Wyncote Care Center

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to revise the care plan for enteral nutrition for one out of 16 residents reviewed. (Resident R26) Findings include:Review of clinical records revealed that Resident R26 was admitted in the facility on December 1, 2025. R26 had diagnoses that included Dysphagia (difficulty swallowing food or liquids, making it hard for them to move from the mouth through the throat and into the stomach), Anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin, impairing oxygen transport, leading to fatigue, weakness, pale skin, and shortness of breath, often caused by iron deficiency, blood loss, or inherited disorders) and ,Gastrostomy Status (Gastrostomy status means a person has a surgically created opening (a stoma) into their stomach, usually to place a feeding tube (G-tube) for nutrition, fluids, or medication when they can't eat by mouth. It's a coded medical status, indicating the presence of this artificial opening for long-term access, requiring specific care for the site). Review of physician order dated December 1, 2025, for Resident R26 revealed an order to administer Tube Feed formula of Glucerna 1.2, at 45mls/hour, continuous every shift, until Osmolite is available. Review of physician order dated December 9, 2025, for Resident R26 revealed an order to administer Osmolite 1.5, 45mls/hour, Continuous, every shift Review of physician order dated December 18, 2025, for R26 revealed an order to administer Osmolite 1.5 45mls/hour, every shift, continuous; Ok (Agreed) to substitute Jevity 1.5 if Osmolite is not available. Review of physician order dated December 29, 2025, for Resident R26 revealed an order to administer two times a day Osmolite 1.5, at 55mls/hour for 12 hours overnight or until total volume infused; up at 1900, off at 0700; total volume to be infused: 660ml Review of Resident R265's care plan revealed under its focus area: The resident has a swallowing problem related to dysphagia, H/O (history of) PD, Peg tube placement on prior hospital-admission; Date Initiated: 12/02/2025; Revision on: 12/07/2025. Continued review of the resident's care plan revealed under its goal area: The resident will maintain weight and nutritional balance through the review date. Date Initiated: 12/02/2025, Target Date: 03/22/2026. The resident will have clear Lungs, no signs and symptoms of aspiration through the review date. Date Initiated: 12/02/2025; Revision on: 12/07/2025. The interventions stated to achieve the goal were All staff to be informed of resident's special dietary and safety needs. Date Initiated: 12/02/2025; Monitor for shortness of breath, choking, labored respirations, lung congestion; Date Initiated: 12/02/2025. Refer to Speech therapist for Swallowing Evaluation, Date Initiated: 12/02/2025 On January 5, 2026, at 11:52 a.m., review of the care plan of Resident R26, revealed that no care plan revision was made to the Peg tube-related focus, goals, and interventions based on different orders to administer different tube feedings, dated December 1, 2025; December 9, 2025; and December 18, 2025, respectively. At the time of the findings, interview with the Director of Nursing confirmed the same.28 Pa Code 211.10 (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to ensure that MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment was completed accurately for one of twenty-one residents reviewed. (Resident R9) Findings include:Review of CMS's RAI Version 3.0 Manual revealed that CH 3: MDS Items [O] October 2025 Page O-1 SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Under Item Rationale Health-related Quality of Life The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life. Planning for Care Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Review of Resident R9's clinical record revealed that Resident R9 was admitted to the facility on [DATE], with diagnosis of but not limited to Malignant Neoplasm of the Breast, Cerebral Infraction, Non-Hodskins's Lymphoma. Further review of Resident R9's clinical record revealed a physician's order for: Hospice consultation and treatment dated September 8, 2025. Review of Hospice contract revealed that the contract was signed by daughter who was the POA (Power of Attorney) on September 10, 2026. Review of significant change MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated September 16, 2025, revealed that Section O - Special Treatments, Procedures, and Programs, K1. Hospice care was coded No (not on hospice) Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E3 conducted on January 2, 2025, at 11:23AM revealed that Resident R9's Hospice contract was signed on September 10, 2025, and that hospice services started on the day the contract was signed. Further interview with Employee E3 confirmed that when she completed Resident R9's significant change MDS dated [DATE], she coded No on Section O - Special Treatments, Procedures, and Programs, K1. Hospice care. 28 Pa. Code 211.10(a) Resident assessment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to develop a person-centered care plan related to skin breakdown for two of twenty-one residents reviewed. (Resident R7 and Resident R8) Findings include: Review of facility policy on Care Planning revealed that under section Purpose: To ensure that each resident at Wyncote Care Center receives individualized person-centered gear through the development implementation and ongoing review of an interdisciplinary care plan in compliance with CMS and Pennsylvania Department of Health requirements. Under section Policy statement: Wyncote Care Center shall develop and maintain a comprehensive resident centered care plan for each resident care plans are based on assessments resident goals and preferences physician orders and ongoing clinical evaluation Care planning is an interdisciplinary process and care plans must be actively implemented and followed by all staff. Review of Resident R8's clinical record revealed that Resident R8 was admitted to the facility on with diagnosis of End Stage Renal Disease, Dependent on Dialysis. Review of Resident R8's oral health assessment dated [DATE], revealed that Resident R8 had four or more decayed or broken teeth/roots. Further review of Resident R8's clinical record revealed that there was no care plan developed to address Resident R8's missing teeth. Observation on Resident R8 conducted on December 29, 2025, at 1:23PM revealed that Resident R8 had one visible front tooth. Interview with Resident R8 conducted at the time of the observation revealed that he only has three teeth. Further Resident R8 also revealed that he was not able to chew the food that he likes because he does not have teeth. Interview with Director of Nursing Employee E2, conducted on December 31, 2025, at 10:46AM confirmed that there oral/dental care plan was not developed for Resident R8. Review of Resident R7's clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of but not limited to Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy (failure of the body to produce insulin), and Disorder of Arteries. Review of Resident R7's progress note dated December 3, 2025, revealed that CNA (nurse aide) staff asked RN (registered nurse) supervisor to assess the resident's right top of foot area, as there is redness on the left aspect of the red foot area that was not seen there last Monday (12/1/2025) when she was with the resident. RN assessed the area: -localized redness, size of quarter, tender to touch, pain (3/10 as per pt). No broken skin observed. Further review of Resident R7's clinical record revealed that there was no care plan addressing Resident R7's potential for skin breakdown on the top of Resident R7's right foot. Observation on Resident R7's right foot conducted with DON (Director of Nursing) Employee E2 conducted on December 31, 2025, at 10:50 AM revealed a skin breakdown with a round dark reddish-brown scab over it, the size of a quarter on top of Resident R7's right foot. Interview of the Director of Nursing, Employee E2 conducted at the time of the observation confirmed that Resident R7 had a skin breakdown on top of Resident R7's right foot. Follow-up interview with Director of Nursing, Employee E2 conducted on December 31, 2025, at 11:46AM confirmed that there was no care plan addressing Resident R7's skin breakdown on top of his right foot. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and interviews with staff, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment for residents in the facility, related with safe maintenance of two of two dryers.Findings include:On January 2, 2026, at 1:44 p.m., during observational tour of the Laundry room, it was detected that the lint of the two dryers was not removed from the lint compartment; and the lint layer was thick. There was no lint removal log available for review. At the time of the finding the same was confirmed with the Supervisor of Housekeeping, and the Administrator of the facility. 28 Pa Code 201.18(b)(1)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, it was determined that the facility failed to provided assistance with toileting for one of 21 residents reviewed. (Resident R23) Findings include:Review of Resident R23's clinical record revealed that Resident R23 was admitted to the facility on [DATE], with diagnosis of but not limited to Hemiplegia/Hemiparesis (paralysis/weakness to one side of the body). Review of Resident R23's MDS (Minimum Data Set, a federally required resident assessment completed at a specific interval) dated October 2, 2025, Section C - Cognitive Pattern C0500 BIMS (brief interview for mental status) summary score was coded 11 indicating that Resident R23 was moderately impaired of cognition; Section GG - Functional Abilities, GG0130. Self-Care C. Toileting hygiene: The ability to maintainperineal hygiene, adjust clothes before and after voiding or having a bowel movement was coded 04. Supervision or touching assistance, Section H - Bladder and Bowel, H0300. Urinary Continence was coded 2. Frequently incontinent, H0400. Bowel Continence was coded 2. Frequently incontinent. Review of Resident R23's care plan for incontinence of bowel and bladder at times related to Impaired Mobility. Further review of the care plan revealed that the resident requires assistance with ADLs (activities of daily living) r/t (related to) impaired mobility Date Initiated: 07/18/2024. The goal was for ADL care needs will be met through next review date and intervention included to: Provide assistance as required for completion of ADL tasks. Date Initiated: 07/18/2024. Observation of Resident R23's room conducted on December 29, 2025, at 11:44 AM together with Director of Nursing (DON) Employee E2 revealed that Resident R23's was in his room sitting on his bed, in street clothes. Further observation revealed a strong odor of urine coming from resident's room. Interview with Employee E2 conducted at the time of the observation confirmed that there was strong odor of urine in Resident R23. Further, Employee E2 revealed that Resident R23 tries to go to the bathroom on his own but sometimes doesn't make it to the bathroom. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(5) Nursing services

Based on the review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect the confidentiality of medical records for one of three records reviewed. (Resident R1) This was cited as past non-compliance.Findings Include:Review of an undated facility policy Medical Records Policy revealed that Wyncote Care Center maintains accurate and confidential medical records for all residents in compliance with federal and state regulations. The facility ensures secure storage, proper retention, and lawful release of medical records in accordance with CMS (Centers for Medicare & Medicaid Services).3. Release of Information:- Medical records will be released only in accordance with applicable federal and state privacy laws (e.g., HIPAA).- Records may be released to:- The resident.- The resident's legally authorized representative (e.g., Power of Attorney, legal guardian).- Healthcare providers involved in the resident's care.- Regulatory agencies and authorities as required by law.- Other parties only with a valid, signed authorization from the resident or their legalrepresentative.- All requests for records must be submitted in writing and will be processed in a timelymanner.-A fee may be charged for record copies in accordance with facility policy and state law.- Documentation of all record releases will be maintained, including the request,authorization (if applicable), date of release, and recipient details. Review of facility reported incident dated August 1, 2025, revealed that Facility made aware that another family received the wrong medical records, causing a HIPAA breach.Further review of the facility reported incident revealed that NHA notified POA of the HIPAA breach, and assistance was extended for any identification protection measures. In addition, the family member who was accidentally given wrong record is scheduled to return the document for proper management.Interview with the Administrator on September 2, 2025, at 12:30 p.m. revealed that the staff provided the wrong record, record of Resident R1, to Resident R2's representative. Facility could not find out what information was provided; however, it was informed by Resident R2's representative that information such as social security number and date of birth was part of the privacy breach. The administrator also confirmed that the facility medical record request process was not followed. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following information. 1. Facility administrator notified the affected resident's (R1) POA(power of attorney) of the possible HIPAA breach, and extended assistance or resources as a result of the breach. In addition, R2 POA (the family who received R1's medical information) was asked to return the documents back to the facility, so it can be properly discarded.2. The Concierge program was utilized in order to monitor other potential breaches of medical information. Since the facility was unable to determine who provided the record, facility administration had to ensure that facility is quick to identify anyone else, if effected. Facility did not identify others effected, and this was an isolated incident. 3. Training was provided for staff on proper Medical Record Request policy and process. Forms were made available for future medical records requests.4. Monthly QAPI and weekly concierge discussions review any medical records requests. NHA is made aware of all medical record requests, in order to prevent future breaches. Facility date of compliance was August 29, 2025.A review was conducted of clinical records, facility documentation, staff education, and documentation of audits conducted by the facility. Interview with staff revealed that the staff was knowledgeable about facility medical record request practices and HIPAA compliance. It was determined that the plan of correction was implemented, and identified as past non-compliance. 28. Pa Code: 201.29(a) Resident Rights28 Pa. Code 211.5(b) Medical Records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with staff, residents, and family members, review of clinical records, it was determined that the facility did not implement appropriate interventions to prevent and support the healing of pressure ulcers for one of four residents reviewed (Resident R1).Findings include:Review of Resident R1 ' s clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Dementia, muscle weakness.Review of Resident R1 ' s clinical record revealed physician order, dated January 31, 2025, for Prevention Devices check every shift. Pressure reducing devices to bed and wheelchair, offload heels on pillows in bed, turn and reposition frequently in bed.Review of Resident R1 ' s MDS (Minimum Data Set) State Optional dated May 3, 2025, under section M1200, dated May 3, 2025, revealed Resident R1 is not enrolled in a turning and repositioning program.Further review of Resident R1 ' s MDS (Minimum Data Set) State Optional dated May 3, 2025, under section G0110, revealed Resident R1 is Total dependence (full staff performance every time during entire shift) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed).Review of Resident R1 ' s Care Plan date-initiated January 28, 2025, revealed that Resident R1 has a potential for alteration in skin integrity r/t incontinence.Review of Resident R1 ' s clinical record revealed progress notes written by Employee E3, Licensed Practical Nurse dated April 7, 2025, While CNA was giving care an open area noted on resident ' s sacrum and CNA reported that to the charge nurse. Charge assessed area and measured it 2 cm x 1.75 cm.Review of Resident R1 ' s clinical record revealed nursing progress note dated April 10, 2025, Seen by wound doctor, see wound consult for more information.Interview with Employee E1, Administrator on 6/24/2025 at 2:30pm revealed that wound consult documentation unavailable to view, A lot of stuff is missing from the switch over.Review of Resident R1 ' s clinical record revealed Wound Evaluation and Management Summary by Wound Physician dated April 17, 2025, Wound with significant deterioration over the past week, not eating per nursing, may be beginning of end stage skin failure. Wound Size measuring 3.2 x 3.2 x not measurable (depth is unmeasurable due to presence of nonviable tissue and necrosis). General recommendations include off-Load wound, reposition per facility protocol, turn side to side in bed.No documented evidence of care plan initiated for facility acquired pressure ulcer. Confirmed by Employee E2, Director of Nursing on June 24, 2025 at 2:05pm. 28 Pa Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to perform weekly skin assessments as ordered by the physician for one of six residents reviewed. (Resident R1)
Findings include:
Review of facility policy titled Skin Check Policy, effective 2025, stated the facility will perform comprehensive skin checks on all residents as prescribed in their care plan, and at a minimum frequency consistent with the physician's orders (e.g., weekly, biweekly, monthly). The goal is to promptly identify changes in skin integrity and initiate appropriate interventions. Findings must be recorded in the resident's clinical record immediately after completion.
Any new or worsening skin condition must be documented and reported to the attending physician and Director of Nursing immediately.
Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (when the body doesn't use insulin properly, resulting in unusual blood sugar levels), bilateral primary of osteoarthritis of knee (condition that affects both knee joints with cartilage damage and inflammation), and dementia.
Review of physician's order, dated April 18, 2025, revealed an order for Skin care: skin and nail checks weekly, every day shift, every Tuesday.
Nursing progress note, dated May 13, 2025, stated Resident R1's skin check was done after (his/her) bed bath, Resident R1 abdominal fold looks irritated and red.
Further review of Resident R1's progress notes revealed no further skin assessments and no indication of skin issues noted.
Review of Resident R1's clinical record revealed on May 30, 2025 Resident R1 was transferred to the hospital due to change in mental status and abnormal vital signs.
Review of Resident R1's hospital documentation, dated May 31, 2025, revealed Resident R1 had an admitting diagnosis of sepsis with acute renal failure (Sepsis is a life-threatening condition caused by an intense response of your immune system to an infection. Sepsis triggers inflammation throughout your body that can result in multiple organ failure. Sepsis is the most common risk factor of acute kidney failure. Acute kidney failure, or acute kidney injury, is a sudden loss of kidney function).
Review of Resident R1's hospital documentation, dated June 02, 2025, revealed a physician's note that stated Resident R1 says ouch when examining abdomen and left lower extremity however more severe pain when examining right lower extremity. Right lower extremity with lower leg swelling, wound of lateral lower leg without parlance/drainage.
Physician note, dated June 03, 2025, revealed right knee fluid gram stain positive for gram positive cocci (strong indicator of septic arthritis). Right ankle fluid clotted. Plan for OR today for right knee irrigation and debridement with possible right ankle irrigation and debridement (surgical procedure that involves washing out and cleaning a wound, by removing debris and dead or damaged tissue).
Interview with on June 04, 2025 at 12:17 p.m. with Director of Nursing, Employee E1, revealed not being aware of any skin issues on Resident R1.
Interview on June 04, 2025 at 2:05 p.m. with Registered Nurse, Employee E2, revealed that she was Resident R1's nurse on May 30, 2025, the day Resident R1 was transported to the hospital. Registered Nurse, Employee E2, was unaware of swelling or skin issues on Resident R1's right lower extremity and no nurse aides reported any concerns.
Interview with Administrator, Employee E2, confirmed the facility was unable to find evidence that there was a wound present on Resident R1's right lower extremity and weekly skin assessment was not performed as ordered.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on the review of clinical record, facility investigation, policies and procedures interview with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to providing appropriate technique during resident care which resulted in resident falling from the bed during care for one of five residents reviewed (Resident R1)
Findings Include:
Review of facility policy Fall Management Program dated December 17, 2024, revealed that The community will maintain systems designed and implemented to identify hazards and individual resident risk; evaluate hazards and risks; implement interventions to reduce hazards and risks; and monitor the effectiveness of measures implemented in an attempt to eliminate or reduce the risk of accidents as much as possible.
Review of Resident R1's clinical record revealed the diagnoses of lack of coordination, unsteadiness on the feet, obesity and muscle weakness.
Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated January 28, 2025, revealed that the resident required partial/moderate assistance on bed mobility and required substantial/maximum assistance on transfers to and from bed to chair. MDS also revealed that substantial/maximum assistance status coding indicated helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Partial/moderate assistance status coding indicated helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
Review of care plan for Resident R1 dated July 22, 2024, revealed that Resident R1 required assistance with ADL's (Activities of Daily Living- bed mobility/transfers/eating/dressing/bathing and hygiene)
Review of facility investigation dated March 30, 2025, revealed that the nursing supervisor heard Resident R1 cry out then the Nurse Aide, Employee E3, called out that she needed help. Upon arrival resident's bed was in high position and the resident was laying on her right side with her head towards the top of the bed, she was complaining of severe right-side pain, resident stated from my shoulder to my hip. Nurse Aide, Employee E3 was in the room at the time of the incident performing morning care. Nurse Aide, Employee E3 stated she resident was holding on the half side rail used for turning and repositioning her hands slipped off the rail rolling to the floor.
Further review of the investigation indicated that resident was an assist of one for bed mobility. Nurse Aide, Employee E3 stated after giving resident a bed bath, she was in the process of changing residents sheets while the resident was in the bed, she rolled resident away from her to roll over the sheets, while she was changing the sheet, the resident rolled over the sheets and fell away from her.
Review of progress note fir Resident R1 dated March 30, 2025, revealed that resident fell from bed and complained of severe right arm and shoulder pain. Resident was transported to the hospital via for further evaluation.
Further review of the progress note revealed that the resident returned from the hospital without any new orders. Resident complained of some discomfort to the right shoulder in the evening shift.
Review of a statement from Nurse aide, Employee E3 dated March 30, 2025, revealed that attempting to do my final round changing the patient, she was holding on, she fell landing on her right side complain of right shoulder pain.
Another statement obtained from the same employee revealed that she was doing a complete bed change on Resident R1, she was turned towards the door (left side) with side rails up, Before she could turn her over the folded linen, she fell out of bed.
Interview with Director of Nursing, Employee E2 on April 22, 2025, at 12:00 p.m. stated on March 30, 2025, Employee E3 was providing morning care for Resident R1. After morning care, she decided to change resident's bed linen while resident was in the bed. Nurse Aide turned resident away from her, folded the linen towards the resident. Before resident rolling back over to the other side, while the resident was on sheet, Employee E3 pulled the sheet out and resident fell to the floor. Employee E2 stated if residents get linen change while they are in the bed, they should complete it with appropriate technique. Employee E2 stated the appropriate technique was staff should turn resident safely to one side, fold the linen, roll the resident to the other side over the folded linen, once the resident was off the sheet, staff should pull the sheet.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility policy, observations, and interviews with staff, it was determined that the facility failed to exercise proper infection control techniques and wear personal protective equipment (PPE) during a dressing change for one of one resident observed (Residents R32).
Findings include:
Review facility policy titled Transmission Based Precautions- Infection Control revised May 28, 2024, revealed precautions should be maintained as long as necessary to prevent the transmission of the infection. Further review of policy under section Enhanced Barrier Precautions (EBP) revealed that gloves and gowns are to be used when providing high contact resident care. High contact resident care activities include wound care. EBP are implemented for any resident with a wound.
Review of Resident R32's clinical record revealed that Resident R32 was admitted to the facility on [DATE] with a diagnoses hydrocephalus (excess fluid in the brain ventricles), edema (swelling caused by too much fluid trapped in the body's tissues), and lack of coordination.
Review of physician orders revealed an order dated November 11, 2024, that stated cleanse left buttock with normal saline, apply anasept gel (prevent and treat skin and tissue infections), calcium alginate (type of wound dressing), and cover with boarder gauze daily and prn (as needed).
Wound care observation on Resident R32 conducted on December 18, 2024, at approximately 10:00 a.m. with licensed nurses Employee E3 and Employee E4 revealed that Employee E3 and Employee E4 donned gloves prior to performing Resident R32's dressing change.
Further, observation revealed that licensed nurse, Employee E4 started performing wound dressing change on Resident R32 without donning a gown.
Interview with Licensed nurse, Employee E4, conducted December 18, 2024, at approximately 11:20 a.m. revealed proper PPE, which includes donning gloves and gown during high contact resident care, is to be worn for residents on enhanced barrier precautions when providing care.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to review and revise a care plan related to feeding assistance for one of 12 residents reviewed (Resident R34).
Findings Include:
Review of facility policy Interdisciplinary Care Planning revised 12/16/2024 revealed it is the responsibility of each discipline to add, revise, and discontinue care plan problems, goals, and interventions as needed.
Review of Resident R34's comprehensive care plan revised December 13, 2024, revealed the resident had potential for alteration in nutrition status related, but not limited to, dementia, varied meal completion, and decline in self-feeding with need for adaptive feeding devices. Intervention dated February 12, 2024, and March 22, 2024, revealed to provide Resident R34 with a Kennedy cup for beverages and inner lip plate for food items with all meals.
Observations in the dining room on December 18, 2024, at 12:00 p.m. revealed Resident R34 was not provided with adaptive equipment for the lunch meal service and was instead being fed by nurse aide, Employee E5.
Interview on December 18, 2024, at 12:00 p.m. with Nurse Aide, Employee E5, revealed Resident R34 had a decline in self-feeding capabilities and was no longer able to use the adaptive equipment at meals. Further interview with nurse aide, Employee E5, revealed Resident R34 required 1:1 feeding assistance with meals.
Review of Resident R34's comprehensive care plan revealed no evidence interventions were revised related to self-feeding capabilities.
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (d)(5) Nursing services

Based on facility policy, observation, interview with residents and staff and review of facility documentation, it was determined that the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services for three of twenty nine residents reviewed relating staff response to call bells, resident needs and nursing required skills. (Resident R16, Resident R39 and Resident R149)
Findings include:
Review of facility policy titled Call System and Response revised February 21, 2020, revealed that the facility will maintain a functional communication system from residents' rooms, bathrooms, and bathing areas. All resident call bells will be answered in a timely manner. Further review of this policy states that answering the call system is primarily the responsibilities of the certified nurse assistants. However, when a resident's call light is activated, the nearest available employee is to respond.
Interview with Resident R16 on February 27, 2024 at 10:40 a.m., revealed that his major concern and complaint of the facility that the call bell was not answered in a timely manner. He continued the interview with an example as recent as the same morning of the interview, Resident R16 activated his call bell in need of toileting and stated he waited an hour for an employee to respond to the call bell. At the time of this interview Resident R16 activated his call bell, there was no response to the call for a period of forty-four minutes. This time was also confirmed in a call bell audit provided by the Director of Nursing, Employee E2.
Interview with Resident R39 on February 28, 2024, at 11:30 a.m. revealed that Resident R39 was observed in gown. The resident expressed that she has been waiting since 6:30 a.m. to be cleansed and dressed. Resident R39 stated that she has requested to be assisted with these activities of daily living (ADLs) and was told later. During this interview, Resident R 39 initiated her call bell, nurse aide, Employee E13 , responded and stated that
Resident R39 had to wait until physical therapy could assists in cleaning and dressing of this resident.
Interview with Physical therapist Employee E3 , February 28, 12:30 p.m. revealed that Resident R39 required a two person assists however did not need to wait for physical therapy to complete this tasks. Employee E3 revealed that any employee could assists with these tasks.
Review of the facility's job description of register nurses revealed that this position essential duties includes assess residents, plans, and implements care plans, receives reports, and relays information to nursing staff, informs physician of resident changes, orders medications as well as is performs resident treatments designed to be done by a licensed nurse, including wound care. Further review of this policy reveals that all supervisors are accountable for their own performance as well as the performance of their direct reports and are accountable to clearly communicate and reinforce department goals and individual job performance expectations.
Observation of Licensed nurse, Employee E18 providing wound care to Resident R149 on February 27, 2023, at 12:10 p.m. revealed that Employee E18 was unprepared and unknowledgeable of Resident R149. Licensed nurse, Employee E18 had limited information pertaining to this resident wounds and care needs. Licensed nurse, Employee E16 was unprepared needing to leaving the room twice for supplies, Licensed nurse, Employee E16 was unaware of location of wounds, condition, and proper wound care techniques. Interview with Licensed nurse, Employee E16 at time of observation revealed that this was her first day, she was not provided information or training of wound care.
Interview with Education Training Instructor, Employee E10 revealed that Licensed nurse, Employee E18 completed her orientation and skills needed for wound care would have been achieved on the floor training. This employee was not assigned to any resident that needed or were provided wound care during on the floor training, therefore was not instructed or provided any practice prior to provided Resident R149's wound care.
28 Pa. Code 201.20 (a)(6)(b) Staff development
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with staff and review of facility documentation, it was determined that the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one of two residents reviewed with falls. (Resident R97)
Findings include:
Review of Resident R97's admission assessment dated [DATE] indicated that the resident was able to make needs know with cognitively intact decision making. The resident was dependent on one staff member for toileting hygiene (ability to maintain perineal hygiene), substantial/maximal assistance to perform sit to stand, and partial to moderate assistance with walking ten feet. Continued review of the resident assesment revealed that the resident was frequently incontinent of bladder and bowel.
Review of clinical record documentation dated January 9, 2024 indicated that this resident had diagnoses that included: osteoporosis (brittle bones), rheumatoid arthritis s(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm).
Review of Resident R97's care plan revealed that the resident was at risk for falls. Interventions included to provide Resident R97 with one person assist with all transfers (how a resident moves from surface to surface). The resident's care plan also indicated that Resident R97 required assistance of one staff member with bathroom needs and incontinence care of bowel and bladder.
Review of occupational and physical therapy documentation dated January 10, 2024 through February 6, 2024 indicated that Resident R97 required stand by assistance and safety cues to prepare for a transfer. The assessment also indicated that Resident R97 required the support of one person for standing from the sitting position and required care giver assistance to ambulate with the wheeled walker.
Interview with the Employee E3, a physical therapist, at 1:00 p.m., on February 29, 2024 confirmed that Resident R97 required stand by assistance to transfer and stand safely. The therapist also confirmed, during this interview, that Resident R97 required care giver hands on assistance for safe toileting.
Clinical record review for Resident R97 revealed that this resident reported to the licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024. The facility incident report indicated that the nursing assistant responsible for assisting Resident R97 with toileting, standing, transferring and ambulating on February 7, 2024 said that she was clearing a path or moving things out of the way, to the resident's bed, when she saw the resident fall.
Interview with employee E2, the Director of Nursing, at 9:00 a.m., on March 1, 2024 confirmed that the nursing assistant responsible for providing toileting, standing, transferring and ambulation assistance for Resident R97 on February 7, 2024; failed to provide this assistance as care planned for Resident R97. The Director of Nursing confirmed during this interview that the lack of proper assistance by the nursing assistance, during toileting, resulting in a fall for Resident R97 on February 7, 2024.
28 Pa. Code 211.12(c)(d)(1)Nursing services
28 Pa. Code 201.18(b)(1) Management

Based facility policy, observation, and interviews, it was determined that facility failed to secure residents privacy relating to confidential medical records for 5 out of 42 residents reviewed. (Residents; R14, R28, R37, R11, and R1)
Findings include:
Review of the center for Disease Control and Prevention (CDC), Public health law titled the Health Insurance Portability and Accountability Act of 1996 (HIPAA) revealed that HIPAA is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule which is a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule standards address the use and disclosure of individuals' health information-called protected health information.
Review of the facility policy titled Transmission-based Precautions last revised June 20, 2023, revealed that the Infection preventionist will identify the type of transmission-based precautions and notification will be placed on the residents doors to which transmission based precaution is implemented, the selection and use of personal protective equipment (PPE), and the clinical conditions for which specific PPE should be used.
Observation of the facility Second floor nursing unit on February 27, 2023 at 10:40 a.m. revealed residents rooms: 404, 419, 420, 422, and 428 with a red colored sign hanging on the outside of the doors for everyone to see, which revealed the residents occupying those rooms were identified as being covid positive.
Interview with Licensed nurse, Employee E18, at time of observation above, confirmed that the signs on these doors declared the residents diagnosis of covid positive.
28 Pa. Code 210.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with staff, facility documentation, policy and procedure reviews and interviews with family members, it was determined that the facility failed to notify the resident's representative of a need to alter treatment significantly and failed to notify the resident's physician of an accident requiring physician intervention for two of 23 residents reviewed. (Residents R96 and R97)
Findings include:
A review of the facility policy titled Notification of Changes revealed that it was the responsibility of the facility to immediately inform each resident and/or resident representative of accidents that have the potential for physician intervention or significant changes in condition. The policy also indicated that it was the facility's responsibility to ensure that the physician was immediately notified of an accident that had the potential for requiring physician intervention. The policy said that the physician was to be notified immediately of a significant change in physical, mental and psychosocial status of the resident.
Clinical record review for Resident R96 revealed that this resident was admitted to the facility on [DATE]. The nursing progress note indicated that Resident R96 had poor cognitive status. The nurse indicated that the resident's diagnosis upon admisssion was CVA (cerebral vasculer accident) with right sisded weakness and aphasia (a loss or impairment of one's capacity to use or comprehend language, which is most commonly caused by injury to a specific area in the brain).
Clinical record review on February 13, 2024 indicated that Resident R96 received testing for the virus that causes COVID-19 and the test results were positive. The nursing progress note on February 13, 2024 indicated that interventions were significantly changed for Resident R96 to include taking transmission based precaustions when providing care or visiting this resident. The nursing progress note dated February 15, 2024 indicated that Resident R96 had a persistent cough.
Interview with Resident R96's responsible party/family member at 1:00 p.m., on February 27, 2024, revealed that the family member was not notified of the need to alter Resident R96's treatment and care due to the fact that Resident R96 was diagnosed as being positive for the virus that causes COVID-19 on February 13, 2024. The family member reported visiting the facility on February 14, 2024 and having to ask nursing staff, the medical status of Resident R96.
Interview with Employee E2, the Director of Nursing, at 9:00 on February 28, 2024 confirmed that the facility had no documentation to indicate that the responsible party for Resident R96 was notified of a significant change (postive results for COVID-19 testing) or change in medical status on February 13, 2024.
Clinical record documentation for Resident R97 indicated that this resident was admitted to the facility on [DATE] and had diagnoses of osteoporosis (brittle bones), rheumatoid arthritis(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm).
Clinical record review for Resident R97 revealed that the resident reported to the Licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024, at approximately 6:00 p.m. The nursing assistant responsible for this resident reported that she was clearing a path or clearing the room to the resident's bed, when she saw the resident fall in the bathroom.
Review of facility's investigation of alleged abuse, neglect and misappropriation of property dated February 8, 2024 indicated that the nursing assistant assigned to provide care to Resident R97 failed to report to the licensed nurse that Resident R97 experienced a fall on February 7, 2024. The fall occurred in the bathroom on February 7, 2024 for Resident R97. After the fall occurred, the nursing assistant responsible for Resident R97 asked another nursing assistant to assist the resident from the floor and they placed Resident R97 into the wheelchair and into bed on February 7, 2024.
Continued review of the faciltiy's investigation revealed that the resident's incident/accident was consequently not reported to the physician, by the licensed nurse, on February 7, 2024, for required intervention post fall. The investigation report form indicated that the facility was not aware of any incident/accident for Resident R97 until the resident reported the incident on February 8, 2024.
Interview with the Director of Nursing, Employee E2, on February 29, 2024 confirmed that lack of notification of the physician of an incident/accident (fall) involving Resident R97 on February 7, 2024. Employee E2, Director of Nursing also confirmed that the lack of notification of the physician, resulted in a delay of assessment, monitoring and potential treatment for Resident R97.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observations of the daily meal preparation and delivery from the Food and Nutrition Department to the nursing unit for 41 of 46 residents reviewed and interviews with staff, it was determined that the facility failed to ensure that essential resident care equipment, for the food service operation was maintained in safe operating condition.
Findings include:
Observations on February 27, 2024 during the noon meal service revealed that the dietary staff was not using the plate warmer according to manufacturer's recommendations. There were no lids in place above the lowerator wells. The every day china plates were stacked above the food service equipment's warming mechanism; preventing proper heating of the dishware.
Observations on February 27 and March 1, 2024 during the plating of foods and beverages and assembly of meal trays; revealed that dietary staff were using opened slotted carts and opened push carts to deliver meals throughout the hallways on the nursing units and into each resident room.
Observations on February 27 and March 1, 2024 of the food service equipment being used to deliver the breakfast, lunch and dinner meals for the residents eating inside their rooms, revealed that the entire thermal set of food service equipment for plating, transporting and delivery of hot foods was not available for use. There were no metal pellets as specified by the equipment manufacturer for the dietary services.
Interview with the Director of Dietary, Employee E11 at 11:30 a.m., on February 27, 2024 and the dietary staff, Employees E5, E6 and E7 confirmed that the thermal heating equipment (pellets) manufactured to keep foods hot and safe during plating, transportation and delivery to each resident's room for breakfast lunch and dinner, were not being used according to manufacturer's recommendations and standards of the food service operation to ensure food service safety.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on observations, review of facility policy, review of facility documentation and review of temperature logs and interviews with dietary staff, it was determined that foods were not being served to residents at temperatures that were appetizing on one of one nursing units. (Second Floor)
Findings include:
The Servsafe Manager Manual, National Restaurant Association; 2019 guidelines for holding hot foods were 135 degrees Fahrenheit or higher to prevent pathogens from growing at unsafe levels.
Review of Facility Policy on Resident Meal Audit- Dining Services, dated January 17, 2019; last revised on May 6, 2021 indicated a served standard for cold food and beverages must be maintained at a temperature 51 degrees F (Fahrenheit) or below, hot food at 140 degrees F to 170 degrees F, and hot beverages at 140 degrees F to 170 degrees F. Frozen desserts need to be at appropriate temperatures (frozen state) at point of service.
On September 27, 2023, at 12:01 p.m., reviewed the temperature of lunch items served at the last point of service at the Second floor revealed the following temperature: Pork Cutlet with Gravy: 115 F.; Sauerkraut: 118 F.; German Potato Salad 120 F.; Apple Sauce: 70 F.; Apple Streusel: 58 F.; Apple Juice: 56 F These temperatures were verified by Employee E7, the Executive Chef, at 12:01 p.m., on September 27, 2023.
28 Pa Code 201.18(a)(b)(1)(2)(3) Management