #6. Unclear if this was ever arranged. Will need to f/u with nursing/HUC (unit clerk). Further review of Resident R3's clinical record failed to reveal a dental follow-up had been scheduled or completed. During an interview on August 5, 2025, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to obtain the required dental services for three of five residents. 28 Pa. Code: 211.15(a) Dental services.

Based on a review of facility documents, policy review, observations, and staff interviews, it was determined that the facility failed to properly restrain hair and failed to properly store food items to prevent possible cross-contamination in the Main Kitchen. Findings include: Review of the facility dietary policy, Personal Hygiene dated 5/1/25, indicated Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. Review of the facility policy, Refrigerated/Frozen Storage dated 5/21/25, indicated that food stored under refrigeration/freezer storage is maintained in a safe and sanitary manner. All foods are labeled with the name of product and the date received and use by date once opened. Prepared foods are labeled and dated with the name of the product, date opened, and use by date. During an observation of the Main kitchen on 7/31/25, at approximately 4:05 p.m., the following was observed: Dietary Employee E5 admitted the surveyor to the kitchen. When the surveyor retrieved a hairnet immediately upon entering the kitchen and stepped to the hall to place it on, Dietary Employee E5 retrieved a hairnet and placed it on. Observation of the food preparation area revealed both the industrial food mixer and the slicing machine to be uncovered. In the main cooler:-One package of deli meat, wrapped in plastic wrap, without a date.-Six packages of sliced or shredded cheese, wrapped in plastic wrap, without a date.-One package of unknown meat strips, wrapped in plastic wrap, without a date.-One pan of gray-colored pureed food, not dated.-One package of butter, partially used, with the paper wrapping folded back over it, not dated. -One large pan of three uncut meat roasts, wrapped in foil, not dated.-One pan of yellowed pureed food, not dated. -One plastic container of premade omelets, covered with plastic wrap, not dated. -One plastic jug of white beans, without an open date, with a preprinted use-by date of 7/12/25. -Five packages of tubes of unsliced deli meat, wrapped in plastic wrap, not dated. -Two unopened packages of bologna, with a preprinted use-by date of 7/19/25.-Three packages of partially sliced ham, wrapped in plastic wrap, not dated.-A large pan of red gelatin, with a sticker on it that indicated it was made on 7/23/25, and was to be used by 7/27/25.-The fan located at the ceiling was observed to be leaking condensed water onto the bags of potatoes and multiple boxes of food items. In the freezer:-One open box of fish filets, with the inside plastic liner opened, exposing the food to air, not dated.-A Styrofoam cup with a personal drink on the shelf.-Boxes of food items stacked directly on the floor of the freezer. During an observation on 7/31/25, at 4:22 p.m., Dietary Employee E6 was observed to have a beard, without a facial covering over it. Dietary Employee E6 confirmed that the beard nets were locked in the Dietary Manager's office. During an interview on 7/31/25, at 4:25 p.m., the Administrator in Training confirmed the observation of open, undated foods, the presence of expired foods, the mixer and the slider not being covered, the compressor fan in the cooler leaking water onto food items, and two of three dietary staff present not wearing hair and/or beard restraints. During an interview on 8/4/25, at 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to properly restrain hair and failed to properly store food items to prevent possible cross-contamination in the Main Kitchen. 28 Pa. Code: 211.6(c) Dietary services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to fully investigate allegations of neglect for four of six residents (Resident R4, R5, R8, and R9).Findings include: Review of the facility policy, Abuse Prohibition dated 5/21/25, defined indicated the facility will Initiate an investigation within 24 hours of an allegation of abuse that focuses on:- whether abuse or neglect occurred and to what extent;- clinical examination for signs of injuries, if indicated;- causative factors; and- interventions to prevent further injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/4/25, included diagnoses of respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C indicated a BIMS score of 10. Review of Section H: Bladder and Bowel indicated Resident R4 was always incontinent of bladder and bowel. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C indicated a BIMS score of 04. Review of Section H: Bladder and Bowel indicated Resident R5 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and history of a stroke. Review of Section C indicated a BIMS score of 03. Review of Section H: Bladder and Bowel indicated Resident R8 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and muscle weakness. Review of Section C indicated a BIMS score of 05. Review of Section H: Bladder and Bowel indicated Resident R9 was frequently incontinent of bladder and always incontinent of bowel. Review of a staff-submitted grievance filed on Resident R4 and R5's behalf dated 5/13/25, indicated When I came in the morning, did my rounds, I noticed [Resident R4 and R5's] brief soaked. I told 11-7 (11:00 p.m. - 7:00 a.m.) assigned CNA (nurse aide) but she stated she just changed them and she is about to leave. Then when 7-3 (7:00 a.m. - 3:00 p.m.) CNA came in they also reported that [Resident R8 and R9] were soaked as well and still in their previous clothes. Review of the resolution of the grievance indicated that the nurse aide who was alleged not to have provided care was from a nursing agency and would not be allowed to return to the facility for work. The facility was unable to provide an investigation into an allegation of neglect based on the above grievance. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing (DON) and the Administrator in Training (AIT) confirmed that that an investigation was not completed to ascertain if the licensed nurse supervising the above nurse aide had concerns about her job performance, if other residents on the above nurse aides assignment were provided care, nor was their documentation that skin checks were completed to ensure no skin injuries were incurred due to Residents R4, R5, R8, and R9's extended time left in soiled briefs/clothing. The DON and AIT further confirmed that the facility failed to failed to fully investigate allegations of neglect for four of six residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

Findings include: Review the facility policy, Storage of Medications dated, indicated, Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used extremally such as lotions, creams, ointments, and suppositories. During an observation on 7/31/25, at approximately 5:37 p.m., the treatment cart stored in the Two North Medication room was observed. Upon opening the top drawer, it was noted that the treatment supplies were placed haphazardly in the drawer, with no separation of medications/biologicals based on resident or route of administration. A partial list of what was noted in the cart:Santyl ointmentsCollagenase ointmentsZinc oxide paste.Voltaren cream.Multiple types of gauze and dressing suppliesWound measuring tools.Anti-dandruff shampoo.Medi-honey.Antifungal sprays.Prescription antifungal powder.Multiple rolls of tape.Iodosorb.Vashe wound cleanser.A non-functional thermometer.A watch. Disposable shavers. Upon opening the second drawer, it was noted that the treatment supplies were placed haphazardly in the drawer, with no separation of medications/biologicals based on resident or route of administration. A partial list of what was noted in the cart:Santyl ointmentsZinc oxide paste.Voltaren cream.Multiple types of gauze and dressing suppliesAquafor.Anti-dandruff shampoo.Facial tissue.Antifungal cream.Bandages.Body cleansing wipes.Multiple rolls of tape.Dakin's Solution.Wound cleanser. During an interview on 7/31/25, at approximately 5:40 p.m., Licensed Practical Nurse Employee E2 confirmed the treatment cart was actively in use daily, confirmed the above observations, and confirmed that not storing medications and biologicals for different residents created the potential for cross-contamination between residents. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to maintain infection control practices during medication storage for one of two treatment carts. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e )(1) Management. 28 Pa Code: 211.10 (d ) Resident care policies.

Based on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program on two of four nursing units (One North and Two South nursing units). Findings include: Review of the facility preventive maintenance policy, Infection Control Practices dated 5/21/25, indicated the facility will provide a pest free environment. During an interview on 7/31/25, at approximately at approximately 1:30 p.m., the Nursing Home Administrator confirmed that there had been a bat in the facility, but it had been disposed of by staff. During an interview on 8/1/25, at approximately 11:54 a.m., Resident R11 stated that she had seen mice in her room. During an observation on 8/1/25, at approximately 11:58 a.m., of Resident R12, R13, and R14's room, fruit flies were observed. During an interview on 8/1/25, at approximately 12:00 p.m., Resident R18 stated that he has seen mice in his room. During an interview on 8/1/25, at approximately 12:04 p.m., Resident R16 stated that she has seen field mice in her room. During an interview on 8/1/25, at approximately 12:10 p.m., Resident R17 stated that he has often seen field mice. Resident R17 was interviewed in the unit dining room. Resident R17 gestured to the PTAC unit (packaged terminal air conditioner, a type of self-contained heating and air conditioning system) and stated that there was a hole there, and the mice would come in. Resident R17 also stated that he has seen mice run from beneath the soda machine. During an interview on 8/1/25, at approximately 12:15 p.m., Resident R14 stated that he saw a mouse yesterday (7/31/25). During an interview on 8/1/25, at approximately 12:20 p.m., when asked if he has seen mice in the facility, Resident R15 Sure, all the time. This whole place is full of mice. I had two in my room. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed that the facility failed to maintain an effective pest control program on two of four nursing units. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 207.2 Administrator's responsibility.

Based on review of facility documents and staff interviews it was determined that the facility failed to document grievance resolutions for four of six residents (Resident R4, R5, R6, and R7). Findings include: Review of the facility policy Grievances/Concern dated 1/8/25, stated The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient. Review of facility grievance forms revealed that the form section titled Resolution of Grievance/Concern included areas to document the following:If the grievance was resolved.Date of resolution.Date that written resolution was provided, if necessary.Method used to notify resident or representative of grievance resolution, if not written.Signature and title of staff member resolving the grievance.Signature and title of the grievance officer. Review of a grievance filed on 5/13/25, on behalf of Residents R4 and R5, failed to include documentation including if the grievance was resolved, the date of the resolution, and notification to resident or representative of the resolution. Review of a grievance filed on 5/25/25, on behalf of Resident R6, failed to include documentation of what staff member received the grievance and the resolution date. Review of a grievance filed on 6/23/25, on behalf of Resident R7, revealed the section titled, Resolution of Grievance/Concern to be blank. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed the facility failed to institute corrective actions and resolve resident grievances for four of six residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from abuse for one of six residents (Resident R10).Review of the facility policy, Abuse Prohibition dated 5/21/25, defined verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that they will never be able to see their family again. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), autism disorder, and excoriation (skin-picking) disorder. Review of Section C indicated a BIMS score of 12 (8-12 moderate cognitive impairment, 13-15 cognitively intact). Review of a grievance filed by Resident R10 dated 7/2/25, indicated Resident R10 reported to Social Worker Employee E10 that he was verbally abused by Registered Nurse (RN) Employee E11. Review of statement written by Social Worker Employee E10 indicated, At 1630 (4:30 p.m.) EDT (Eastern Daylight Time) 7/2/25, resident asked to see undersigned. In mtg. (meeting), resident tearful. Resident stated: 'Today when [RN Employee E11] was doing treatment on my back, I guess I may have scratched it again, but she was very mean to me. She started yelling at me, and she said to me' You better stop picking at your wounds or you will never go back home. I have another care meeting next Friday July 11th with the group home staff. I'm afraid [RN Employee E11] is going to say or do something and I will never be able to go back home. She was so mean to me. She was so mad at me.' Review of an employee statement dated 7/2/25, written by RN Employee E11, indicated, [Resident R10] has a large trauma wound on his left shoulder/back. He has increased his picking causing his wound to have extreme delay in healing. On this day [Resident R10's] dressing was removed by him x2 and he picked his wound and caused moderate bleeding and removing tissue from the wound. I have educated him several times that his picking can cause the wound to become infected and delay his discharge. I had to replace his dressing for the third time on 7/2/25 and I did raise my voice to the resident and tell him he needed to stop picking at his wound and that his group home will not take him back until his wound is healed and they do not give that level of care. Resident was seen by psych and his trazodone has now been increased to TID (three times daily). Review of supporting documents attached to the grievance indicated that Resident R10 was interviewed on 7/8/25, at 12:02 p.m., and confirmed that RN Employee E11 yelled at him about picking his wound. He still feels that she will do or say something so he can't go back home. He prefers not to have to deal with her. During an interview on 8/5/25/25, at approximately 12:00 p.m., the Director of Nursing (DON) and the Administrator in Training confirmed that that RN Employee E11 spoked negatively to Resident R10 about a symptom of a diagnosed medical condition, and confirmed that RN Employee E11 raising her voice and verbalizing what was perceived to Resident R10 as a threat to not be able to return to his group home constituted verbal abuse. The DON further confirmed that the facility failed to implement policies and procedures to protect residents from abuse for one of six residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for failing to implement policies and procedures to report allegations of abuse and/or neglect for six of ten residents (Resident R4, R5, R7, R8, R9, and R10). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility policy, Abuse Prohibition dated 5/21/25, indicated that immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the facility will perform the following. -Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury.-Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/4/25, included diagnoses of respiratory failure with hypoxia (condition where the body doesn't have enough oxygen in the tissues) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C indicated a BIMS score of 10. Review of Section H: Bladder and Bowel indicated Resident R4 was always incontinent of bladder and bowel. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C indicated a BIMS score of 04. Review of Section H: Bladder and Bowel indicated Resident R5 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and history of a stroke. Review of Section C indicated a BIMS score of 03. Review of Section H: Bladder and Bowel indicated Resident R8 was frequently incontinent of bladder and bowel. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia and muscle weakness. Review of Section C indicated a BIMS score of 05. Review of Section H: Bladder and Bowel indicated Resident R9 was frequently incontinent of bladder and always incontinent of bowel. Review of a staff-submitted grievance filed on Resident R4 and R5's behalf dated 5/13/25, indicated When I came in the morning, did my rounds, I noticed [Resident R4 and R5's] brief soaked. I told 11-7 (11:00 p.m. - 7:00 a.m.) assigned CNA (nurse aide) but she stated she just changed them and she is about to leave. Then when 7-3 (7:00 a.m. - 3:00 p.m.) CNA came in they also reported that [Resident R8 and R9] were soaked as well and still in their previous clothes. Review of reports submitted to the local state field office did not include a report of allegations of neglect for Residents R4, R5, R8, and R9. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of amyotrophic lateral sclerosis (ALS, a progressive neurological disorder which results in weakened muscles and deformity) and neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination). Review of Section C indicated a BIMS score of 15. Review of a grievance filed on Resident R7's behalf dated 6/23/25, indicated Resident R7 was crying because her nurse would not provide her as needed medications: Zofran (medication for nausea, Gas-x (medication to treat excess digestive gas) and Flexeril (medication used to treat muscle spasms and pain). Additionally, the grievance stated, Come on man, I don't have time for this. If you are going to keep asking about your medication, I am (missing information). Review of reports submitted to the local state field office did not include a report of allegations of neglect or verbal abuse for Resident R7. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and excoriation (skin-picking) disorder. Review of Section C indicated a BIMS score of 12. Review of a grievance filed by Resident R10 dated 7/2/25, indicated Resident R10 reported to Social Worker Employee E10 that he was verbally abused by Registered Nurse (RN) Employee E11. Supporting documents attached to the grievance indicated that Resident R10 was interviewed on 7/8/25, at 12:02 p.m., and confirmed that RN Employee E11 yelled at him about picking his wound. He still feels that she will do or say something so he can't go back home. He prefers not to have to deal with her. Review of reports submitted to the local state field office did not include a report of possible verbal abuse for Resident R10. During an interview on 8/5/25, at approximately 12:00 p.m., the Director of Nursing and the Administrator in Training confirmed that facility failed to implement policies and procedures to report allegations of abuse and neglect for six of ten residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) (e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and interviews with residents and staff it was determined that the facility failed to maintain personal dignity for two of six residents observed (Resident R1, R2)
Findings Include:
Facility policy titled Residents Rights Under Federal Law , revised 2023, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
Clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included fracture of upper end of left humerus, schizophrenia (mental health condition that affects how people think, feel, and behave), and muscle weakness.
Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 06, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact.
Review of Resident R1's MDS assessment, dated June 10, 2025, revealed under section GG- functional abilities, Resident R1 is dependent (helper does all the work) on upper and lower body dressing (the ability to dress and undress)
Observation on 1st floor unit 2 wing on June 21, 2025 at 11:02 a.m. revealed Resident R1's door open. Resident R1 was observed to be exposed with only a brief on.
Interview with Resident R1 on June 21, 2025 at 11:04 a.m. revealed Resident R1 felt uncomfortable that his/her door was open while he was laying in bed with only a brief on. Resident R1 stated staff did not close the door when exiting the room.
Clinical record review revealed Resident R2 was admitted to the facility on [DATE] with a diagnosis that congestive heart failure (chronic condition that affects the hearts ability to pump blood well), rhabdomyolysis (serious condition where the muscles break down and release toxins into your blood and kidneys), and muscle weakness.
Review of Resident R2's MDS assessment, dated May 08, 2025, revealed Resident R2 had a BIMS score of 13 indicating cognitively intact.
Review of Resident R2's MDS assessment, dated May 20, 2025, revealed under section GG- functional abilities, Resident R2 requires supervision or touching assistance (helper provides verbal cues and/or touching/ steadying assistance as resident completes activity) on upper and lower body dressing.
Observation on 2nd floor unit 4 wing on June 21, 2025 at 11:13 a.m. revealed Resident R2's door open. Resident R2 was observed sitting on his/her bed with lower body exposed and no brief on.
Interview with Resident R2 on June 21, 2025 at 11:14 a.m. revealed Resident R2 needed assistance with lower body dressing.
Interview with Certified Nursing Assistant, Employee E1, on June 21, 2025 at 11:17 a.m. confirmed Resident R2 requires assistance with dressing and Resident R2's door should be closed for privacy.
Residents R1 and R2 both had their doors and privacy curtains open, revealing their body to anyone who walked past their rooms.
28 Pa. Code: 201.18(b)(2) Management.
28 Pa. Code: 201.29(j) Resident's rights.

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a significant weight change for one of the 35 residents reviewed (Resident 114).
Findings include:
A review of the facility's policy titled Weights and Heights, last revised on February 1, 2023, revealed, that if the body weight is not expected, re-weigh the patient. A significant weight change is defined as 5% in one month and 10% in six months. Significant weight changes will be reviewed by the licensed nurse for assessment. The physician and Dietitian will be notified, and notification of the physician and Dietitian will be documented in the Weight Change Progress Note.
Clinical records review revealed Resident 114 had a diagnosis of Congestive Heart Failure (CHF weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs).
A review of Resident 114's weights and vitals revealed a weight of 131.2 pounds on November 4, 2024, and 150.2 pounds on December 5, 2024, a 19 pounds (14.48%) significant weight gain in one month.
The clinical records review failed to reveal that the resident was assessed and that the physician was notified of the significant weight change identified on December 5, 2024.
Clinical records review revealed Resident 114's weight was not rechecked until December 11, 2024, six days after significant change was identified with a weight result of 154.2 pounds.
December 11, 2024, clinical records review failed to reveal that the physician was notified of the significant weight change.
An interview with licensed nurse Employee E9 conducted on December 12, 2024, at 11:30 a.m., confirmed that the physician was not notified of Resident 114's significant weight change.
The facility failed to ensure physician was notified of Resident 114's significant weight change.
28 Pa Code: 211.10(c) Resident care policies
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for four out of 35 residents reviewed (Resident 11, Resident 59, Resident 64, and Resident 164).
Findings include:
Review of facility policy titled Enhanced Barrier Precautions, revision date January 8, 2024, states Enhanced Barrier Precautions (EBP) is based on the Centers of Disease Control & Prevention (CDC) guidance, Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent spread of multidrug-resistant organisms (MDROs).
Review of Resident 11's clinical record revealed the resident was admitted [DATE], with an admitting diagnosis of sepsis (occurs when your immune system has a dangerous reaction to an infection, resulting in tissue damage and organ failure).
Additional review of Resident 11's clinical record revealed an active order for indwelling foley catheter due to: neurogenic bladder (a condition where a problem in the brain, spinal cord, or central nervous system causes loss of bladder control), with a start date of July 5, 2024.
Review of Resident 11's clinical record failed to reveal an order for enhanced barrier precautions.
Observations conducted on December 11, 2024, and December 12, 2024, revealed that Resident 11 did not have any EBP signage or PPE located in or outside of his room.
Interview conducted with the Director of Nursing (DON) on December 12, 2024, at 10:37 a.m. confirmed the facility failed to establish enhanced barrier precautions for Resident 11.
Clinical records review revealed Resident 59 had an order for a GT (Gastrostomy tube- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth) feeding for diagnosis of protein calorie malnutrition.
Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 59's room.
Clinical records review revealed Resident 64 had an order for a GT feeding .
Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 64's room.
Clinical records review revealed Resident 164 was admitted on [DATE], with a diagnosis of small bowel cancer. The resident had an admission order for a PICC line (Peripherally Inserted Central Catheter- a thin, flexible tube inserted into a vein in the vein near arm and threaded into a large near the heart) to the left upper arm, a foley catheter for urinary retention and a GT attached to a collection bag for abdominal decompression.
Observation and interview with the Resident 164 confirmed that presence of a PICC line to the left upper arm, indwelling foley catheter, and GT attached to a collection bag.
Observation on December 9, 10, and 11, 2024, failed to reveal an EBP signage/communication or PPE set up in or outside of Resident 164's room.
An interview with licensed nurse Employee E6 conducted on December 12, 2024 at approximately 10:00 a.m., revealed that residents requiring EBP needed to have a signage by the door for communication and PPE set up outside of the resident's room. Employee E6 acknowledged the absence of the signage and PPE set up for Resident 64 and 164 and reported that she/he just notified the staff responsible in placing the signage and PPE's for the resident mentioned above.
An interview with the Regional nurse Employee E9 and Director of Nursing on December 12, 2024, at 1:00 p.m., confirmed EBP process was not implemented for Resident 59, 64, and 164.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of the facility's policy, observations, and staff interview, it was determined that the facility failed to ensure medications were properly stored and labeled for one of the two units observed (1 North).
Findings include:
A review of the facility policy titled Medication Storage undated, revealed medications and biologicals are stored properly, following manufacturers' or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements. Medications are to remain in these containers and stored in a controlled environment.
An observation on the 1 North short hall med cart was conducted on December 10, 2024, at 9:30 a.m., with the presence of licensed Employee E6. Observation of the top drawer of the medication cart revealed the following: five white tablets in a medication cup; 12 loose Allegra tablets (A medication used to treat allergies) tablets; and five loose Famotidine tablets (A medication used to treat heartburn).
An interview with Employee E6 conducted on December 10, 2024, revealed that the white tablets in the medication cup were Acetaminophen (A medication used to treat mild pain) taken from its original container from another medication cart. Employee E6 was unable to provide an answer as to why Allegra and Famotidine were not in their original container.
An observation on 1 North long hall medication cart was conducted on December 10, 2024, at 9:45 a.m., with the presence of Licensed Employee E7. Observation of the medication cart revealed the following: 53 loose tablets/pills (different colors and sizes) were scattered in the drawer where all medications on a blister pack were stored; an uncovered glucose gel tube with no pharmacy label; and a vial of used Lantus (A long-acting type of Insulin) dated (opened) October 25, 2024.
An observation of the 1 North medication room was conducted on December 10, 2024, at 10:00 a.m., with the presence of licensed Employee E8. Observation of the medication room refrigerator revealed 23 Acetaminophen suppositories and 22 Bisacodyl suppositories (A medication used for constipation). Both medications were stored in a zip-lock bag with no pharmacy label.
An interview with Employee E8 conducted on December 10, 2024, confirmed that the acetaminophen and Bisacodyl suppositories should be in their original container.
The above was conveyed to the Nursing Home Administrator on December 12, 2024.
The facility failed to ensure medications on the 1 North Unit medications carts and the room was properly stored and labeled.
28 Pa Code: 211.10(c) Resident care policies
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interview, it was determined that the facility failed to provide a consistent non-pharmacological intervention (NPI) and failed to provide an appropriate indication for the use of as-needed psychotropic medication for one of five residents reviewed (Resident 164).
Findings include:
A review of Resident 164's physician's order dated October 21, 2024, revealed an order for Lorazepam (A medication used to treat Anxiety) 0.5 mg one tablet two times daily. An order for Lorazepam 0.5 mg one tablet by mouth every six hours PRN (as needed) for Anxiety was also made on the same day.
A review of the December 2024, Medication Administration Record revealed that from [DATE], until December 12, 2024, aside from the schedule two times daily Lorazepam order, Resident 164 was administered with PRN Lorazepam order six times in 12 days.
Clinical records review revealed that from December 1, 2024, until December 12, 2024, Resident 164 was administered with PRN Lorazepam four times with no NPI (non-pharmacological interventions- intervetnions that should be attempted prior to the administration of medications) before administering the medication. In addition, a record review revealed resident was administered with PRN Lorazepam six times with no appropriate indication.
An interview with the Director of Nursing conducted on December 12, 2024, at 1:30 p.m., confirmed NPIs were not consistently provided and appropriate indications were not provided before administering the PRN Lorazepam.
The facility failed to ensure Resident 164 was provided with an NPI before administering an anti-anxiety medication and appropriate indication was documented for the use of the anti-anxiety medication.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication to treat Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time) was made available for one of 35 residents reviewed (Resident 13).
Findings include:
A review of Resident 13's physician order dated August 28, 2024, revealed an order for Trulicity (A medication used to help lower blood sugar levels in people with type 2 diabetes) 4.5mg/0.5ml Inject 4.5 mg subcutaneously one time a day every Wednesday for Diabetes.
A review of the October and November 2024, Medication Administration Record revealed Trulicity was not administered on October 9, 30, and November 13, 2024.
Nursing progress notes dated October 9, 2024, October 30, 2024, and November 13, 2024, all indicated medication Trulicity (not administered), pharmacy notified.
A review of the laboratory report dated April 10, 2024, revealed an HbA1c (A hemoglobin A1C test is a blood test that shows what your average blood sugar level was over the past two to three months) result of 8.1 (NORMAL: HbA1c below 5.7%, PREDIABETES: HbA1c 5.7-6.4%, DIABETES: HbA1c 6.5% and ABOVE). A laboratory report dated November 6, 2024, revealed an HbA1c result of 11.5.
A review of the physician's progress notes dated November 21, 2024, revealed Resident 13's HbA1C was very high at 11 this month which is significantly higher than eight (8) in April 2024. The physician documented Unfortunately he/she did not get three doses of Trulicity recently which will impact his/her HbA1c.
An interview with Employee E9 confirmed that Trulicity was not adminstered due to medication not being delivered from the pharmacy.
The facility failed to ensure Resident 13's medication to help treat high blood sugar was consistently made available for the resident.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility procedure and clinical record review, it was determined that the facility failed to adequately monitor and address significant weight loss in one of nine residents reviewed for nutrition (Resident 130).
Findings include:
Review of facility procedure Weights and Heights, last revised February 1, 2023, revealed: If the body weight is not as expected, re-weigh the patient. The policy further stated: Significant weight changes will be reviewed by the licensed nurse for assessment. The licensed nurse would then notify the provider and dietitian of significant weight changes, document notification, and notify the physician of recommendations made by the dietitian.
Review of Resident 130's weights revealed on September 6, 2024, the resident was documented as weighing 131.5 pounds (lbs.) On October 3, 2024, the resident was documented as weighing 123.8 lbs., a 5.86% loss in one month. The next documented weight in Resident 130's clinical record was not obtained until November 8. 2024, where the resident was documented as weighing 117.4 lbs., a 5.45% loss in one month. Further review of Resident 130's weights revealed the next weight was not obtained until December 11, 2024, where the resident was recorded as weighing 122.6 lbs.
Review of Resident 130's progress notes and assessments failed to reveal evidence that the resident's weight loss was communicated to or addressed by the dietitian.
Review of Resident 130's care plan and order summary failed to reveal any interventions added to the care plan or orders to address the resident's weight loss following the resident's weight loss.
The above findings were discussed and confirmed with the Nursing Home Administrator on December 12, 2024, at approximately 9:50 a.m.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa Code: 211.10(c) Resident care policies

Based on review of facility procedure, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consistent, adequate catheter care was provided to one of five residents reviewed for catheters (Resident 167).
Findings include:
Review of facility procedure, Catheter: Indwelling Urinary - Care of, last revised February 1, 2023, revealed that catheter care is to be performed twice daily and as needed, and the catheter care is to be documented in the clinical record.
Observation of Resident 167 on December 10, 2024, at approximately 9:00 a.m. revealed the resident had a Foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine).
Review of Resident 167's physician's orders, Medication Administrator Records, Treatment Administration Record, and care plan failed to reveal evidence that the resident was receiving routine catheter care.
The above findings were discussed and confirmed with the Nursing Home Administrator on December 12, 2024, at approximately 9:50 a.m.
28 Pa Code 211.12(d)(5) Nursing Services

Based on clinical record review and employee interview it was determined that the facility failed to ensure physician's orders were followed for one of 35 residents reviewed (Resident 19).
Findings include:
Review of Resident 19's physician's orders revealed an order dated October 3, 2023, for oxygen 2 liters via nasal cannula (tubing that wraps around the ears that supplies oxygen via the nose). Further review of Resident 19's physician's orders revealed an order dated March 7, 2024, to maintain ear protectors on oxygen tubing at all times.
Review of Resident 19's Treatment Administration Records revealed staff were signing off that the ear protectors were maintained on the oxygen tubing.
Review of Resident 19's progress notes revealed a practitioner note dated August 28, 2024, which stated: this is [an acute] visit per nurse request. Patient has [significant] redness and swelling behind left ear. Patient has oxygen and per nurse she injures area with oxygen tubing. The practitioner prescribed doxycycline (antibiotic) 100 milligrams twice daily for seven days, hydrocortisone cream to the left ear twice daily for 10 days, and Bactroban (antibiotic ointment) to the left ear for 10 days.
Further review of Resident 19's progress notes revealed a nurse's note dated August 28, 2024, which stated: Skin note: abrasion to behind left ear caused by nasal cannula without oxyears [(protection on the oxygen tubing to prevent skin breakdown to the ears)].
Further review of Resident 19's progress notes revealed a practitioner note on September 19, 2024, which stated that the area to the resident's left ear resolved.
The facility's failure to maintain ear protectors on Resident 19's oxygen tubing was discussed with and confirmed with the Nursing Home Administrator on December 12, 2024, at 9:50 a.m.
28 Pa. Code 201.18(b)(1) Management
28 Pa. 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f) Clinical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical records review, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided to prevent a fall for one of the 35 residents reviewed (Resident 156).
Findings include:
A review of Resident 156's diagnosis list includes cerebral infarction (a condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), contracture (a permanent tightening of the muscles, tendons, and ligaments that prevents normal movement of a joint or body part), falls, and intellectual disabilities.
A review of the Quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated November 8, 2025, revealed Resident 156 had a moderate cognitive impairment. The same MDS revealed that the resident had impairment to one side of the upper and lower extremities. The resident was dependent on toileting and personal hygiene. State MDS dated [DATE], revealed that the resident required extensive assistance with two-person help with bed mobility.
An observation conducted on December 9, 2024, at 10:00 a.m., revealed the resident lying in bed with left hand /wrist bent inward and left knees bent.
A review of the Occupational Therapy (OT-A professional staff that assists people in regaining their physical and psychological well-being) evaluation report dated November 6, 2024, revealed that functional Skills Assessment with toileting and dressing on the lower body revealed resident was dependent with two or more helpers.
A review of the nursing progress notes dated November 27, 2024, at 2:25 a.m., revealed Resident was observed in a side-lying position (on the floor), the caregiver stated that she/he turned the resident onto his/her side and lunged off the edge of the bed. The resident was assessed with no visible sign of pain.
A review of the facility's investigation revealed that on November 27, 2024, the resident was observed lying on his left side on the bedroom floor, with his face towards the bed. The resident was unable to give an account of the incident.
A review of the statement completed by unlicensed staff Employee E10 on November 27, 2024, revealed While doing care on the resident, he/she suddenly lunges to the side of the bed and landed on the floor, I called out for help.
An interview with the Nursing Home Administrator, conducted on December 12, 2024, at 10:30 a.m., confirmed that during the fall, there was only one staff providing care to the resident.
The facility failed to ensure adequate supervision of two staff memebers was provided to Resident 156 while care was being provided resulting in a fall.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure non-pharmalogical interventions (NPIs) were attempted prior to the administration of as-needed narcotic pain medication for one of thirty-three residents reviewed (Resident 98).
Findings include:
Review of Resident 98's physician's orders revealed an order dated October 25, 2023, for oxycodone (narcotic pain reliever) 5 milligrams (mg) give every 4 hours as needed, and document all NPIs prior to administering the medication.
Review of Resident 98's April 2024 Medication Administration Record (MAR) revealed the resident received as-needed oxycodone 5 mg a total of 21 times. Review of Resident 98's May 2024 MAR revealed the resident received as-needed oxycodone 5 mg a total of 20 times. Review of Resident 98's June 2024 revealed the resident received as-needed oxycodone 5 mg a total of 26 times as of June 21, 2024.
Further review of Resident 98's April 2024, May 2024, and June 2024 MARs and progress notes failed to reveal NPIs were documented prior to administering the resident's oxycodone 5mg.
Interview with the Director of Nursing on June 24, 2024, at approximately 1:25 p.m. confirmed the facility failed to document NPIs prior to administering Resident 98's as-needed pain medication.
28 Pa Code 211.5 (f) Clinical records
28 Pa code 211.10 (c) Resident care policies
28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on the clinical records review interview with staff and physician, it was determined that the facility failed to notify the physician of an abnormal blood result for one of the three residents reviewed (Resident R1).
Findings include:
A review of Resident 1's physician order dated July 31, 2024, revealed an order for Coumadin 5 mg one tablet one time a day on Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for A-Fib (Irregular heartbeat).
Clinical records review revealed a blood work for INR (International Normalized Ratio- A standardized measurement of prothrombin time, which is the test that measures how long it takes blood to clot. An INR for healthy people is between 0.8 and 1.2.) was done on August 13, 2024t, with a result of 4.1 indicating a critical high result.
The laboratory result revealed that the result was reported on August 13, 2024.
Clinical records review failed to reveal that the physician was notified of the critical high INR result.
A review of Resident 1's Medication Administration Record revealed that the resident was administered with Coumadin 5mg on August 13, 14, and 15, 2024, with an INR level of 4.1.
A review of the physician notes dated August 15, 2024, at 9:51 a.m., revealed laboratory shows INR of 4 on August 13, 2024, not sure if it was reported or not. Called the nursing home at 9:45 p.m., and as per the nurse, Coumadin was already received tonight. Ordered to hold the Coumadin until the next INR.
A clinical records review revealed repeat INR done on August 16, 2024, was 8.1, indicating a critically high result, Coumadin was placed on hold.
A review of the progress notes dated August 18, 2024, at 4:41 a.m., revealed INR remained critically high at 8.4. NP was notified, Vitamin K (A medication used to manage and treat bleeding due to the coagulation disorder caused by Warfarin and Vit K deficiency) was ordered and administered, resident was monitored for bleeding.
An interview conducted with the Nurse Practitioner on August 21, 2024, at 11:00 a.m., confirmed that the physician was not notified of the critical high INR result reported by the laboratory on August 13, 2024. The NP reported that she/he would have ordered to hold the Coumadin if was notified of the 4.1 INR result on August 13, 2024.
An interview with the Director of Nursing conducted on August 13, 2024, at 11:30 a.m., revealed that once a laboratory result was reported, it was the nurse's responsibility to notify the physician of the critical high result. The DON was unable to provide documented evidence that the facility notified the physician of Resident R1's critical high INR result on August 13, 2024.
The facility failed to ensure physician was notified of the abnormal INR result of Resident 1.
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility policy and procedure, clinical record, and staff interview it was determined the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed. (Resident 264)
Findings include:
Review of Facility policy and procedure titled Accidents/Incidents, last revised on March 1, 2024 revealed, When conducting an investigation the Administrator, DON, or designee will make every effort to ascertain the cause of the accident/incident .Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident.
Review of Resident 264 progress notes revealed a nursing entry dated February 21, 2024 at 1:44 p.m. stating, during rounds resident grimacing and moaning when left lower extremity moved, resident have limited to no movement of left leg, NP (Nurse Practitioner) seen and examined and resident with new order for stat (immediate) x-ray of the left hip, pelvis, and femur and knee.
Further review of Resident 264 progress notes revealed a nursing entry on February 21, 2024 at 4:48 p.m. stating x-ray results received: moderately displaced intertrochanteric fracture of the left hip (hip fracture). New orders to send to the ER (emergency room).
Review of the Incident Report for the injury to Resident 264 on February 21, 2024 revealed the resident was found to be non-mobile this am. STAT (meaning - immediately) x-rays ordered and resulted positive for moderately displaced fracture of the left hip. There were no witnesses listed and two statements from an LPN and a CNA who worked the 3-11 shift on February 20, 2024 and stated the resident was ambulating normally and provided no information as to the possible cause of the injury.
The facility failed to conduct a thorough investigation by not interview staff who cared for the resident on the shift the injury was identified, or the previous night shift staff assigned to the resident and were unable to determine a timeline of when the injury could have occurred or the cause of the injury.
Interview with the Director of Nursing on June 24, 2024 at 1:30 p.m., confirmed the investigation into Resident 264 hip fracture was not thoroughly completed.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.29(a)(d) Resident Rights
28 Pa. Code 211.5(f) Clinical Records

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication ordered by the physician was followed for one of the 33 residents reviewed (Resident 70).
Findings include:
Review of Resident 70's diagnosis list includes Chronic Kidney Failure and Dependence on Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).
Review of Resident 70's clinical record revealed the resident goes for dialysis services every Tuesday, Thursday, and Saturday at 10:00 a.m.
Review of the Resident 70's blood work dated June 4, 2024, revealed a Phosphorus level of 6.8 mg/dl (normal range 2.5- 4.5)
Review of Resident 70's physician's orders dated June 2, 2024, and June 13, 2024, revealed an order for Calcium Acetate (Phosphate binder) 667 mg one tablet by mouth with meals for elevated phosphorus. The medication was scheduled for 8:30 a.m., 12:30 p.m., and 5:00 p.m.
Review of Resident 70's medication administration record revealed that the medication was not administered on June 4, 6, 15, 18, and 20, 2024, at 12:30 p.m.
Interview with the Director of Nursing conducted on June 15, 2024, revealed that the medication was not administered due to the resident being out of the facility for dialysis.
The clinical records review failed to reveal the physician was notified of the missed medication until June 24, 2024.
The facility failed to ensure medication (Calcium Acetate) to treat elevated Phosphorus was followed.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263)
Findings include:
Review of facility policy and procedure titled Assessment: Nursing last revised March 2022, revealed A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. Assessments will be reviewed and certified as completed by an RN within 24 hours and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment, he/she completed.
Review of Resident 263's clinical record revealed the resident was admitted to the facility on [DATE] from the hospital.
Review of Resident 263's documentation from the hospital revealed the resident went to the hospital and was admitted after a near syncope (fainting) episode during which she was hypotensive (low blood pressure) and had difficulty getting into her house. Further review of the hospital documentation revealed the resident was discharged with a diagnosis of Hypotension and Syncope.
Review of Resident 263's physical therapy documentation while in the hospital revealed the resident was determined to be at risk for falls and to have ambulation deficits, balance deficits, bed mobility deficits, strength deficits, transfer deficits and safety awareness deficits.
Review of Resident 263's facility diagnosis list revealed diagnosis of Hypotension (low blood pressure), Syncope (sudden, temporary drop in the amount of blood that flows to the brain), and collapse.
Review of Resident 263's Vital Signs revealed a blood pressure on December 17, 2023 at 9:32 P.M. of 102/45 (normal 120/80).
Review of Resident 263's admission assessment dated [DATE] revealed the resident was determined to have no risk factors for falls related to history or fear of falls or factors such as current diagnosis or medications that would increase the risk for falls and there was no risk for falls due to the resident's presence or history of gait, strength, or balance factors.
Review of Resident 263's progress notes revealed a nursing entry dated December 18, 2023 at 2:53 a.m. that indicated CNA (Certified Nursing Assistant) heard a noise and went into the room to check on patient and found her on the floor face down next to the bed. R (right) facial laceration at smile line measuring 4 cm (centimeters) and one of R eye measuring 1.5 cm. Peri orbital (eye) swelling noted on right side. EMS (Emergency Medical Services) called at 0233 (2:33 a.m.).
Review of Resident 263's care plan revealed there was no care plan developed for risk for falls or interventions in place prior to the fall of December 18, 2023.
Resident 263 was inaccurately assessed at the time of admission as not being at risk for falls and there were no interventions in place to prevent falls leading to a fall with major injury that required hospitalization on December 18, 2023.
This information above was relayed to the Nursing Home Administrator on June 24, 2024 at 1:15 p.m.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to monitor and address significant weight changes in a timely manner for two of six residents reviewed for nutrition (Residents 54 and 60).
Findings include:
Review of Resident 54's weights revealed the resident had not been weighed since April 24, 2024.
Review of Resident 54's progress notes revealed a dietitian entry dated May 20, 2024 stating No updated weight this month. Rt refused to be weighed Attempted to get weight again today but sit to stand scale is broken.
Review of Resident 54's clinical record revealed there was no other documentation of resident refusing to be weighed and there was no care plan developed for the resident related to refusals.
Interview with the Director of Nursing confirmed Resident 54 had not been weighed since April 24, 2024 and there was no other documented evidence Resident 54 had refused weights.
Interview with the Nursing Home Administrator on June 24, 2024 at 1:15 p.m. revealed the maintenance director had inspected the scale used for Resident 54 and it was in working order.
The facility failed to get at least monthly weight of Resident 54 to properly evaluate his nutritional status.
Observation of Resident 60 on June 20, 2024, at 9:00 a.m. revealed the resident had a PEG tube (percutaneous endoscopic gastrostomy - plastic tube inserted into the stomach to provide nutrition, hydration, and medication).
Review of Resident 60's care plan initiated November 6, 2016, revealed the resident was identified as at risk for alteration in nutrition status related to anoxic brain injury, dysphagia (difficulty swallowing), and the need for enteral nutrition, with an intervention to review weights and to notify the physician and responsible party of significant weight changes.
Review of Resident 60's weights revealed on June 2, 2024, the resident was recorded as weighing 147.6 pounds (lbs.). On June 4, 2024, the resident was recorded as weighing 158 lbs., a 10.4 lb., or 7.05% weight gain in two days.
Review of Resident 60's progress notes revealed a nutrition note on June 19, 2024, which stated: Brief weight change note. Resident shows potential 7% wt gain x 2 days, and x 1 month, which is significant. Wts reviewed: 158# (6/4), 147.6# (6/2), 147.8# (5/3). Resident will need reweight to confirm 10.4# wt gain x 2 days. Reweight requested. No edema noted. Full weight change/nutrition assessment to follow once reweight is obtained and sig wt change is confirmed.
Review of Resident 60's weights as of June 24, 2024, failed to reveal that a reweight was obtained.
Interview with the Director of Nursing on June 24, 2024, at approximately 1:20 p.m. failed to reveal an explanation as to why a reweight for Resident 60 was not obtained.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa Code: 211.10(c) Resident care policies

Based on Clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of five residents reviewed. (Resident 54)
Findings include:
Review of Resident 54's clinical record revealed the resident returned from the hospital on February 28, 2024 with a PEG tube (feeding tube- tube surgically inserted into the stomach when oral intake is not adequate).
Review of the physician orders revealed an order dated April 24, 2024 for Jevity 1.5 (tube feeding) running at 65 ml per hour starting at 5 p.m. and ending at 9 a.m. for a total of 1040 ml per day.
Review of resident 54's Medication Administration Record (MAR) for the months of April, May and June 2024 revealed there were no days where it was documented the resident received a total of 1040 ml per day as ordered by the physician.
Interview with the Director of Nursing on June 24, 2024 at 11:15 a.m. confirmed there was no documented evidence Resident 54 had received the amount of tube feeding as ordered by the physician.
28 Pa Code: 211.5(f) Clinical records
28 Pa code: 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for four of five residents reviewed (Resident 16, 29, 77, and 137).
Findings include:
Review of Resident 16's Consultation Report for the Medication Regimen Review completed on September 1, 2023, revealed a recommendation to consider a trial dose reduction of Aripiprazole (anti-psychotic medication) to 2 mg at night.
Review of Resident 16's clinical record failed to reveal that the above recommendation was addressed by the physician.
Interview with the Director of Nursing on June 25, 2024, at 1:00 p.m., confirmed that the pharmacy recommendation made on September 1, 2024, was not addressed by the physician.
Review of Resident 29's Consultation Report for the Medication Regimen Review completed on February 1, 2024, revealed a recommendation for a dose reduction evaluation for the medications Clonazepam (Anti-anxiety medication), Haloperidol (Anti-psychotic medicines), and Escitalopram (ant- depressant medication).
Review of Resident 29's clinical record failed to reveal that the above recommendation was addressed by the physician.
Interview conducted with the DON on June 25, 2024, at 1:00 p.m., confirmed that the pharmacy recommendations made on February 1, 2024, were not addressed by the physician.
Review of Resident 77's Consultation report for the Medication Regimen Review completed on May 4, 2024 revealed the pharmacist recommended the facility only order as needed Xanax (anti-anxiety medication) for a duration of 14 days per CMS (Centers for Medicare and Medicaid) regulations. This recommendation was not addressed by the physician until June 24, 2024.
Interview conducted with the Director of Nursing on June 24, 2024 at 1:35 p.m. confirmed Resident 77 recommendations from the pharmacist on May 4, 2024 was not addressed timely.
Review of Resident 137's clinical record revealed Resident 137 was admitted into the facility on May 19, 2023, with a BIMS (Brief Interview of Mental Status) score of 3, indicating severely impaired cognition.
Review of Resident 137's clinical record including admission diagnoses of Dementia with Agitation, Dysphagia (swallowing disorder), Restlessness, Agitation, Psychosis, Depression, Seborrhea Capitis (skin condition), Anemia (low blood cells), and Hypokalemia (low potassium).
Review of Resident 137's clinical records revealed a physician order dated February 23, 2023, for Haloperidol Oral Tablet 1 mg. for psychosis.
Review of Resident 137's clinical records revealed a physician order dated June 2, 2023, for Olanzapine Oral Tablet 5 mg. for dementia with agitation.
Further review of Resident 137's clinical records revealed a physician order dated June 20, 2023, for Mirtazapine Tablet 7.5 mg. for depression.
Review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on January 4, 2024, with two recommendations, 1.) semi-annual dose reduction evaluation requested for the above medications, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg). 2.) Periodically reevaluate [NAME] antipsychotic use.
Further review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on May 10, 2024, with the recommendation, trial dose reduction of the above medications requested, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg).
Review of Resident 137's clinical record failed to reveal documented evidence the pharmacist recommendations were addressed by the attending physician.
Interview with the Director of Nursing on June 24, 2024, at 1:35 p.m. confirmed there was no documented evidence of a response by the physician to the recommendations made by the consultant pharmacist.
483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
28 Pa. Code 211.12(c) Nursing Services
Previously cited 8/25/23, 10/23/23,
28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 8/25/23, 10/23/23,
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 8/25/23, 10/23/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications by attempted dosage reductions and periodical reevaluation of psychotropic drug usage for three of five residents reviewed (Residents 16, 29, and 137).
Findings include:
Review of the facility's policy titled Psychotropic Medication Use dated December 1, 2007, revealed the facility should ensure that the ordering physician reviews the medication plan and considers a Gradual Dose Reduction (GDR) of psychotropic medications to find the lowest effective dose unless a GDR is clinically contraindicated. The physician should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.
Review of Resident 16's physician order dated September 1, 2023, revealed an order for Aripiprazole (anti-psychotic medication) 5 mg (milligram) given by mouth at bedtime for Major Depressive Disorder (MDD).
Review of Resident 16's clinical record failed to reveal the facility attempted to do a GDR for Resident 16's Aripiprazole.
Interview with the Director of Nursing (DON) on June 24, 2024, at 1:00 p.m., confirmed there was no attempt to perform GDR of Aripiprazole medication and no documentation of a physician's rationale for Resident 16.
Review of Resident 29's physician order dated March 31, 2016, revealed an order for Klonopin tablet (Anti-anxiety medication) 0.5 mg give one tablet by mouth at bedtime for anxiety,
Review of Resident 29's physician order dated July 1, 2021, revealed an order for Lexapro (Anti-depressant medication) 20 mg by mouth one time a day for depression.
Review of Resident 29's physician order dated October 6, 2021, revealed an order for Haloperidol Lactate Concentrate 2mg/ml given 1mg by mouth at bedtime for Dementia with behavioral disturbances.
Clinical records review failed to reveal that the facility attempted to do GDR for the Klonopin, Lexapro, and Haloperidol medication for Resident 29.
Interview with the Director of Nursing (DON) on June 24, 2024, at 1:00 p.m., confirmed that there was no attempt to perform GDR on Klonopin, Lexapro, and Haloperidol medications and no documentation of a physician's rationale for not attempting the GDR for Resident 29.
Review of Resident 137's clinical record revealed Resident 137 was admitted into the facility on May 19, 2023, with a BIMS (Brief Interview of Mental Status) score of 3, indicating severely impaired cognition.
Review of Resident 137's admission diagnoses revealed Dementia with Agitation, Dysphagia (difficulty swallowing), Restlessness, Agitation, Psychosis, Depression, Seborrhea Capitis (skin condition consisting of scaly patches, inflamed skin affecting oily areas of the body), Anemia (low blood cells), and Hypokalemia (low potassium).
Review of Resident 137's clinical records revealed a physician order dated February 23, 2023, for Haloperidol Oral Tablet 1 mg for psychosis.
Review of Resident 137's clinical records revealed a physician order dated June 2, 2023, for Olanzapine Oral Tablet 5 mg. for dementia with agitation.
Further review of Resident 137's clinical records revealed a physician order dated June 20, 2023, for Mirtazapine Tablet 7.5 mg. for depression.
Review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on January 4, 2024, with two recommendations, 1.) semi-annual dose reduction evaluation requested for the above medications, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg). 2.) Periodically reevaluate [NAME] antipsychotic use.
Further review of Resident 137's clinical record revealed that a MRR (Medication Record Review) was completed on May 10, 2024, with the recommendation, trial dose reduction of the above medications requested, (Haloperidol 1mg, Olanzapine 5mg, Mirtazapine 7.5 mg).
Review of Resident 137's clinical record failed to reveal documented evidence a trial dose reduction or a semi-annual dose reduction evaluation was performed.
Further review of Resident 137's clinical records failed to reveal documented evidence of periodical evaluations for dual antipsychotic drug usage was performed.
Interview with the Director of Nursing on June 24, 2024, at 1:35 p.m. confirmed there was no documented evidence that trial dose reductions, semi-annual dose reductions or periodical evaluations for dual antipsychotic drug usage was performed for Resident 137.
483.45 Drug Regimen Review, Report Irregular, Act on
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
28 Pa. Code 211.5(f) Clinical records
Previously cited 11/1/21, 12/30/22, 3/24/23, 8/25/23, 10/23/23
28 Pa. Code 211.12(c) Nursing Services
Previously cited 8/25/23, 10/23/23
28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 8/25/23, 10/23/23
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 8/25/23, 10/23/23

Based on clinical records review and staff interview, it was determined that the facility failed to perform laboratory services for one of the 33 residents reviewed (Resident 29).
Findings include:
Review of Resident 29's clinical records revealed Resident 29 had a diagnosis of Epilepsy (disorder in which nerve cell activity in the brain is disturbed causing seizures).
Review of Resident 29's physician order dated August 26, 2022, revealed an order for Depakote 750 mg in the morning and 500 mg at bedtime.
Review of Resident 29's physician's notes dated April 29, 2024, at 9:30 a.m., revealed Today's order: TSH, CBC, CMP, and Depakote level for May 1, 2024.
Review of Resident 29's physician's notes dated May 22, 2023, at 3:49 p.m., revealed the Depakote level was ordered but not completed on May 1, 2024, then reorder for May 2023.
Clinical records review failed to reveal that Depakote level was completed on May 1, 2024, and/or May 23, 2024.
An interview conducted with the Director of Nursing on June 24, 2024, at 1:00 p.m., confirmed Depakote level was not completed until June 22, 2024.
The facility failed to ensure Resident 29's Depakote level was completed.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of thirty-three residents reviewed (Resident 101).
Findings include:
Review of Resident 101's progress notes revealed a nurse's note dated April 2, 2024, which stated: Resident return from schedule [doctor] appointment. Per [doctor] recommendation to check vitamin D level, increased vitamin D to 2000, Calcium 600 mg, Prolia [(medication used to treat bone loss)] injection [every] six months. Next office visit May 2024 for Dexa scan [(low-dose x-ray that measures bone density and risk for osteoporosis and fractures.)]
Further review of Resident 101's progress notes revealed a nurse's note dated May 20, 2024, which stated: Resident was supposed to go out on appointment this afternoon, transport did not show- up.
Further review of Resident 101's progress notes revealed a late entry nurse's note effective date May 20, 2024, which stated: Resident was scheduled for a dexascan today. The order was placed for stretcher transport, [transportation company] called and said they cannot do stretcher today but could we send her in a wheelchair with an escort. We sent her via [wheelchair] with [nurse aide] escort but they were unable to complete the procedure due to not being able to get resident on table for testing. Upon arrival back at facility the scheduler was made aware of need for dexa scan to be rescheduled.
Further review of Resident 101's progress notes revealed a late entry nurse's note effective date June 17, 2024, which stated: Transportation called to say they could not take resident to her appointment by stretcher as ordered but could take her by [wheelchair]. This nurse agreed that she could try it and go by [wheelchair] with an escort. Resident went for her dexascan appointment but was unable to be transferred to the table for test. Resident came back to [the] facility and request for another appointment sent.
Further review of Resident 101's progress notes revealed a nurse's note dated June 24, 2024, which stated: Resident is scheduled for her dexascan this Friday [(June 28, 2024)].
Interview with the Director of Nursing on June 24, 2024, at 12:05 p.m. confirmed that Resident 101's DEXA scan was delayed twice due to the resident being unable to transfer to the table from the wheelchair.
Pa. Code: 211.12(b) Nursing services
Pa. Code: 211.12(d)(1)(3) (5) Nursing services
Pa. Code: 211.10(d) Resident care policies

Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility of ensuring that the beverage temperature policy/guidelines included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage burns.
Findings include:
Review of the Nursing Home Administrator's (NHA) job description includes the following responsibilities: Managing all business-related activity to achieve the facility's vision and supporting strategies and assures ethical and high-quality provider of health services is maintained; Knowing and respecting resident rights; Safety-follows established safety policies, ensures potential safety/health hazards are eliminated, and demonstrate job-specific knowledge of disaster procedures; Staff development-participates in QAA program communicates new policy and regulations to staff to ensure compliance; Administration Provision and Services Responsibilities-drives quality assurance program process in the center, and ensures the implementation of follow-up or corrective actions. Intervenes as appropriate in potentially threatening situations and follow-up with staff after the crisis has been resolved; Organizes the functions of the nursing home through appropriate departmentalization and the delegations of duties; Establishes formal means of accountability.
Review of the Director of Nursing's (DON) job description includes the following responsibilities: Works in concert with the Administrator and directs the Nursing Department to maintain a quality standard of care in accordance with current Federal, State, and facility standards, guidance, and regulations. The position conducts the nursing process assessment, planning, implementation, and evaluation under the scope of the State's Nurse Practice Act of Registered Nurse Licensure; Observes the safety needs of the patient as in indicated in the care plan; Promotes nursing process and critical thinking in the nursing care delivery; Oversees the consistency of clinical systems within and between clinical units and specialty areas; Ensures and evaluates systems to plan, promote, develop, assess, interpret, validate, and evaluate the implementation of the clinical program, policies, and procedures.
The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties and ensure federal as well as state guidelines and regulations were followed.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 6/24/24, 2/20/24, 8/25/23,11/16/22
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 6/24/24, 2/20/24, 8/25/23,11/16/22
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
Previously cited 6/24/24, 2/20/24, 8/25/23, 4/4/23, 11/16/22
28 Pa Code: 211.10(c) Resident care policies
Previously cited 6/24/24, 2/20/24, 8/25/23, 4/4/23, 11/16/22

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from abuse (Resident CL1).
Findings include:
Review of facility policy, Abuse Prohibition, last reviewed [DATE], revealed that Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients.
Review of Resident CL1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of lung cancer with metastasis to the brain and expired on [DATE].
Review of Resident CL1's comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.
Review of Resident CL1's roommate's clinical record, Resident CL2, revealed a comprehensive MDS dated [DATE], with a BIMS score of 15, indicating that the resident was cognitively intact. Further review of Resident CL2's clinical record revealed the resident was discharged home on [DATE].
Review of information submitted by the facility revealed that on [DATE], at approximately 2:00 a.m., Resident CL1 was attempting to call a family member. Licensed Nurses Employees E4 and E5 entered the room at the time. Employee E4 grabbed the phone from the resident and threw it against the nightstand, breaking it. Resident CL2 was awake at the time and witnessed the interaction.
Interview with Employee E6 on February 20, 2024, at approximately 1:00 p.m. revealed the employee was the Manager on Duty on [DATE]. Employee E6 revealed that Resident CL1's family member reported the incident to her after visiting the resident. Employee E6 and Licensed Nurse Employee E7 went to the residents' room and interviewed Residents CL1 and CL2 and noted that the resident's phone was broken. Employee E6 stated that Employees E4 and E5 were suspended on [DATE], following the abuse allegations.
Further review of facility investigation revealed the phone was later fixed by Employee E8.
Review of witness statement from Resident CL1 from [DATE], revealed: Around 2:30 in the morning I was trying to make a phone call and a different nurse came in .who grabbed by house phone from me slammed it on my table and told me I was not allowed to make calls at that time of the morning.
Review of witness statement from Resident CL2 from [DATE], revealed: Around 2am she (my roommate) tried to make a call and another .nurse .came in, snatched her phone and slammed it on the table and told her she wasn't allowed to call her sister.
Interview with the former Nursing Home Administrator (NHA), Employee E3, on February 20, 2024, at approximately 12:00 p.m. revealed licensed nurse Employee E4 was terminated on February 1, 2024, for not allowing Resident CL1 to call family and breaking the phone, and licensed nurse Employee E5 was terminated on February 1, 2024, for witnessing the interaction and not stopping it or reporting it.
Interview with the current NHA and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that [NAME] Skilled Nursing and Rehabilitation Center failed to ensure that residents were assessed and monitored to prevent pressure ulcers for one of one residents reviewed (Resident R72).
Findings include:
Review of Resident R72's clinical record revealed resident was admitted on [DATE]. Further review of clinical record revealed Resident 72's diagnoses include; Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Vascular Dementia (lack of blood carrying oxygen and nutrient to a part of the brain, causing problems with reasoning, planning, judgment, and memory); Malnutrition; and Abnormalities of gait.
Review of Resident R72's clinical record revealed most recent Braden Scale (assessment of risk of developing pressure ulcers) dated June 15, 2023 which indicated resident was considered High Risk to develop pressure ulcer/wound.
Review of Resident R72's clinical record revealed a care plan addressing skin integrity. Further review of care plan revealed interventions initiated on April 17, 2023 of barrier cream to peri area (skin between the genitals and the anus) and buttocks; encourage fluids; encourage repositioning as needed; and use assistative devices as needed.
Additional review of Resident R72's skin integrity care plan revealed an intervention added on October 23, 2023 of Administer treatment per physician orders.
Review of Resident R72's clinical record including Tasks documentation for showers failed to reveal documented showers on designated shower days of Tuesday/Thursdays for previous 30 days. Further review of Resident R72's clinical record revealed most recent showers recorded for September 26 and September 29, 2023.
Review of Resident R72's September 2023 and October 2023 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed body audits occurred on September 5, 2023; September 12, September 19, September 26, October 3, and October 10, 2023.
Further review of Resident R72's clinical record including September 2023 and October 2023 MAR/TAR failed to reveal documetnation of the administration of barrier cream to resident's peri area/buttocks to prevent pressure wounds.
Review of Resident R72's clinical record revealed a General Progress Note dated October 23, 2023 (02:25 a.m.) indicating; Pt.[patient] alert and responsive; +[positive] confusion noted; during inc.[incontinence] care it was noted that stage 2 pressure ulcer on sacral area shape of butterfly both R&L[right&left] buttocks; measuring 1cm[centimeter]X .5cm R buttoks and 1/2 cm X 1/2 cm L buttocks; N.O. [new order] for cleanse wound with wound cleanser and apply med honey and foam dressing and to change BID [twice a day]; rep.[repeat] freq.[frequently] and monitor for placement; DON [Director of Nursing] made aware; family message left and will recall in AM; MD [medical doctor] made aware.
Further review of Resident R72's progress notes revealed a General Progress note dated October 23, 2023 (13:18 or 1:18 p.m.) which indicated, MD assessed and wrote new order for medihoney to b/l buttocks wound daily with foam dressing. New order for Roho cushion (cushion that distributes pressure off bony prominence of buttocks), will be ordered. [Family] was here and notified of new orders.
Review of Resident R72's clinical record revealed a Medical Practitioner's Note dated October 23, 2023 (14:13 aka 1:13 p.m) indicated [Resident] [DOB] HPI [History Physical Information]: Pt seen for follow up for wound on buttocks. St III (Stage 3 - wound that progressed to the third layer of skin into the fatty tissue) with small amount of slough (form of necrotic tissue, contains ingredients such as fibrin, leukocytes, dead cells, microbes, and proteinaceous materials) noted to multiple small areas ~1cm. Plan medihoney and ROHO cushion for WC (wheelchair).
Review of Resident R72's clinical record failed to reveal skin assessments documenting appearance or condition of skin during observations times such as showers or body audits.
The above information was relayed to the Nursing Home Administrator and Director of Nursing on October 23, 2023 at approximately 10:15 p.m.
The facility failed to monitor and assess Resident R72's skin to prevent pressure wound.
28 Pa Code

Based on clinical records, and interviews with residents and staff, it was determined that the facility failed to make certain that the medications ordered were available and administered by the acceptable standards of care for one of the 31 residents reviewed (Resident 20).
Findings include:
Clinical records review revealed Resident 20's had a diagnosis of Chronic Pain Syndrome.
Review of Resident 20's Physician's order sheet (POS) revealed an order for Oxycodone HCL (A medication to treat moderate to severe pain) 10mg tablet Give one tab every six hours for pain.
Review of Resident 20's July 2023 Medication Administration Record (MAR) revealed that the Oxycodone was not administered on the following dates/times: July 9, 2023, at midnight, July 10, 2023, at noon, July 11, 2023, at 12:00 a.m., 6:00 a.m., and 12 noon, and July 12, 2023, at midnight. Resident 20 did not received her/his ordered Oxycodone medication six times on July 2023.
Review of the nursing progress notes dated July 9, 2023, revealed that at midnight, the nurse called the pharmacy because Oxycodone 10mg was not available. A five milligram of Oxycodone was available in the Omni pix box (An automated medication dispensing machine). A call was placed to the physician for the script.
Review of the nursing progress notes dated July 11, 2023, revealed Oxycodone was not available, the pharmacy was aware.
Interview with the Director of Nursing (DON) on August 2, 2023, at 12:45 p.m., confirmed that Resident 20 did not receive the ordered medication on the above-mentioned dates/time because Oxycodone with a dosage of 10mg was not available. The DON reported that the pharmacy did not deliver Resident 20's Oxycodone 10 mg.
Interview with Resident 20 conducted on August 2, 2023, at 12:57 p.m. revealed concerns regarding medications not being administered due to unavailability from the pharmacy.
The facility failed to ensure that ordered pain medication was available and administered to Resident 20.
28 Pa. Code 211.12(c) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022

Based on clinical record review and staff interview it was determined the facility failed to have a consultant pharmacist provided a monthly medication review or a physician respond to the recommendations made by the pharmacist during the monthly medications review for five of 5 residents reviewed (30, 33, 35, 68, 92)
Findings include:
Review of Resident 30's clinical record revealed diagnoses including but not limited to Vascular Dementia with psychosis (Memory loss with loss of reality in higher brain functions)
Review of Resident 30's clinical record revealed a physician's orders for various medications including antipsychotics, anticonvulsants, opioids, antidepressant, and antianxiety medications.
Review of Resident 30's pharmacy monthly consultation report dated February 22, 2023, and July 4, 2023, revealed that irregularities were found by the pharmacist, but the irregularities were not documented.
Interview with the DON on August 3, 2023, at 11AM confirmed that pharmacy irregularity reports were not received by the facility and was therefore not provided to the attending physician for review for Resident 30.
Review of Resident 33's clinical record revealed that the medication regimen review (MRR) was reviewed on April 25, 2023- see report for comments/reccomendation(s) noted. There was no further documentation.
Review of Resident 33's clinical record revealed that the medication regimen review (MRR) was reviewed on June 5, 2023- see report for comments/reccomendation(s) noted. There was no further documentation.
Review of Resident 35's clinical record revealed diagnoses including but not limited to schizoaffective disorder (A mental disorder with both schizophrenia and mood disorder symptoms)
Review of Resident 35's clinical record revealed a physician's orders for various medications including antipsychotics, anticonvulsants, opioids, and antianxiety medications.
Review of Resident 35's pharmacy monthly consultation report dated February 22, 2023, March 13, 2023, April 1, 2023, May 9, 2023, and July 4, 2023, revealed that irregularities were found by the pharmacist, but the irregularities were not documented.
An inteview with the Director of Nursing on August 3, 2023 at 11:00 a.m. revealed that the facility could not provide these comments/reccomendations to show that they were acted upon for Resident 33 and Resident 35.
Review of Resident 68's Medication Regimen Reviews revealed the pharmacist had recommendations for the physician on April 10, 2023 and July 3, 2023.
Review of the clinical record revealed there was no response from the physician regarding these recommendations.
Interview with the Director of Nursing on August 3, 2023 at 11:30 a.m. confirmed there was no documented evidence of a respond by the physician to the recommendations made by the consultant pharmacist.
Review of Resident 92's Medication Regimen Reviews revealed the pharmacist had recommendations for the physician on March 28, 2023, February 24, 2023, and January 31, 2023.
Review of the clinical record revealed there was no response from the physician regarding these recommendations.
Further review of the clinical record revealed there was no documented evidence the consultant pharmacist had performed a medication regimen review prior to January 31, 2023.
Interview with the Director of Nursing on August 3, 2023 at 11:30 a.m. confirmed there was no documented evidence of a respond by the physician to the recommendations made by the consultant pharmacist and that a Medication regimen review had been completed prior to January 31, 2023.
28 Pa. Code 211.5(f) Clinical records
Previously cited 11/16/22, 2/10/22, 8/23/21, 7/8/21
28 Pa. Code 211.12(c) Nursing services
Previously cited 11/16/22, 2/10/22, 8/23/21, 7/8/21
28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 11/16/22, 2/10/22, 8/23/21, 7/8/21
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/16/22, 2/10/22, 8/23/21, 7/8/21

Based on observations, a review of medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and stored in two of six medication carts observed (1 North long hall and 1 North short hall medication cart).
Findings include:
Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening.
Review of manufacturers' storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening.
Review of the manufacturer's guidelines for Basaglar Insulin Kwikpen (a long-acting insulin) revealed that the medicine should be discarded 28 days after opening or removal from refrigeration.
Review of the manufacturer's storage guidelines for Levemir FlexTouch (long-acting insulin), revealed in-use Levemir insulin must be discarded 42 days after opening.
Review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening.
Review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening.
Review of the Moxifloxacin Ophthalmic Solution (A medication to treat eye infection) manufacturer's guidelines revealed not to use the medication after the expiry date. Discard 28 days after opening.
Review of manufacturer's guidelines revealed Prednisolone eye (Used to treat mild to moderate non-infectious eye allergies and inflammation) drops must be kept for four weeks once the bottle had been opened.
Observation conducted of short hall medication cart on 1 North on August 1, 2023, at 9:30 a.m., in the presence of licensed nurse Employee E6, revealed the following: one Insulin Lispro pen, opened and undated; One Insulin Gargline pen, opened and undated; One Basaglar Insulin pen, opened and undated; One Levemir Insulin pen opened, uncapped, and undated; Two Moxifloxacin eye drops bottle, opened and undated; and Two Prednisolone eye drops bottle, opened and undated.
Interview with Employee E6 conducted on August 1, 2023, at 9:35 a.m. revealed Employee E6 was unable to identify date when the medications were opened. Employee E6 confirmed the above medications failed to be dated once opened.
Observation of long hall medication cart on 1 North conducted on August 1, 2023, at 9:40 a.m., in the presence of licensed nurse Employee E7, revealed the following: Two Basaglar Insulin pen, opened and undated; Three Gargine Insulin pen, opened and undated; One Novolog Insulin pen, opened and undated; one Lantus Insulin vial. Opened and undated; and One Insulin Lispro, opened and undated.
Interview with Employee E7 was conducted on August 1, 2023, at 9:50 a.m. Employee E7 was unable to say when the medications were opened. Employee E7 confirmed that the above medications should have been dated once opened.
The above findings were discussed with the Director of Nursing on August 2, 2023, at 12:45 p.m.
The facility failed to ensure medications on 1 North long and short hall medication carts were properly labeled.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety.
Based on observation of the first-floor pantry refrigerator and cabinets on August 1, 2023, at 9:23 a.m. it was determined that there were six unlabeled 4 oz milk cartons that expired on June 26, 2023.
Additional observation of the refrigerator showed four peanut butter and jelly sandwiches, two open loaves of bread, a pizza box, a container of macaroni and cheese and four bags of take-out food all of which were unlabeled and undated.
Further observation of the refrigerator showed and an open 16 oz ginger ale soda that was unlabeled.
Observation of the facility's Food from Outside Sources policy stated that food must be labeled with the resident's name and date it was brought to the facility. The policy further states that the nursing and dietary department is assigned responsibility for monitoring the designated refrigerator and discarding outdated foods once a day.
Interview with DON and NHA on August 2, 2023, at 9:26 a.m., confirmed that food was not stored properly in the pantries. Further it was confirmed by the DON that items were not properly labeled or dated, items were expired, and those items were discarded on August 1, 2023.
28 Pa Code 201.18(b)(1) Management

Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to
for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration needing emergency medical treatment. The Administration failure resulted in an immediate jeopardy situation for 42 additional residents who resided on the same unit as Resident 88.
Findings include:
Review of the Nursing Home Administrator's (NHA) job description includes the following responsibilities: Managing all business-related activity to achieve the facility's vision and supporting strategies and assures ethical and high-quality provider of health services is maintained; Knowing and respecting resident rights; Safety-follows established safety policies, ensures potential safety/health hazards are eliminated, and demonstrate job-specific knowledge of disaster procedures; Staff development-participates in QAA program communicates new policy and regulations to staff to ensure compliance; Administration Provision and Services Responsibilities-drives quality assurance program process in the center, and ensures the implementation of follow-up or corrective actions. Intervenes as appropriate in potentially threatening situations and follow-up with staff after the crisis has been resolved; Organizes the functions of the nursing home through appropriate departmentalization and the delegations of duties; Establishes formal means of accountability.
Review of the Director of Nursing's (DON) job description includes the following responsibilities: Works in concert with the Administrator and directs the Nursing Department to maintain a quality standard of care in accordance with current Federal, State, and facility standards, guidance, and regulations. The position conducts the nursing process assessment, planning, implementation, and evaluation under the scope of the State's Nurse Practice Act of Registered Nurse Licensure; Observes the safety needs of the patient as in indicated in the care plan; Promotes nursing process and critical thinking in the nursing care delivery; Oversees the consistency of clinical systems within and between clinical units and specialty areas; Ensures and evaluates systems to plan, promote, develop, assess, interpret, validate, and evaluate the implementation of the clinical program, policies, and procedures.
The findings in this report identified the facility administration failed to implement interventions, supervision, and effective safety measures to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration needing emergency medical treatment. The Administration failure resulted in an immediate jeopardy situation for 42 additional residents who resided on the same unit as Resident 88. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties and ensure federal and state guidelines and regulations were followed.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 210.18(b)(3)(e)(1) Management
28 Pa. Code 207.2(a) Administrator's Responsibility
28 Pa. Code 211.12(c) Nursing services
Previously cited 2/10/22, 8/23/2021, 7/8/21
28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 2/10/22, 8/23/2021, 7/8/21
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/10/22, 8/23/2021, 7/8/21, 4/20/2021

Based on interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to medications and treatments for one of six residents reviewed (Resident 35).
Findings include:
Review of facility policy Medication Pass Policy dated last revised June 14, 2017, revealed that After you have finished assisting with medication, it is very important that you immediately write in the MAR and record the following information: the vital signs if and required for the medication, your initials in the appropriate box, your name and title in the appropriate space, the resident refusal to take the medication if applicable.
Clinical record review for Resident 35 revealed a physician's order for Paliperidone ER (antipsychotic medication used to treat Schizophrenia and Schizoaffective disorder) 3 milligrams every night at bedtime. Per the resident's notes dated July 15, 2023, the medication was on order. Per the resident's progress notes dated July 23, 2023, the medication was on order, progress notes for July 24, 2023, document awaiting pharmacy. Further review of the resident's progress notes from July 31, 2023, showed that the medication was still not available and waiting delivery.
Review of Resident 35's Medication Administration Record (MAR), the medication was administered to the resident and initialed by staff every night including the nights when the medication was reported to be not available.
Interview with Director of Nursing, on August 3, 2023, at 11:00 a.m. confirmed the facility did not have the medication since July 15, 2023, staff were waiting the pharmacy to fill the order, yet staff documented on the MAR that the medication was provided to the resident although it was not available. A new physician order was made and dated for August 2, 2023.
The facility failed to maintain complete and accurate medical records for one resident.
28 Pa. Code: 201.18(b)(1) Management
28 Pa Code: 211.5(f) Clinical records
28 Pa Code: 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration to the forehead requiring emergency hospital treatment. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. The facility failed to ensure interventions were in place to prevent falls for two residents (Residents 67 and 68) reviewed resulting in actual harm to Resident 68 who sustained a fracture.
Findings include:
Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed.
Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected.
Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.
Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities).
Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member.
Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her.
Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others.
Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents.
Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation.
Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified.
Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first.
Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated.
Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty.
Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher.
Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents.
Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88.
Review of Resident 88's clinical record revealed a progress notes dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her.
Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead.
Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment.
Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable) . Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates.
The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy.
An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023, regarding the facility's failure to ensure the residents were free from threat of physical violence when staff failed to provide supervision for a resident with a history of violent and aggressive behavior.
The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review.
The action plan was accepted on August 17, 2023, at 6:09 p.m.
On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan.
The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy.
Review of Facility policy and procedure titled Falls Management, revised June 15, 2022 revealed Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Adjust and document individualized intervention strategies as patient condition changes.
Review of Resident 68's demographic sheet revealed the resident was admitted to the facility on [DATE].
Review of Resident 68's admission Evaluation, dated April 8, 2023 revealed in the section titled Fall Risk Factors Resident 68 was identified as having worries about falling or feeling unsteady when standing or walking as well as having incontinence as risk factors for falls. Resident 68 was indicated as requiring a care plan for risk for falls. Further review of the document failed to reveal fall prevention interventions to be included on the care plan.
Review of Resident 68's clinical record failed to reveal subsequent fall risk assessments completed until May 20, 2023.
Review of Resident 68's admission Minimum Data Set (MDS- periodic assessment of resident needs) dated April 14, 2023 revealed the resident had a fall in the last 2-6 months prior to admission and triggered for a falls care plan. The assessment was coded as being completed on April 20, 2023.
Review of Resident 68's admission care plan failed to reveal a care plan for the prevention of falls.
Review of Resident 68's Progress Notes revealed a nursing entry dated April 26, 2023 at 6:23 p.m. stating resident was found on the floor next to her bed five or six feet from her wheelchair at 3:45 p.m. states 'my foot slipped' when asked what happened. No injuries were noted and denies pain anywhere.
Further review of Resident 68's progress notes revealed a note dated April 26, 2023 at 6:54 p.m. indicating, Resident had just finished up with visit from her daughter, resident trying to go out of the dinning room and back to her room. Resident had a previous fall and was being closely monitored. CNA (certified nurse aide) on shift was pushing resident in wheelchair back into the dinning room when resident removed her feet from the leg rest and tried to stop the chair. Resident placed her feet on the floor to stop the wheelchair and fell front. When falling the resident did strike the left side of her head. Resident had a small bruise to the chest area along with an abrasion to the left side of her head. MD (medical doctor) gave order to send resident out for cat (Computed Tomography-diagnostic cross-sectional X-ray images of the body) scan and to be evaluated.
Further review of Resident 68's progress notes revealed a nursing entry dated April 27, 2023, at 1:22 a.m. indicating resident returned to the facility after being sent to the hospital for a fall with a diagnosis that included a fracture of the left clavicle (collar bone).
Review of Resident 68's current care plan revealed a care plan for falls wasn't developed until April 28, 2023.
Interview with the Nursing Home Administrator and the Director of Nursing on August 2, 2023 at 12:30 p.m. confirmed there was no comprehensive assessment of Resident 68's falls risk and no care plan developed upon admission to prevent falls.
The facility failed to comprehensively assess Resident 68 and develop interventions to prevent falls for Resident 68 resulting in actual harm to Resident 68 when Resident 68 had two falls on April 26, 2023 requiring evaluation and treatment for a fractured clavicle at the hospital.
Observation of Resident 67 on July 31, 2023 at approximately 11:00 a.m. revealed the resident was nonverbal with bilateral contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) to both the upper and lower extremities.
Review of Resident 67's clinical record revealed a diagnosis of Anoxic Brain Injury (brain injury from lack of oxygen).
Review of Resident 67's care plan revealed the resident was identified as requiring assistance for mobility with an intervention added March 25, 2022, for the resident to have two staff person assistance with repositioning in bed.
Review of Resident 67's progress notes revealed a nursing note dated July 20, 2023, which indicated; [Staff person] was changing resident and since the bed was saturated she was trying to change the sheets. Resident kicked and when she kicked she rolled out of bed and hit the floor. When she hit the floor she hit her head on either the dresser or the floor resulting in bleeding.
Further review of Resident 67's progress notes revealed the resident was sent to the hospital and returned a few hours later when the CT scan showed no injuries, and the resident did not require sutures.
Review of facility documentation including incident report dated July 20, 2023 revealed there was only one staff person assisting Resident 67 to turn in bed.
Interview with the Director of Nursing on August 3, 2023, at 10:30 a.m. confirmed Resident 67 should have had two staff people present when repositioning in bed.
F 0689 Free of Accidents/Hazards/Supervision/devices was previously cited on November 16, 2022 at scope and severity level J.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited on 11/16/22
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited on 04/04/23; 11/16/22
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.5(f) Clinical records
28 Pa code 211.10 (d) Resident care policies
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
Previously cited on 4/4/23, 11/16/22, 2/10/22, 8/23/21, 7/8/21, and 4/20/21

Based upon review of facility documentation and clinical record review, it was determined the facility failed to ensure care plans were revised and updated after falls and an episode of aggression for two of 31 residents reviewed.(Resident 88 and Resident 100).
Findings include:
Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to schizophrenia, dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder.
Review of Resident 88's clinical record revealed that on May 30, 2023, the resident struck another resident with a cane causing a laceration to the scalp.
Review of Residents 88's current plan of care failed to reveal a revised and updated interventions to address the aggression displayed on May 20, 2023.
Review of Resident 100's diagnosis list revealed diagnoses including seizure disorder.
Review of Resident 100's clinical record and facility documentation revealed Resident 100 had sustained falls on May 4, 2023, May 11, 2023, May 18, 2023, and July 31, 2023.
Review of Resident 100's current plan of care failed to reveal evidence that Resident 100's plan of care was revised and updated to include interventions to address Resident 100's falls on May 4, 2023, May 11, 2023, May 18, 2023, and July 31, 2023.
The above information was conveyed to the Director of Nursing on August 2, 2023, at 1:00 p.m.
The facility failed to update and revise Resident 88's care plan to include new interventions after the above aggressive act and Resident 100's care plan to include revisions after the above-mentioned falls.
28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that an appropriate indication was present and non-drug interventions were attempted before administering an as-needed anti-anxiety medication for two of the 31 residents reviewed (Resident 35 and Resident 69).
Findings include:
Clinical record review revealed Resident 35's diagnosis list includes Schizoaffective Disorder.
Review of Resident 35's physician's order revealed Xanax (anti-anxiety medication) 0.25 milligrams by mouth every six hours as needed for anxiety.
Review of Resident 35's Medication Administration Record (MAR) revealed the resident's behaviors and refusals should be documented every shift daily.
Further review of Resident 35's MAR revealed that the resident's behaviors were only documented on the Medication Administration Record for three shifts from July 1,2023, until July 31, 2023.
Interview with the Director of Nursing on August 3, 2023 at 11:00 a.m. confirmed that staff was not documenting the resident's behaviors because the system did not prompt them to do so.
Clinical records review revealed Resident 69's diagnosis list includes Major Depression and Anxiety Disorder.
Review of Resident 69's physician's order revealed Lorazepam (anti-anxiety medication) 0.5 mg Give one tablet by mouth every 24 hours as needed for anxiety.
Review of Resident 69's July 2023, Medication Administration Record revealed that from July 1, 2023, until July 31, 2023, Resident 69 was administered with needed Lorazepam 12 times without an appropriate indication/s and without attempting a non-pharmacological intervention before administering the medication.
Interview with the Director of Nursing on August 2, 2023, at 12:45 p.m., confirmed that Resident 69 was administered with needed Lorazepam 12 times without an appropriate indication and without attempting to provide a non-drug intervention before administering the medication.
28 Pa. Code 211.12(c) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022

Based on clinical record review, it was determined that the facility failed to ensure a comprehensive care plan was initiated for a resident receiving hospice services for one of 31 residents reviewed (Resident 4).
Findings include:
Review of Resident 4's clinical record revealed an order for hospice (end of life care) dated June 5, 2023.
Review of Resident 4's care plan failed to reveal evidence of a care plan related to hospice or end of life care.
Interview with the Director of Nursing on August 3, 2023, at 10:30 a.m. confirmed there was no care plan addressing Resident 4's hospice needs.
28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan

Based on Clinical record review and staff interview it was determined the facility failed to accurately code Minimum Data Set assessments for five of 24 residents reviewed. (Residents 4, 72, 78, 85, 92,)
Findings Include:
Review of Resident 4's Significant Change Minimum Data Set (MDS- periodic assessment of resident needs) dated June 6, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS.
Review of Resident 72's Modification of Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated May 11, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS.
Review of Resident 78's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated July 20, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS.
Review of Resident 85's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated May 6, 2023 revealed Sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS.
Review of Resident 92's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated May 9, 2023 revealed Sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS.
Interview with Licensed Nursing Employees E3 and E4 on August 2 2023 at 1:00 p.m. confirmed that the MDS assessments of Residents 4, 72, 78, 85, and 92 were not completed before submission and did not accurately reflect the resident status.
28 Pa. Code: 211.5(f) Clinical records
28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to notify the Office of the State Long Term Care Ombudsman of resident transfers in writing for four of five residents reviewed Resident (69, 100, 127, and 412)
Findings include:
A review of Resident 69's nursing progress notes dated July 7, 2023, at 5:54 a.m., revealed resident was transferred and admitted to the hospital with a diagnosis of Urinary Tract Infection. A written letter with the required content was not provided to the Office of the State Long-Term Care Ombudsman after transfer to the acute care facility occurred.
Review of Resident 100's clinical record revealed Resident 100 was transferred to an acute care facility on March 5, 2023.
The facility failed to provide documentation that the Office of the State Long Term Care Ombudsman was notified of Resident 100's transfer to an acute care facility.
Review of Resident 127's clinical record revealed that they were transferred to the hospital on April 13, 2023. A written letter with the required content was not provided to the Office of the State Long-Term Care Ombudsman after transfer to the acute care facility occurred.
A review of Resident 412's nursing progress notes dated July 22, 2023, at 7:14 a.m., revealed resident was sent to the hospital for abnormal blood works and was admitted with a diagnosis of Acute Kidney Injury. A written letter with the required content was not provided to the Office of the State Long-Term Care Ombudsman after transfer to the acute care facility occurred.
An interview with the Director of Nursing on August 3, 2023. Revealed that the facility did not send transfer information to the ombudsman.
28 Pa Code 201.14(a) Responsibility of Licensee

Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to ensure residents were free from physical abuse by Resident 88 who previously demonstrated physical aggression towards other residents, which resulted in harm requiring emergency medical treatment of Resident 141. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88.
Findings include:
Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed.
Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected.
Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.
Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities).
Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to the local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member.
Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her.
Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others.
Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents.
Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation.
Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified.
Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first.
Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated.
Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty.
Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher.
Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents.
Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88.
Review of Resident 88's clinical record revealed a progress note dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her.
Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead.
Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment.
Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable). Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates.
The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy.
An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and an Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023. Upon supervisory review dated August 25, 2023 it was determined the facility placed residents in Immediate Jeopardy of abuse on August 17, 2023 concurrently with Immediate Jeopardy of Supervision. The facility was notified on August 25, 2023 at 10:00 a.m. of the supervisory review and presented with the Immediate Jeopardy template for failure to ensure residents on the secured nursing unit were safe from Resident 88 who had a known physical aggression history.
The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review.
The action plan was accepted on August 17, 2023, at 6:09 p.m.
On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan.
The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy.
The facility failed to ensure Resident 88 with known physical aggression history from physical abuse towards other residents resulting in an injury to Resident 141 which required emergency hospital treatment.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.5(f) Clinical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations and staff interview it was determined the facility failed to ensure the dignity of resident for two of 24 resident reviewed. (Residents 68 and 78)
Findings Include:
Review of resident 68's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated July 5, 2023 revealed the resident had cognitive impairment.
Observation of resident 68's room on July 31, 2023 at 9:45 a.m. and August 1, 2023 at 10:00 a.m. revealed a sign on the wall above the bed with instructions on how to use the resident's palm guard, ensure items are within resident's reach, and provide a scoop dish and handled mug at each meal. The sign was dated June 2023 and was signed by an occupational therapist.
Review of Resident 78's quarterly MDS dated [DATE] revealed the resident had cognitive impairment.
Observation of resident 68's room on July 31, 2023 at 9:45 a.m. and August 1, 2023 at 10:00 a.m. revealed a sign on the outside of the door and observable from the hallway with instructions to help with tray set up, removes unnecessary items from tray, use built up utensils and divided plate, allow 10-15 minutes for self-feed and offer assistance after self-trial while food is still fresh.
Interview with the Nursing Home Administrator and the Director of Nursing on August 2, 2023 at 12:30 p.m. confirmed that signs with directions for the resident care should not be posted in area visible in public areas.
28 Pa. Code 201.29(j) Resident Rights
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based upon review of facility policy and procedure and clinical record review, it was determined that the facility failed to follow physician orders for the administration of medication for two of 31 residents reviewed (Resident 69 and Resident 142).
Findings include:
Review of facility policy titled General Dose Preparation and Medication Administration, revised January 1, 2022, revealed Facility staff should comply with Facility policy, Applicable Law and the State Operations Manual when administering medications.
Further review of the facility policy revealed Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record.
Further review of the facility policy revealed Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule.
Clinical records review revealed Resident 69's diagnosis list includes Hypertension (Elevated blood pressure), and Heart Failure.
Review of Resident 69's Physician's order (POS) revealed an order for Metoprolol Succinate ER (A medication to lower blood pressure) 25mg Give one tablet by mouth one time a day for Hypertension. Hold for Blood Pressure (B/P) below 110 and Pulse Rate (PR) below 60.
Review of the July 2023, Medication Administration Record revealed Metoprolol was administered to Resident 69 eight times with a BP below 110 mmHG (July 3, 17, 18, 20, 23, 24, 26, and 30, 2023) and was administered four times with a PR of below 60 BPM (July 4, 12, 22, and 24, 203).
The clinical records review failed to reveal the physician was notified of the medication being administered out of parameter.
Interview with the Director of Nursing (DON) on August 8, 2023, at 12:45 p.m., confirmed that Metoprolol was administered to Resident 69 with out-of-parameters vital signs.
The facility failed to ensure physician's order to administer medication within vital sign parameters were followed.
Review of Resident 142's April 2023 physician's orders revealed an order for Midodrine (medication used to treat low blood pressure) HCL 5 milligrams (mg) to be administered three times per day and to hold the medication if resident's systolic (top number) blood pressure is greater than 120 mmHg (millimeters of mercury).
Review of Resident 142's April 2023 Medication Administration Record revealed Resident 142 received Midodrine 5 mg five times when Resident 142's systolic blood pressure was greater than 120 mmHg which was not according to Resident 142's physician's orders.
Review of Resident 142's May 1,2023 through May 4, 2023, physician's orders revealed an order for Midodrine 5mg to be administered three times per day and to hold the medication for systolic blood pressure greater than 120 mmHg.
Review of Resident 142's May 2023 MAR revealed between May 1, 2023, and May 4, 2023, Resident 142 received Midodrine 5 mg seven times when Resident 142's systolic blood pressure was greater than 120 mmHg which was not according to Resident 142's physician's orders.
Further review of Resident 142's May 2023 physician's orders revealed an order for Midodrine 5 mg to be administered 3 times per day and to hold the medication if Resident 142's systolic blood pressure was greater than 110 mmHg.
Review of Resident 142's May 2023 MAR revealed Resident 142 received Midodrine 5 mg ten times when Resident 142's systolic blood pressure was greater than 110 mmHg which was not according to Resident 142's physician's orders.
Review of Resident 142's June 2023 physician orders revealed an order for Midodrine 5 mg to be administered three times per day and to hold the medication if Resident 142's systolic blood pressure was greater than 110 mmHg.
Review of Resident 142's June 2023 MAR revealed Resident 142 received Midodrine 5 mg twenty-five times when Resident 142's systolic blood pressure was greater than 110 mmHg which was not according to Resident 142's physician's orders.
Review of Resident 142's July 2023 physician orders revealed an order for Midodrine 5 mg to be administered three times per day and to hold the medication if Resident 142's systolic blood pressure was greater than 110 mmHg.
Review of Resident 142's July 2023 MAR revealed Resident 142 received Midodrine 5 mg thirty times when Resident 142's systolic blood pressure was greater than 110 mmHg which was not according to Resident 142's physician's orders.
Interview with the Director of Nursing on August 2, 2023, at 1:00 p.m. confirmed Resident 142 received Midodrine 5 mg against physician's orders on the above-mentioned dates.
The facility failed to ensure medication was administered according to physician orders.
28 Pa. Code 211.12(c) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(3) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022
28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 4/4/2023, 11/16/2022, 10/6/2022

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, clinical record review, and interview it was determined the facility failed to obtain weights upon admission and failed to obtain weekly weights for nutrition maintenance for two of 31 residents reviewed. (Resident 68 and Resident 153).
Findings include:
Review of facility policy and procedure titled Weights and Heights, revised June 15, 2022 revealed Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. Hospital weight will not serve as admission or re-admission weight.
Review of Resident 68's demographic sheet revealed the resident was admitted to the facility on [DATE].
Review of Resident 68's weights revealed the first weight was not obtained until May 18, 2023.
Interview with the Nursing Home Administrator and the Director of Nursing on August 3, 2023 at 12:30 p.m. confirmed there was no admission weights and weekly weights completed as should have been per policy.
Review of Resident 153's clinical record revealed Resident 153 was admitted to the facility June 23, 2023.
Review of Resident 153's Weight Summary revealed an admission weight of 116 pounds obtained on June 23, 2023.
Further review of Resident 153's Weight Summary revealed the following weights: July 3, 2023 - 105 pounds; July 5, 2023 - 105 pounds; August 1, 2023 - 99.6 pounds.
Further review of Resident 153's Weight Summary failed to reveal evidence Resident 153's weight was obtained weekly after admission.
Review of Resident 153's nutrition/weight note dated July 5, 2023 revealed [resident] with confirmed wt [weight] loss per reweight obtained 7/5. Will continue with newly implemented interventions per weight change note 7/5 and continue weekly wts [weights]. Current BMI remains normal, but low for age. Maintenance or gradual gain favorable. See wt change note 7/5 for further information.
Review of Resident 153's nutrition/weight note dated August 2, 2023 revealed [resident] triggers for unplanned, unfavorable wt loss r/t [related to] recent episodes of nausea and vomiting impacting overall ability to consume meals. Reweight recommended, will re-order weekly wts in setting of sparse wt trends and to monitor for further change.
Interview with Employee E5 on August 2, 2023 at 12:30 p.m. confirmed that Resident 153 is having a gradual weight loss and weekly weights were not obtained as per policy and as per dietitian recommendation.
The above information was conveyed to the Director of Nursing on August 4, 2023 at 1:00 p.m.
28 Pa Code 211.12(d)(3)(5) Nursing Services