**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, facility documentation, clinical records, and staff interview, it was determined that the facility failed to monitor resident's skin condition and follow wound physician's treatment orders/recommendations resulting in harm to Resident CL1 of discovering the wound at an advanced Stage 3 (full thickness loss of skin that extends into the subcutaneous tissue but does not cross the fascia beneath), wound deterioration, and unnecessary pain/discomfort for one of two residents reviewed (Resident CL1). Findings include: Review of the facility's policy titled Skin Integrity and Wound Management, reviewed May 1, 2024, revealed that nursing assistants will observe skin daily and report any changes or concerns to the nurse. The licensed nurse will evaluate any reported or suspected skin change or wounds and perform daily monitoring of wounds or dressing for the presence of complications or declines. Implement wound care treatments/techniques as indicated and ordered. Review of Resident CL1's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Urinary Tract Infection (UTI), and Peripheral Vascular Disease (PVD- circulatory condition that causes blood vessels outside the heart and brain to narrow, block, or spasm). Review of Resident CL1's clinical admission assessment revealed resident was admitted to the facility on [DATE]. Further review of admission assessment under section skin assessment revealed the presence of scabs on both lower extremities. Additional review of the clinical admission assessment failed to reveal any skin wounds to the sacral area (tailbone). Review of Resident CL1's admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 22, 2024, revealed Resident CL1 had severe cognitive impairment. Further review of the admission MDS assessment revealed Resident CL1 was rating as always being incontinent of both bowel and bladder and was dependent on bed mobility. Additonal review of the MDS revealed resident did not have pressure ulcer upon admission and was at risk for developing a pressure ulcer. Review of Braden Scale Assessment (scale used for predicting pressure sore risk) dated March 1, 2024, revealed a score of 14 indicating Resident CL1 was moderately at risk for developing a pressure ulcer. Review of Resident CL1's skin and incontinent care plans revealed interventions including observing skin for signs of skin breakdown (redness, cracking, blistering, decreased sensation, and skin that does not blanche easily), and monitoring for skin redness/irritation and reporting as indicated. Review of Resident CL1's clinical record revealed that weekly skin assessments were conducted but issues with skin integrity were not noted. Review of Resident CL1's nursing progress notes dated March 7, 2024, at 12:24 p.m., revealed a new open area was discovered on Resident CL1's sacrum. Upon further assessment, a new Stage 3 was noted on the sacrum. The wound was assessed, treatment was applied, all parties were notified, the care plan was updated, and a new treatment order was placed. Review of Resident CL1's skin assessment dated [DATE], revealed Resident CL1's sacrum Stage 3 wound was determined to be in-house acquired, measuring 3.3 x 1.7 x 0.1 cm. with light serosanguinous drainage (type of wound drainage that is a combination of blood and serum). Review of Resident CL1's physician orders dated March 7, 2024, revealed a wound treatment to cleanse the wound with wound cleanser, apply Thera honey (wound dressing saturated with Manuka Honey, used to maintain a moist environment conducive to wound healing while permitting the passage of exudate into a secondary dressing), and cover it with foam dressing. Change every other day and as needed if soiled or dislodged. Review of the facility's documentation, including Incident Report dated March 7, 2024, revealed wound nurse was notified of the new Stage 3 wound discovered on the resident's sacrum. The investigation failed to reveal why the resident's sacral wound was discovered at an advanced Stage 3 level. Review of Resident CL1's wound consult report dated March 18, 2024, revealed Resident CL1's sacral wound was a Stage 3 measuring 2.5 x 3.5 x 0.2 cm. with 60% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The wound order was to cleanse the sacral wound with normal saline and apply Medi honey to the wound cover with border dressing change daily and as needed. Review of Resident CL1's March 2024, Treatment Administration Record (TAR) revealed that the March 18, 2024, treatment recommendation/order of the wound doctor was not followed. Resident CL1's Stage 3 sacral wound was treated every other day instead of daily as ordered by the physician. Review of Resident CL1's wound consult report dated March 24, 2024, revealed Resident CL1's sacral wound continued to be categorized as Stage 3 wound with measurements of 3.2 x 3.5 x 0.5 cm. with 60% slough. The wound recommendation/order was to cleanse the sacral wound with normal saline and apply Medi honey to the wound cover with border dressing change daily and as needed. Review of Resident CL1's March 2024, Treatment Administration Record (TAR) revealed the March 24, 2024, treatment recommendation/order of the wound doctor was not followed. Resident CL1's Stage 3 sacral wound was treated every other day instead of daily as ordered by the physician. Interview on August 22, 2024 at 11:00 a.m. with the wound nurse, licensed Employee E3 revealed that Employee E3 does wound rounds with the wound doctor on a weekly basis. Employee E3 indicated the attending physicians automatically approve the recommendations of the wound physician. Employee E3 reported that he/she was responsible for reviewing the wound doctor's consult and placing the order. Employee E3 confirmed that the wound doctor's treatment order/recommendation made on March 18, and 24, 2024, was not followed. Review of the wound consult dated April 3, 2024, revealed Resident CL1's sacral wound is now categorized as Unstageable (obscured full-thickness skin and tissue loss) measuring 2.8 x 3.9 x 0.8 cm with 60% slough. The wound treatment order was to cleanse the sacrum with wound cleanser, pack the wound lightly with ¼ Dakin's moistened gauze, and cover with border dressing daily and as needed. Review of Resident CL1's March and April 2024, TAR revealed from March 18, 2024, until April 4, 2024, Resident CL1's sacral wound was documented as administered/treated on March 20, 21, 22, 26, 28, 30, and April 1, 2024. Review of Resident CL1's wound consult dated April 11, 2024, revealed Resident CL1's sacral wound was categorized as Unstageable with measurements of 4.5 3 x 1 cm. Undermining has been noted at 9:00 and ends at noon with a maximum distance of 1.2 cm. There is a moderate serosanguinous drainage which has a strong odor. 80% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). The wound is deteriorating. Review of Resident CL1's physician's notes dated April 11, 2024, revealed resident was examined after evaluation by the wound care team. The sacral wound was worsening with malodorous discharge with concern for Osteomyelitis (Bone infection). A transfer to the hospital was ordered by the physician. Review of Resident CL1'S hospital records revealed that in the ER (Emergency Room) patient was found to have a mucopurulent (combination of mucous and pus), malodorous sacral wound. The same note revealed that the patient had a sacral wound for about one month that had become progressively painful. The pain was burning, non-radiating, and worse with the pressure shown. MRI (Magnetic Resonance Imaging - medical imaging that uses strong magnetic fields and radio waves to generate images of the organ of the body) revealed early Coccygeal Osteomyelitis. The wound was debrided and washed out by surgery and was placed on IV antibiotics (Intravenous- medications administered in the vein). The above information was discussed with the Nursing Home Administrator on August 22, 2024, at 12 p.m. The facility failed to ensure Resident CL1's skin was appropriately monitored, and the physician's order was followed resulting in a harm of discovering an advanced Stage 3 sacral wound, further wound deterioration, and pain. 28 Pa. Code 211.11(d) Resident care plan Previously cited 7/18/24 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 7/18/24 28 Pa. Code 211.10 (d) Resident care policies Previously cited 7/18/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility investigative documentation, clinical and hospital records, it was determined that the facility failed to ensure one of 24 residents was free from neglect, which resulted in actual harm to Resident 120, through Employee E3's failure to report a fall to registered nurse, the resident experienced a delay in assessment, treatment, and subsequent hospitalization for intracranial hemorrhage (brain bleed) resulting in death. Findings include: Review of facility policy, Abuse Prohibition, last revised [DATE], revealed: Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Review of Resident 120's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia, Abnormalities of Gait and Mobility, muscle weakness, history of falls, unspecified lack of coordination, and altered mental status. Review of Resident 120's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident had a BIMS score of 09, indicating moderate cognitive impairment. The MDS further indicated the resident required supervised, one person physical assist for all activities of daily living, including transfers, walking in their room, and walking in the corridor on the unit. Review of Resident 120's care plan revealed the resident was identified as at risk for decreased ability to perform activities of daily living, with an intervention added on [DATE], to provide the resident with cuing for safety, and an intervention added on [DATE], to provide the resident with supervision transfers using a stand and pivot transfer. Further review of Resident 120's care plan revealed the resident was identified as a risk for falls on [DATE], with interventions added on the same date to monitor for changes in the resident's condition, keep the resident's environment free of clutter, and encourage the resident to attend activities to maximize their full potential. Review of facility investigation revealed a witness statement from licensed nurse Employee E10 dated [DATE], which stated that Around 8am I went into her room to give her her medication and she was still asleep. I called her name to notified [(sp.)] her I was there to give her medication and she would not respond or wake up. Due to resident not responding to verbal stimuli I touched her knee and she yelled ouch .I asked her if she could sit up to take her pills she stated 'yes' but would not sit up, so I asked if she want me to come back and she shook her head yes. I returned around 8:30 to attempt to give her her pills again. She would not respond to verbal stimuli so I touched her other knee and she yelled ouch again. I then assisted resident to a sitting position to assess why she kept yelling ouch. During assessment I noted bruising to both her knees. Due to bruising I assessed skin and noted abrasions to her left pinky and ring finger. Resident tried to lay down during assessment and her sleeve went up that's when I noted bruising to her right shoulder going down her arm MD was notified and made aware of new findings. I was ordered to put in x-rays which were placed and later canceled due to resident being sent to the hospital. Review of Resident 120's progress notes revealed a physician's note on [DATE], at 1:55 p.m. which stated: I was asked to see patient by nursing staff today. The patient is noted to have lethargy today. She is also noted to have bruising on right shoulder, bilateral knees. She is not responsive to verbal stimuli but responds to physical stimuli. Further review of the physician's note revealed the resident had been on Eliquis (anticoagulant - blood thinning medication) in the past but not at the time of the change in condition. The physician ordered the resident be sent to the hospital as soon as possible. Further review of Resident 120's progress notes revealed a nurse's note on [DATE], at 8:14 a.m., following up with hospital, which stated the resident had been admitted to the hospital with a diagnosis of altered mental status. Review of facility investigation documentation revealed a witness statement from licensed nurse Employee E3 dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Review of Employee E3's witness narrative indicated, On [DATE] resident was sitting at nurse's station until 10:30 p.m. Resident was eating watermelon and drinking water. At 10:30 p.m. I assisted resident to her room and helped her into bed. I left resident's [wheelchair] beside her bed because that is where she normally keep it. During the night the resident yelled out a few times but when checked on resident was still in bed and did not require any assistance. No bruises were noticed on resident. Further review of facility investigation documents revealed a witness statement from nurse aide Employee E4, dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Employee E4's witness statement revealed the employee last cared for Resident 120 on [DATE], when the employee assisted the resident with a meal on the 3-11 shift. Review of facility documentation revealed a timeline which indicated the facility was informed on [DATE], at 1:30 p.m. by the hospital that Resident 120 had a brain bleed. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with nurse aide Employee E9 on [DATE], at 4:55 p.m. Employee E9 was asked if any residents fell on the 3-11 shift on [DATE]. Employee E9 stated: No one fell but there was a lady who was laying on the floor. When asked who was laying on the floor, Employee E9 identified Resident 120 and stated this happened around 7:30 p.m. Employee E9 stated: Before I went into the room I called for help and the nurse came down and so did [Nurse Aide, Employee E4.] Employee E9 stated that the nurse did not ask her for a statement and Employee E9 did not know if the nursing supervisor was notified. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with licensed nurse, Employee E11 on [DATE], at 5:40 p.m. Employee E11 was identified as the nursing supervisor for the 3-11 shift on [DATE]. Employee E11 indicated that no one reported any falls, incidents, or behaviors from Resident 120 on [DATE]. Employee E11 was asked if any staff member made Employee E11 aware of anything occurring with Resident 120, and Employee E11 stated: No, the aides did not reach out to me and I saw [Licensed Nurse Employee E3] Monday night when I was down there and she mentioned nothing. Further review of facility investigation documents revealed a follow up witness statement from licensed nurse Employee E10 on [DATE], which stated: [Employee E3] relieved me from the cart on [DATE] at 5 pm. I gave her report on the incident that occurred with [Resident 120.] I asked her if anything happened to her knowledge. She stated, 'No.' Further review of facility investigation revealed a follow up interview conducted with nurse aide Employee E4 by the Nursing Home Administrator and Director of Nursing on [DATE], at 5:00 p.m. Employee E4 admitted to helping pick Resident 120 off the floor on [DATE] at 7:30 p.m. Employee E4 stated that they were not asked to write a statement and they did not know if licensed nurse Employee E3 notified the supervisor. Additional review of facility investigation revealed a follow up interview conducted with licensed nurse Employee E3 by the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 p.m. Employee E3 admitted that Resident 120 was found on the floor on [DATE], at approximately 7:15 or 7:30 p.m. Employee E3 admitted to not completing an incident report or alerting the supervisor of Resident 120 being found on the floor. Review of Resident 120's hospital records from [DATE], through [DATE], revealed that CT scans showed the resident had multiple brain bleeds. The resident was then transported to a trauma center, started on comfort measures, and died on [DATE]. The hospital discharge summary listed that death was due to intracranial hemorrhaging. Interview with the Nursing Home Administrator on [DATE], at 11:50 a.m. confirmed the facility substantiated neglect allegations against licensed nurse Employee E3 and nurse aide Employee E4 for failing to report Resident 120's fall. 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor and provide wound treatment timely and consistently resulting in harm of a new pressure ulcer discovered at an advanced stage (Stage 3- Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) for one of nine residents reviewed (Resident 54). Findings include: Review of facility policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed the purpose is to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Further review of the facility's policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed residents will be observed by the NA (nurse aide) daily. Changes or concerns will be reported to the licensed nurse, who will evaluate any reported or suspected skin changes or wounds, and document newly identified skin/wound impairments as a change in condition. Review of Resident 54's current diagnosis list revealed injury of the left hip with ORIF, (open reduction and internal fixation), a surgery used to stabilize and heal a broken bone. Additional review of Resident 54's clinical record included an admission Nursing Evaluation which revealed Resident 54 was readmitted to the facility on [DATE], with no other skin impairments other than a left hip surgery wound. Review of the Significant Change/readmission Minimum Data Set (MDS- Standardized assessment tool that measures health status in long-term care residents) dated September 9, 2023, revealed the resident had no pressure ulcers. Review of Resident 54's care plan initiated October 6, 2019, revealed a care plan focus of risk for skin breakdown related to advanced age (greater than 75 years). The skin breakdown care plan interventions were listed as follows: observe skin for signs/symptoms of skin breakdown i.e., redness, cracking, blistering, and skin that does not blanche easily, and provide preventative skin care i.e., lotions, barrier creams as ordered. Further review of Resident 54's clinical record failed to reveal additional interventions were added to the care plan upon readmission on [DATE], after Resident 54's right hip ORIF, (open reduction with internal fixation). Review of Resident 54's clinical record including assessment notes dated September 11, 2023, (4:35 p.m.), revealed a skin check was performed and the following skin injury/wound(s) were previously identified and were evaluated as follows: discoloration(s): description: multiple marks left forearm, right upper arm, right forearm, abrasion(s): description: dime size scratch on right side of face near lower corner of eye. Other wound(s): location(s): sutures left thigh. Review of Resident 54's care plan revealed a revision dated September 12, 2023, documenting the resident being at risk of falls, cognitive loss, lack of safety awareness and previous fall with right hip ORIF, (open reduction with internal fixation), as well as alteration in comfort related to left hip ORIF, (open reduction with internal fixation). Review of the Braden Scale (tool used to predict risk for pressure sore development) dated September 12, 2023, revealed Resident 54 was AT RISK for developing a pressure sore. Further review of Resident 54's care plan revealed a revision dated September 19, 2023, documenting the resident having impaired skin integrity. Resident 54's care plan also revealed a revision dated September 26, 2023, documenting the resident having risk for skin breakdown related to advanced age, with a September 18, 2023, left heel wound. Further review of Resident 54's clinical record including assessment notes dated September 18, 2023, (6:16 p.m.) revealed a skin check was performed and the following new skin injury/wound(s) were identified: pressure area(s): location(s): (left) heel. Further review of skin assessment dated [DATE], failed to reveal measurements or condition of left heel wound. Skin assessment further revealed the area was cleansed, foam dressing applied, wound team consulted, and heel boot obtained to offload heel. Review of Incident Report dated September 18, 2023, revealed that during morning care a nurse aide reported blood on resident's sock and bed. During assessment a stage 3 ulcer to the left heel with a small amount of blood was discovered. Review of Resident 54's progress notes dated September 19, 2023, revealed a nutrition note indicating the resident has a Stage 3 wound and recommended addition of Liquid Protein 30 ml (milliliter) daily. Review of Resident 54's wound care notes dated September 25, 2023, revealed the heel wound measured 1.9 cm (centimeter) x 1.7 cm x 0.1 cm. The pressure ulcer has moderate amount of drainage. The drainage is serosanguineous, (discharge that contains both blood and serum, a clear yellow liquid.) Interview with the Director of Nursing (DON) and E1 Skin Health Team Lead on September 29, 2023, at 10:11 a.m., confirmed Resident 54's left heel wound was not identified until September 18, 2023, and the wound was diagnosed as Stage 3 upon identification. E1 stated that staff did not recognize the wound until Stage 3 and staff failed to properly prop the resident's heels, which caused the wound. The Director of Nursing confirmed investigation was performed and education was provided to staff. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services